L3- suicide, bereavement, trauma, and stress related disorders

suicidal ideations are highest in who?

children and adolescents with severe mood disorders

while suicidal ideations are highest in children and adolescents-what is a caveat?

children often do not possess the cognition to create a plan for suicide

suicide deaths are highest in what patient population?

elderly

highest in adult men ≥75 y/o and in audlt women 45-64 y/o

most common methods of suicide deaths

- firearms

- hanging

- ingesting toxic substances

- carbon monoxide

suicide is the most severe risk of _________

major depression (most pts w/ depression will not attempt suicide)

suicide is the leading cause of premature death in _____

schizophrenia

what patients are increased risk of suicide

- mania

- anxiety

- OCD related disorders

emotional risk factors for suicide

- sense of hopelessness

- impulsivity

- recurrent substance abuse

- hx of aggressive behavior

it is important to screen all patients for suicide when _____

dx pts w/ mental illness

universal feature of suicide etiology

adolescents are unable to synthesize viable solutions to ongoing problems and have a lack of coping strategies to deal with immediate crises

neurobiology considerations

- family studies support a genetic contribution to suicidal behavior

- higher concordance for suicide among monozygotic twins (specific studies inconsistent)

- alterations in central serotonin have been found

postmortem studies of suicide neurobiology have shown what?

- significant prefrontal and hippocampal alterations

- areas assoc w/ emotional regulation and problem-solving

- alterations in serotonin metabolism and CSF metabolite changes

suicide risk factors

- psychiatric illnesses

- FHx (1st degree) = 2-4x incr risk

- hx of prev attempt

- living alone, death of recent spouse

- substance use/alcohol use

- exposure to family violence and/or abuse (physical/sexual abuse and neglect)

- alienation from peers, disconnection, isolation (more specific to youth)

- sexual orientation (2-6x incr risk)

suicide is the ______ leading cause of death among adolescents (15-19)

third after unintentional injuries and homicide

which sex has a higher rate of suicide attempts?

female suicide attempts are 3x higher than males, but males are more likely to involve highly lethal methods

which sex has a higher rate of suicide deaths?

males have 5x higher death by suicide rate

what does CDC say about suicide rates?

adolescent suicide mortality has increased

suicide mortality is particularly high amongst ______

- the oldest adults, especially older men

- older adults often have fewer nonfatal attempts but greater lethality when an attempt occurs

suicide remains an important _______ cause of mortality in older adults (more medically complex to treat)

preventable

important risk facotrs for suicide and the elderly

- depression and other psychiatric illness

- social isolation and loneliness

- chronic pain, serious illness, or functional decline

- bereavement and loss of independence

- access to lethal means

_______ increases suicide risk, particularly among older widowed men

recent partner loss increases risk

bereavement

psychological reactions related to the death of a loved one (a significant loss)

duration of bereavement

no strict duration, varies considerably based upon:

support system in place

may not fully resolve, may reemerge in response to specific triggers

sx of bereavement

- sadness

- insomnia

- diminished appetite

- weight loss

- withdrawal

- anhedonia

- difficulty concentrating

- difficulty with ADL's

is uncomplicated bereavement a DSM-5 disorder?

NO- sadness is proportionate and appropriate

complicated bereavement aka

persistent complex bereavement aka prolonged grief disorder

complicated bereavement has a higher risk of

suicide

DSM-5 criteria for complicated bereavement

- loss at least 12 mos ago, or 6 for children, w sx most days

- at least 1 sx of separation distress

- and at least 6 cognitive/emotional/behavioral sx

primary care screening for suicide risk

- screen all patients w psychiatric illness or hx of prev suicide attempt

- otherwise, not generally rec to routinely screen for suicide

is there evidence suggesting asking about suicide thoughts will incr the likelihood of such behavior

no evidence suggests this

what to ask pts when screening for suicide

- ideation

- intent

- plan

- accessibility/means

suicide ideation =

thoughts about wishing they were dead, family would be better off? thoughts of killing self? hx of attempt?

suicide intent

- asses the pts intent

ideation w/o intent =

passive suicidal ideation

what to ask about suicide plan

- specific details planned out?

- evaluate specificity of their plan

- be aware that suicide can also occur impulsively (esp in adolescents)

what to ask about suicide accessibility/means

- does the pt have the ability to carry out the plan?

- consider asking what has prevented them from acting on it

- may disclose info that decr acute risk OR incr if factors change (ex: religious beliefs, impact on loved ones)

what classifies as high acute suicide risk

current intent, specific plan or preparatory behavior, recent attempt, or inability to maintain safety

high suicide risk requires what

- immediate emergent psych eval + usually hospitalization

- do not leave the pt alone > continuous obs per facility policy

- arrange safe transfer to the ED or psych emergency service

- if pt attempts to leave, follow facility procedures and state law for involuntary eval, involve security if needed

possible pharmacologic tx for acute suicidality

- lithium

- IV ketamine

- Intranasal esketamine

- SSRIs and psychotherapy

long-term use of lithium is assoc w

reduced suicide risk in mood disorders

can you use lithium acutely?

not a rapid intervention for an acute suicidal crisis

mechanism of lithium

uncertainty > may include reduced mood recurrence, aggression, and impulsivity

IV ketamine may rapidly reduce SI, sometimes w/in hrs, but evidence is stronger for

reducing ideation than preventing suicide attempts or deaths

does intranasal esketamine prevent suicide

has not been established

Intransal esketamine is FDA approved for ?

w an oral antidepressant for adults w MDD and acute SI or behavior but does not replace hospitalization or other necessary safety measures

SSRIs and psychotherapy - how do they help w suicidality?

- important for tx of underlying psych d/o

- does not provide immediate safety

since SSRIs and psychotherapy doe not provide immediate safety as stand-alone tx, what other things should be in place?

safety planning and other brief suicide-specific interventions should begin immediately

what classifies as low acute suicide risk

SI w/o current intent, plan, preparatory behavior, or inability to maintain safety

Low acute suicide riks can often be managed outpt provided there is:

no imminent safety threat

safe and supportive environment

restricted access to lethal means

a collaborative safety plan

rapid and reliable f/u

plan for low acute suicide risk

- manage underlying medical/psych disorders

- assess and tx SUD

- teach the pt and supports when and how to access 988, mobile crisis services, the ED or 911 for immediate danger

remember: _____ trumps _____

safety trumps confidentiality

safety plan for suicide risk

- brief, collaborative, written plan for recognizing and responding to suicidal crisis

- pt develops plan of who to call and what to do

what's the standard suicide safety plan

the standard Stanley-Brown sequence

a safety plan does not replace what?

suicide-risk assessment, appropriate disposition, or tx of the underlying condition >> not a promise that the pt will remain safe

the standard Stanley-Brown Sequence contains what 6 steps

1. personal warning signs

2. internal coping strategies

3. people and social settings that provide distraction

4. people who can provide help

5. professionals and crisis resources

6. making the environment safer by restricting lethal means

the suicide safety plan should contain what?

specific names, numbers, locations, coping activities, and concrete means-safety actions

what is "contracting for safety"

clinicians asking if pt can "contract for safety" or agree to a "no harm contract" >> pt's promise that they will not harm themselves and will seek help

how useful is "contracting for safety"

widely used, but not supported, may provide false sense of security

what is better than "contracting for safety"

better to maintain open, nonjudgmental dialogue and reasses risk whenever sx or circumstances change

ongoing care for suicide risk

- ongoing eval and tx of psych d/o

- schedule f/u visit soon after release if appicable

- confirm pts are engaged in their ongoing care plan

- attempt to confirm tx adherance

"should have ongoing eval and tx of psych d/o" >> what does this look like?

- freq varying depending on situation

- consider changes in life, precipitating events, mental d/o

why should you schedule a f/u vist soon after release if applicable for suicide risk

incr risk soon after b/c of loss of therapeutic support from their hospitalization

what should be part of the ongoing care plan for suicide risk

- antidepressant (SSRI) for an appropriate depressive or anxiety disorder

- mood stabilizer (antipsychotic) for bipolar disorder

- substance-use tx when indicated

- CBT-based suicide-prevention tx, problem-solving therapy, or DBT depending on clinical pic

trauma and stressor-related disorders is a group of disorders characterized by

exposure to sig stress or trauma

stressor-related disorders co-occur w many psych disorders, so what do you need to evaluate/be aware of?

- ensure that they are not better explained by the other d/o

- depression, substance abuse, anxiety, bipolar

- higher risk of suicidality

trauma and stressor-related disorders include

- Posttraumatic stress disorder (PTSD): incr stress and anxiety after event

- Acute stress disorder: precursor to PTSD

- Adjustment disorder: emotional response to stressful event

PTSD overview

complex physical / cognitive / mood / behavioral effects following exposure to a traumatic event

PTSD leads to

pattern of reliving the event(s) and high-alert avoidance behaviors

proposed neurobiology of PTSD

altered fear conditioning, threat processing, contextual memory, and stress-response regulation

neuroimaging findings of PTSD may include

- reduced hippocampal volume in some populations

- incr amygdala reactivity to threat

- reduced regulatory activity in prefrontal regions

incr ______ may contribute to heightened alertness in PTSD

noradrenergic and autonomic reactivity

what may incr risk of PTSD

repeated trauma exposure incr risk, but findings are variable and not diagnostically specific

PTSD risk factors

- presence of childhood trauma

- borderline, paranoid, dependent, or antisocial personality disorder traits

- inadequate family or peer support system

- female (affected ~3x compared to males)

- genetic vulnerability to psych illness

- recent stressful life changes

- recent excessive alcohol intake

- external locus of control rather than an internal one

"external locus of control rather than an internal one" - what does this mean?

belief that events outside of one's control drives their actions rather than believing one is in control of an responsible for one's own actions

onset of PTSD

onset of PTSD sx can be soon after event or take years to manifest

PTSD clinical features

- the persistence of sx despite the termination of the threat, combined w the inability to regain a sense of safety

- tried to avoid reminders of it

- involuntary state of hyperarousal (hyper alertness)

- typically affects how they view themselves or life in some way

"the persistence of sx despite the termination of the threat, combined w the inability to regain a sense of safety" -- how does this manifest in PTSD

- form of flashbacks or dreams

- vivid and intense emotional proximity

pts w PTSD try to avoid reminders of the event- what does this manifest as?

- scanning the environment, vigilant for threats, remaining on guard

- involuntary state of hyperarousal (hyper alertness)

- leads to restlessness

DSM-5 criteria for PTSD- 5 categories

1. exposure to "actual threatened death, severe injury, or sexual trauma"

2. At least one "intrusion" sx

3. pattern of avoidance of stimuli assoc w event

4. at least 2 sx of negative cognition or mood

5. at least 2 sx of altered level of arousal

what could be an "intrusive sx" of PTSD

intrusive memory

recurrent nightmares

dissociative reliving (i.e. flashback)

psychological distress

psychological response from related stimuli that reminds them of trauma

the DSM-5 criteria sx of PTSD, what are the caveats?

- sx last longer than 1 month

- must cause sig distress or impairment in fct

- not related to substance use or another medical condition

common PTSD subtypes

- with dissociative sx

- w delayed expression

PTSD w dissociative sx

meets criteria for PTSD and experiences sx of either despersonalizaion or derealization

depersonalization

feeling detached from one's mind or body

derealization

experiencing the world as non-reality

PTSD w delayed expression

at least 6 mos b/w event and fully meeting DSM-5 criteria for PTSD

assessment tools for PTSD

- PCL-5

- PC-PTSD-5

- CAPS-5

PCL-5

- PTSD screening checklist

- 20 item self-report tool that can screen PTSD and monitor severity over time

scoring of PCL-5

- scored b/w 0-80

- score of 31-33 = probable PTSD

note about PCL-5 scoring

not universal

clinician must assess core in the context of the rest of the patient's evaluation

what is the PTSD diagnostic assessment and gold standard

CAPS-5

= 30-item structured interview evaluating the 20 DSM-5 PTSD sx, sx severity, and functional impairment

when do you use PC-PTSD-5

in Primary care, often used as bried intial screen

pos result of PC-PTSD-5 may then be followed by

longer PCL-5 or dx interview such as CAPS-5

scoring of PC-PTSD-5

score of 4 or more is a common cut off point

prognosis of PTSD

- spontaneous recovery in 30-50% of pts after 1 yr

- the very young and the very old typically have more difficulty

why do younger people have more difficulty with PTSD

less developed coping skills

why do older people have more difficulty with PTSD

more likely to have rigid coping skills and their physical disabilities can exacerbate the autonomic hyperarousal

positive prognostic factors for PTSD

1. rapid onset of the sx

2. shorter duration of the sx (

first line pharmacotherapy for PTSD

SSRI's

what may be contraindicated for use in PTSD

benzos - lack evidence and used to be contraindicated d/t risk of abuse