Global Perspectives
| Reviews |
| DEPRESSION AND SUICIDAL IDEATION Compiled by Dr. Nilesh Shah “Suicide” or self inflected death is one of the multitudinous threats to public health. Many episodes of deliberate self-harm appear to be impulsive acts by vulnerable persons who have been emotionally upset in response to some kind of disturbing event. The intention is of either to seek temporary oblivion or to achieve change in situation, perhaps by appealing others through an act that highlights the degree of personal distress. Suicidal ideation is the existence of thoughts pertaining to ending one's own life. Active suicidal ideation is accompanied by a plan, indicating a greater degree of risk. A suicidal gesture is self-inflicted harm perpetrated without a realistic expectation of death, whereas a suicide attempt is an act of self-inflicted harm with clear expectation of death. Assessment of suicide risk can be elusive and the risk factors, if present raises the clinicians index of concern. It is seen that women are more likely to attempt suicide than men are. This is more often seen in elderly people aged 60 years or older. Other risk factors include people who are unmarried, divorced, widowed or living alone; financial difficulties; chronic or severe disease; psychiatric history of major depression or schizophrenia or addictive disorders such as alcoholism. Suicide and Depression Harwitz D and Ravizza L have reviewed the common presentations of patients who should be considered as at risk for suicide1. They have stated that psychiatric history of major depression or schizophrenia and history of addictive disorders are the two most powerful predictors of suicidal behavior, and they often occur concomitantly. Suspicion of unverbalized suicidal ideation or the presence of risk factors should prompt the clinician to explore carefully the patient's mental status and impetus for coming to the hospital. Patients presenting with symptoms such as depressed mood (either reported or observed), anhedonia, significant increase or decrease of appetite, insomnia or hypersomnia, observable or reported psychomotor agitation or retardation, loss of energy, inappropriate feelings of guilt or worthlessness, diminished concentration, recurring thoughts of death (passive or suicidal ideation; suicidal gestures or attempts) could be suffering from major depressive disorders. Pharmacologic management of the suicidally depressed patient is dictated by specific symptomatology. Often, such patients exhibit pronounced anxiety and agitation that when alleviated, can significantly reduce the suicidal feelings which are in fact the cause in some cases. Depression in the geriatric population can be attributable to various factors, including neurobiologic deterioration and psychosocial conditions. Between 15% and 20% of patients with Alzheimer's type dementia meet criteria for a major depressive episode, whereas over 50% present with significant depressive symptomatology. Also the symptoms of depression such as prevalence of physical complaints, cognitive deficits, insomnia, anxiety and evidence ofinadequate nutrition are present more commonly in elderly patients. As suicide rates among this group have been reported to be disproportionately high, it is essential that the patient should be thoroughly evaluatedfor medical conditions contributing to the presenting symptoms as well as a thorough psychosocial assessment should be obtained1. suicidality is a finding that an emergency physician should be prepared to recognize, assess, and manage emergently. When there are certain risk factors inherent in the patient's presentation elicited from the history and physical examination which might elicit suspicion in such cases, the clinician should obtain a directed history, with particular attention to symptoms of major mood disorders, especially depression. If there is any uncertainty concerning the patient's safety, he or she should be placed immediately on one-to-one observation and prevented from leaving the hospital pending the completion of the work-up and psychiatric consultation. Appropriate and capable intervention in this setting can prove highly effective in the short term by the prevention of death and injury1. Biology Of Suicidal Behavior Quendo M A and Mann J J2, in a review“The Biology Of Impulsivity And Suicidality” have discussed studies conducted on both ‘Suicide Attempts’ and ‘Suicide Completion’. According to them suicidal behavior seems to be influenced mostly by 5-HT factors, although noradrenergic effects have also been associated. The Drug–Challenge Studies conducted in the ‘Suicide Attempt’ group have indicated that depressed patients typically have a blunted prolactin response to fenfluramine, but depressed patients with a history of a suicide attempt or prominent aggressive and impulsive traits have lower prolactin responses than do patients without such a history. A greater blunting of prolactin response to fenfluramine is observed if the attempt was highly lethal than if the attempt caused low medical damage, indicating that this biological correlate reflects the seriousness of the suicidal behavior2. Platelet 5-HT2A receptors havebeen found to be increased in proportion to the lethality of the suicide attempt in depressed subjects. The Cerebrospinal Fluid Studies also conducted in the ‘Suicide Attempt’ group have shown that suicide attempters have low levels of CSF 5-HIAA. Also even when the presence of major depression is controlled and patients are studied in a drug free, controlled environment, the CSF 5-HIAA levels were found to be low2. In Postmortem Presynaptic Serotinergic Studies conducted in ‘Suicide Completion’ group the 5-HT transporter has been studied using, among other ligands, 3H-imipramine, 3H-cynoimipramine and 3H-paroxetine2. In one such study examining suicide victims with and without depression reported that suicide victims who had depression had the lowest levels of imipramine binding in frontal cortex2. Studies Based On Depression And Suicidal Behavior Suicidal Ideation in Adolescents3 study was conducted in Secondary schools in two regions of Finland to assess the relation between being bullied or being a bully at school, depression and severe suicidal ideation. About 16,410 adolescents aged 14-16 years were included in the study. The study was based on survey of health, health behaviour, and behaviour in school which included questions about bullying and the Beck depression inventory, which includes items asking about suicidal ideation. The survey demonstrated that about 1 in 10 schoolchildren report being bullied weekly at school. Adolescents who are bullied or who are bullies have an increased risk of depression and suicidal ideation. Bullies are often as depressed as those who are bullied, and suicidal ideation is even more common among bullies. Interventions aimed at reducing bullying in schools, as well as psychiatric assessment and treatment of bullies and those who are bullied, might also prevent depression and suicidal ideation3. Completed Suicide Among Older Patients in Primary Care Practices: A Controlled Study4 Suicide rates in la0te life are higher than at any other point in the life course. Psychological autopsy studies have repeatedly demonstrated that diagnosable psychiatric illness is present in 88% or more of completed suicides. A case control study was conducted by Conwell Y et al4 at New York to determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not. The data was collected by psychologic autopsies of suicides and prospective patient interviews for control. 42 patients aged 60 years and older who visited a primary care provider within 30 days of death and 196 patients aged 60 years and older from a group practice of general internal medicine or family medicine participated in the study. Psychiatric diagnosis on Axis I were made with the Structured Clinical Interview for DSM-III-R (SCID) using all available sources of data including, where available, the patient's report, informant derived data, interviews with healthcare providers, and medical records. To measure depressive symptom severity, a 24-item Hamilton Depression Rating Scale score (HDRS) was derived using data from patient interviews for PCs (Primary care) and information from all other available sources for SCs (Sample comparisons). A physician investigator reviewed primary care and all available inpatient records for all subjects to establish measures of physical health status. In addition, primary care providers were interviewed regarding the health status of SCs. Affective illnesses were heavily represented, consistent with previous findings of a close association between suicide and depressive disorders in later life. Depressed suicide completers and depressed primary care patients were equally likely to have been treated with antidepressant medications despite the significantly greater severity of symptoms in the former. Although anxiety disorders were uncommon, anxiolytic agents were often prescribed, suggesting that the physicians recognized their suicidal patients' emotional distress to some degree. Many studies have indicated that major depressive illness is frequently misdiagnosed or undertreated in primary care settings and among victims of suicide. The above data cannot define the extent to which these primary care providers diagnosed and managed other patients successfully, avoiding suicidal outcomes. However, the prominence of psychiatric illness and its treatment as issues in those who went on to take their own lives further reinforce primary care physicians' need for knowledge and skills in the diagnosis and management of depressive illness4. CONCLUSION The significant associations of suicide with depressive disorders has important implications for clinical practice and future research. As in the general population, depressive illness places older people at increased risk for suicide. That risk appears proportional to the severity of depressive symptoms. Support must be provided to primary care providers to enhance their ability to recognize patients with depressive disorders and intervene to prevent suicides. References
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