Info
🌱 來自: Huppert’s Notes
Depressed MoodSuicidal Ideation🚧 施工中
Depressed Mood/Suicidal Ideation
• Definitions:
- Suicidal ideation (SI)
• Active SI: Thoughts about acting to kill oneself with intent and/or plan (e.g., considering whether to shoot oneself with an owned gun, etc.)
• Passive SI: Thoughts about dying without intent and/or plan; an expression of despair/not wanting to be in a current mood, state, or situation (e.g., thoughts of “being better off dead,” thoughts of being hit by a car, etc.)
• Conditional SI: Thoughts of suicide that are dependent on specific conditions, such as satisfying a need, obtaining secondary gain, or remaining in the sick role (e.g., “If you don’t prescribe pain medications, I’m going to kill myself”)
- Suicide attempt: Self-injury made in an attempt to kill oneself that does not result in fatality
- Suicidal gesture: Self-injury made in an attempt to lead others to think that one wants to kill oneself even though there is no intention of dying; clinical feature of borderline personality disorder (e.g., holding a knife to one’s neck, putting a rope around one’s neck)
• Risk factors for suicide: Prior attempts, psychiatric disease (>90% of patient who attempt), hopelessness, married, member of sexual minority, certain occupations, veterans, chronic pain, traumatic brain injury, access to firearms
• Differential diagnosis for depressed mood:
- Psychiatric disease:
• Major depressive disorder
• Bipolar disorder
• Anxiety disorders
• Personality disorders (e.g., borderline personality disorder)
• Post-traumatic stress disorder (PTSD)
• Psychotic disorders (e.g., schizophrenia)
• Substance use disorders
- Other causes:
• Depression due to another medical condition
- Cardiac disease
- Malignancy (especially oropharyngeal and pancreatic)
- Neurologic disease (including stroke, movement disorders)
- Diabetes
- Hypothyroidism
- Chronic infection (including HIV, HCV)
• Depression due to medication effect
• Traumatic brain injury
• Chronic pain
• Malingering
• Approach:
- Safety assessment:
• Assess the suicidal ideation (i.e., passive vs. active; assess for plan, intent, means, lethality of means, rehearsal [i.e., elements of the plan being practiced, making preparations for one’s death])
• Assess protective factors (e.g., children or pets who rely on the person, loved ones who would be affected by their death, willingness to engage in safety planning/contingency planning for worsening symptoms, having hopes for the future [“future-oriented”], etc.)
• Assess for risk factors (see list of risk factors above), especially for prior suicide attempts
- Assess for triggers/stressors
• Work-up: CBC, BMP, LFTs, TSH (assess baseline organ function in anticipation of pharmacotherapy; rule out fatigue due to medical comorbidities, e.g., anemia or hypothyroidism mimicking depression). Consider additional testing based on exam/review of symptoms.
• Management:
- Medical stabilization (if patient has attempted suicide and attempt was non-fatal) with involvement of psychiatry to make appropriate holding plan
- Determine appropriate level of care (e.g., inpatient, day program, intensive outpatient therapy, outpatient): Inpatient hospitalization always indicated for recent attempt or high imminent risk (e.g., patients with plan/intent, poor social support, inability to discuss safety planning)
- Create a safety plan
• Know warning signs and precipitants
• Secure/remove lethal agents
• Utilize individual coping strategies, such as reflecting on reasons to live, distraction activities, relaxation, and exercise
• Utilize interpersonal coping, such as friends or family who lift mood
• Create a list of professionals who can help and how to contact them
- Initiate pharmacotherapy: See Table 13.3