Anxiety, depression and suicide in the general hospital

1
Anxiety, depression and suicide in the general
hospital
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Psychiatry in the General Hospital

• High rates of medically unexplained symptoms
• Gastro 53
• Neuro 42
• Cardio 32
• More than 80 of patients experiencing a first
  psychiatric crisis seek medical rather than
  psychiatric treatment
• Up to 80 of individuals who complete suicide
  have seen a health professional in the last month

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Diagnosing depression in the medically ill

• Hopelessness, helplessness
• Loss of interest (especially in people)
• Feeling bad about oneself (not the situation)
• Feeling that illness is a punishment for
  wrongdoing
• Recurrent thoughts of death (not just to end
  physical suffering)
• Degree of participation in medical care
• Psychomotor agitation or retardation (not
  explained by delirium, dementia, physical illness
  or treatments)

4
High comorbidity between respiratory disease and
anxiety disorders

• Subset of vulnerable asthmatic patients with
  neurophysiologic diathesis to panic attacks
• Medications used to treat respiratory illness may
  induce anxiety symptoms that are
  indistinguishable from primary anxiety disorders
• Somatic symptoms associated with respiratory
  disease could exacerbate catastrophic cognitions
  and panic attacks in patients vulnerable to
  anxiety
• Patients with advanced lung disease have high
  rates of functional disability, poorer quality of
  life and lower self-esteem

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Suicide in the General Hospital

• Dept of Health Guidelines and mandatory policy
  directives
• 50 of patients who committed suicide exhibited
  some form of signal or known risk factors
  including stating that they wanted to die,
  feeling more depressed or anxious and admitting
  to a previous suicide attempt or self harm.
  Hanging (curtains and nurse call cords) and
  jumping were most common. (Japan)

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Completed suicide in medical/surgical patients

• Emphasizes the importance of both agitation and
  readily available lethal means in suicides that
  are almost invariably impulsive
• Traditional risk factors such as past history of
  psychiatric illness, substance abuse, or
  suicidality typically are absent as are present
  depression and known current suicidality
  (Bostwick et al, 2007)

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Suicide

• Our ability to predict suicide is poor
• False positives are very common
• Up to 40 of suicides are not predicted by a
  mental health professional
• The best predictors of suicidal behaviour are
  past suicide attempts and plan/intent

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Psychiatric diagnoses associated with suicide

• Major depressive disorder
• Alcohol abuse
• BAD
• Schizophrenia
• Anxiety disorder
• Personality disorder (borderline and antisocial)

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SAD PERSONS scale

• S sex
• A age
• D depression
• P previous attempt/psych care
• E ETOH/drug abuse
• R relational thinking loss (psychotic)
• S separated, divorced, widowed
• O organized plan/lethal means
• N no social support
• S sickness

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SAD PERSONS scale

• 0-2 send home with F/up
• 3-4 home but close F/up
• 5-6 strongly consider hospital depending on
  confidence in F/up arrangements
• 7-10 hospitalise/schedule
• A patient with a plan, access to lethal means,
  recent social stressors and symptoms of a
  psychiatric diagnosis needs hospitalisation

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Suicide Protective Factors

• History of self control
• Relevant cultural/religious beliefs
• Fears of harming or letting down family members
• Parents of children under 18 have lower rates of
  suicide
• Any alliance increases safety

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?suicide prevention

• No amount of diligence will take away another
  individuals ability to choose to commit suicide.
• The best we can do is ensure that we have
  adequately assessed the individual who is coming
  to us for help and have offered them appropriate
  treatment and interventions.