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The most important complication is suicide, which often includes some elements of aggression Suicide rates in the general population vary from 9 per 100,000 in Spain to 20 per 100,000 in the United States to 58 per 100,000 in Hungary In individuals with depression, the lifetime risk rises to 10 15% Men tend toward successful suicide, particularly in older age groups, whereas women make more attempts with lower mortality rates An increased suicide rate is being observed in the younger population, ages 15 35 Patients with cancer, respiratory illnesses, AIDS, and those being maintained on hemodialysis have higher suicide rates Alcohol is a significant factor in many suicide attempts There are four major groups of people who make suicide attempts By far the greatest number fall into the category of situational problems (the despair of ordinary people) There is often great ambivalence they don t really want to die, but they don t want to go on as before either A suicide attempt in such cases may be an impulsive or aggressive act not associated with significant depression In other cases a suicide attempt is clearly a stratagem for controlling or hurting others The high-risk groups are those with severe depressions or psychotic illnesses Severe depression may be due to exogenous conditions (eg, AIDS, whose victims have a suicide rate over 30 times that of the general population) or endogenous conditions (eg, panic disorders) This group also includes those who may not be diagnosed as having depression but who are overwhelmed by a stressful situation often with an aspect of public humiliation (eg, the man charged with child molestation who hangs himself in his cell) Anxiety, panic, and fear are major findings in suicidal behavior A patient may seem to make a dramatic improvement, but the lifting of depression may be due to the patient s decision to commit suicide Those with psychotic illness tend not to verbalize their concerns, are unpredictable, and are often successful but make up only a small percentage of the total Suicide is ten times more prevalent in patients with schizophrenia than in the general population, and jumping from bridges is a more common means of attempted suicide by schizophrenics than by others In one study of 100 jumpers, 47% had schizophrenia
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Any illness, severe or mild, can cause significant depression Conditions such as rheumatoid arthritis, multiple sclerosis, and chronic heart disease are particularly likely to be associated with depression, as are other chronic illnesses Hormonal variations clearly play a role in some depressions Varying degrees of depression occur at various times in schizophrenic disorders, central nervous system disease, and organic mental states Alcohol dependency frequently coexists with serious depression The classic model of drug-induced depression occurs with the use of reserpine, both in a clinical and a neurochemical sense Corticosteroids and oral contraceptives are commonly associated with affective changes Antihypertensive medications such as methyldopa, guanethidine, and clonidine have been associated with the development of depressive syndromes, as have digitalis and antiparkinsonism drugs (eg, levodopa) It is unusual for -blockers to produce depression when given for short periods, such as in the treatment of performance anxiety Sustained use of -blockers for medical conditions such as hypertension may produce depression in some patients, although the literature is unclear on this subject It is also unclear whether non lipid-soluble -blockers are less likely to be associated with depression than lipid-
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tazapine, (2) the TCAs and clinically similar drugs, and (3) the MAO inhibitors (see Table 25 8) These groups are described in greater detail below ECT is effective in all types of depression and will also rapidly resolve a manic episode It is also very effective for postpartum depression Megavitamin treatment, acupuncture, and electrosleep are of unproved usefulness for any psychiatric condition Hospitalization is necessary if suicide is a major consideration or if complex treatment modalities are required Drug selection is influenced by the history of previous responses if that information is available If a relative has responded to a particular drug, this suggests that the patient may respond similarly If no background information is available, a drug such as sertraline, 50 mg daily, or desipramine, starting with 50 mg and gradually increasing to 150 mg daily, can be selected and a full trial instituted The medication trial should be monitored with patient assessments every 1 2 weeks until week 6 If successful, the medication should be continued for 6 12 months at the full therapeutic dose before tapering is considered Antidepressants should usually be continued indefinitely at full dosage in individuals with more than two episodes after age 40 or one episode after age 50 If the response is inadequate the best alternatives are to switch to a second agent or to try augmenting the first agent according to the STAR*D study The latter course is often taken when there has been at least a partial response to the initial drug If a second drug is tried, it does not appear to matter whether that drug is from the same or different class If the second drug fails or augmentation was selected as the second step, the choices include lithium (eg, 600 900 mg/d), buspirone (eg, 30 60 mg/d), or thyroid medication (eg, liothyronine, 25 mcg/d) Dysthymia is also treated in this way The Agency for Health Care Policy and Research has produced clinical practice guidelines that outline one algorithm of treatment decisions (Figure 25 2) Psychotic depression can be treated with a combination of an antipsychotic such as olanzapine and an antidepressant such as an SSRI at their usual doses Mifepristone may have specific and early activity against psychotic depression Major depression with atypical features or seasonal onset can be treated with an MAO inhibitor or an SSRI with good results Stimulants such as dextroamphetamine (5 30 mg/d) and methylphenidate (10 45 mg/d) have enjoyed a resurgence of interest for the short-term treatment of depression in medically ill and geriatric patients Their 50 60% efficacy rate is slightly below that of other agents The stimulants are notable for rapid onset of action (hours) and a paucity of side effects (tachycardia, agitation) in most patients They are usually given in two divided doses early in the day (eg, 7 am and noon) so as to avoid interfering with sleep These agents may also be useful as adjunctive agents in refractory depression Caution: Depressed patients may have suicidal thoughts, and the amount of drug dispensed should be appropriately controlled The older TCAs have a narrow therapeutic index, and one advantage of the newer drugs is their wider margin of safety Nonetheless, even with newer agents, because of the possibility of suicidality early in antidepressant treatment, close follow-up is indicated This is particularly true in the treatment of children and adolescents where suicide risk has
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The immediate goal of psychiatric evaluation is to assess the current suicidal risk and the need for hospitalization versus outpatient management The intent is less likely to be truly suicidal, for example, if small amounts of poison or drugs were ingested or scratching of wrists was superficial, if the act was performed in the vicinity of others or with early notification of others, or if the attempt was arranged so that early detection would be anticipated Alcohol, hopelessness, delusional thoughts, and complete or nearly complete loss of interest in life or ability to experience pleasure are all positively correlated with suicide attempts Other risk factors are previous attempts, a family history of suicide, medical or psychiatric illness (eg, anxiety, depression, psychosis), male sex, older age, contemplation of violent methods, a humiliating social stressor, and drug use (including long-term sedative or alcohol use), which contributes to impulsiveness or mood swings Successful treatment of the patient at risk for suicide cannot be achieved if the patient continues to abuse drugs The patient s current mood status is best evaluated by direct evaluation of plans and concerns about the future, personal reactions to the attempt, and thoughts about the reactions of others The patient s immediate resources should be assessed people who can be significantly involved (most important), family support, job situation, financial resources, etc If hospitalization is not indicated (eg, gestures, impulsive attempts; see above), the clinician must formulate and institute a treatment plan or make an adequate referral Medication should be dispensed in small amounts to at-risk patients Although TCAs and SSRIs are associated with an equal incidence of suicide attempts, the risk of successful suicide is higher with TCA overdose Guns and drugs should be removed from the patient s household Driving should be interdicted until the patient improves The problem is often worsened by the long-term complications of the suicide attempt, eg, brain damage due to hypoxia, peripheral neuropathies caused by staying for long periods in one position causing nerve compressions, and medical or surgical problems such as esophageal strictures and tendon dysfunctions The reasons for self-mutilation, most commonly wrist cutting (but also autocastration, autoamputation, and autoenucleation, which are associated with psychoses), may be very different from the reasons for a suicide attempt The initial treatment plan, however, should presume suicidal ideation, and conservative treatment should be initiated Sleep disturbances in the depressions are discussed below
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