Suicidality- base steps based on urgency

Low- ask why questions

High- come up with plan
Can ask scale Means, method, plan = intent
8 or higher- possible hospitalization

MOOD DISORDERS
 MOOD DISORDERS-AFFECTIVE DISORDERS

• Defining feature = abnormal mood

• Emotional extremes
• Intense, persistent, and maladaptive disturbances
• Other symptoms or co-occurring disorders
• *Anxiety, substance use*
• Always assess for substance use
 WHAT ARE MOOD DISORDERS

• Two key moods

• -MANIA
• Can just be manic disorder
• Most commonly mistaken for ADHD- childhood
• More often than not- will turn into bipolar
• -DEPRESSION
 WHAT ARE MOOD DISORDERS?

• UNIPOLAR Just manic or just depressed BIPOLAR

• Defining feature = abnormal mood BIPOLAR I, BIPOLAR ii
• Emotional extremes CYCLOTHYMIC
• Intense, persistent, and maladaptive disturbances
• Other symptoms or co-occurring disorders

• DUE TO ANOTHER
MEDICAL CONDITION
• SUBSTANCED INDUCED
 PREVALENCE

Lifetime prevalence of unipolar depression is nearly 17%

12-month prevalence rates are nearly 7%

About twice as common in women than men

Lifetime prevalence for bipolar disorder is near 1%

DEPRESSION
 MAJOR DEPRESSION SYMPTOMS
Suicidality
• 5+ symptoms over 2 week period
• Depressed mood most of the day
• Diminished interest/pleasure in activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Movements and body irritable or can’t do anything
• Fatigue/loss of energy nearly every day
• Feelings of worthlessness or excessive guilt
• Diminished ability to think or concentrate
• Suicidal ideation
DEPRESSION’S THAT ARE NOT MOOD DISORDERS

When depression is not

mood disorder:
Loss and grieving process
Postpartum “blues”
 Differentiating bipolar 1 and 2- depression
Bipolar 1: Might see psychotic features- result of level is irrelevant *
mania, wouldn’t diagnose with schizophrenia or Only relevant is level of mania- are they
anything manic or hypomanic (diet mania)

BIPOLAR DISORDERS Manic- Bipolar 1

Hypomanic- Bipolar 2

• Distinguished from unipolar disorders by presence of manic or hypomanic

symptoms
• CYCLOTHYMIC DISORDER
• Less severe than those of bipolar disorder
• Symptoms present for at least 2 years
• Lacking severe symptoms and psychotic features of bipolar disorder
Level of depression is relevant in
cyclothymia

Mild depression, along with mild mania -

more mild than any of bipolar stuff
 BIPOLAR I AND II

• BIPOLAR I
• Includes at least one manic or mixed episode

• BIPOLAR ii
• Includes hypomanic episodes but not full-blown manic or mixed episodes
Can see sympathetic nervous ADHD may be differential
system signs- dilated pupils
MANIC EPISODES

• 1. Inflated self-esteem or grandiosity. I’m so wonderful

• 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
• ADHD- usually good sleep
• 3. More talkative than usual or pressure to keep talking.
• 4. Flight of ideas or subjective experience that thoughts are racing. * gives a lot of yes to manic
• 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
• stimuli), as reported or observed.
• 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. (e.g. creativity)
• ADHD not as much
• I’m gonna go to psych school, law school, med school
• 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments
• Side effect: addiction
MANIC-DEPRESSIVE SPECTRUM
WRITERS AND ARTISTS
 BIPOLAR OR ADHD?

• John is a 10-year-old child who is currently repeating the third grade. His teachers have requested that his parents
have John evaluated for possible ADHD. At school John talks excessively, is frequently out of his seat, and his teacher
describes him as, at times, so difficult to control that she “can’t get a word in edgewise.” His teacher reports that when
John is very active it is as if he has a “motor” inside. He can also be somewhat irritable, “fidgety,” and has difficulty
not interrupting the other children. His teacher notes that she likes the fact that when John is like this that he believes he
can be the best student in her class and focuses more on his assigned tasks. At home, his parents report few problems.
They acknowledge that he is extremely active at times but report that they send him outside to play and that he will
eventually “wear himself out.” His parents report that John sometimes has difficulty playing by himself quietly. Once
again, when this is a problem, they simply send him outside to play. Finally, they report that John may simply be one of
those children who don’t need much sleep. When he is very active he may sleep only a few hours each night, spending
the rest of the time working on his “special projects” to catch up at school

51 psychs said bipolar

49 said adhd
 PHARMACOTHERARAPY & ALTERNATIVES

• Antidepressants, mood-stabilizing, antipsychotic drugs used to treat mood disorders

• Lithium common mood stabilizer for bipolar
• Electroconvulsive therapy
• Transcranial magnetic stimulation
• Deep brain stimulation
• Bright light therapy
 Rarely used- common in the 80s for depression
Common side effect is memory loss

ELECTROCONVULSIVE THERAPY

• ECT is often used with informed consent as a last line of intervention for major
depressive disorder, mania and catatonia
• 2008 Metaanalysis- significant superiority of ECT versus simulated ECT, placebo,
antidepressants (Pagnin, et al., 2008)
• A round of ECT is effective for about 50% of people with treatment-resistant major
depressive disorder, whether it is unipolar or bipolar. Follow-up treatment is still
poorly studied, but about half of people who respond relapse within 12 months
 ECT

• The FDA considers ECT machinery to be experimental devices.

• In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo
involuntary ECT.
• However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common
justification for its involuntary use, especially when other treatments are ineffective
• Can be used with informed consent

• Similar side effects of general anesthesia: confusion, memory loss, muscle soreness- typically benign
• Sometimes memory loss can be permanent
• Can produce seizures in those with epilepsy, so typically contraindicated
• Also, caution for those with cardiovascular conditions, have had a stroke,
• Not done in combination with drugs that can cause toxicity, e.g. lithium and benzodiazepines
• Death 4/100,000
 PSYCHOTHERAPY

• Cognitive-behavioral therapy
• Behavioral activation treatment
• Interpersonal therapy & Family and marital therapy
 STUDENT HEALTH AND WELLNESS

• 1 in 3 CSUCI students report being unable to function academically over the past year due to
depression
• 56% reported feelings of overwhelming anxiety in the past year
• 44% say they felt hopeless at least once in the past year
• Counseling and Psychological Services: http://www.csuci.edu/caps/
• Monday, Tuesday and Thursday 8:30 a.m. - 5:00 p.m. Wednesday and Friday 10:00 a.m. - 5:00 p.m.
• Bell Tower East 1867
• 805-437-2088. If you reach the voicemail, select option 1 to access 24/7 phone counseling.
• Magazine: http://readsh101.com/csuci.html
 About 5 years ago

DEPRESSION AND SUICIDE

• SUICIDE RISK IS A SIGNIFICANT FACTOR IN ALL TYPES OF DEPRESSION

• SUICIDE IS THE 10TH LEADING CAUSE OF DEATH IN THE U.S.
• -2ND LEADING CAUSE IN CA. FOR AGES 25-34
• -3RD LEADING CAUSE IN CA. FOR AGES 10-24
• 1 PERSON DIES EVERY TWO HOURS IN CA BY SUICIDE
• 8.1% OF CSUCI STUDENTS REPORT HAVING SERIOUSLY CONSIDERED
SUICIDE AND 1.2% ATTEMPTED.
Women 3x more likely to
attempt; men 4 x more likely to
complete
 WHO ATTEMPTS AND COMMITS SUICIDE

• Suicide attempts are most common in people between 18 and 25 years old
• Each year over 1,100 college students commit suicide
• Completed suicides are most common in the elderly (65 and older)
• Women are more likely to attempt suicide (3x more likely), but men are more
likely to complete suicide (4x as often)
• White males are highest. White males account for 7/10 suicides in 2014
 SUICIDE METHODS

• Firearms used in 50% of all suicides

• Suicide accounts for ~6/10 firearm deaths
Percent of
Suicides by
Method-
Other 2015
8%
Poisoning
15 %
Firearms
50 %
Suffocation
27 %
 RISK FACTORS FOR DANGEROUSNESS

• Stressful life events

• Access to lethal means (e.g. firearms and drugs)
• Odds ratios from 1.38-10.38x for firearm ownership in meta-analysis (Anglemyer, Horvath, Rutherford, 2014)
• Exposure to another person’s suicide
• media coverage of suicidal behaviours and actual suicidality are associated (Sisask & Varnik, 2012)
• Family history or own history of suicide/attempts
• Serious or chronic health condition
• Substance abuse
• Impulsivity
• Pessimism
Attempted before- more likely to attempt again
 COMORBIDITY

• 90% have a mental disorder at the time of suicide Not like psychotic disorder diagnosis
• Bipolar: 32-50% have lifetime history of suicide attempt
• Twice the risk of those with depression
• 15% of those with depression will die of suicide
• 10x the risk of the general population
• Higher risk of suicide if relative of individuals with bipolar
May be even more likely to
attempt when manic vs
depressed
SUICIDE BY AGE, GENDER, RACE
Older people- passive suicide- stop
doing what’s needed, including eating
 NOTES

• 67% of college students who have suicidal thoughts tell a friend first
• 2/3
• Only 15-25% of completed suicides leave notes
• Some notes include statement of love and concern
• Others include very hostile content
 Likes Olive View in Burbank for hospitalizations

WHEN TO ADMIT TO A HOSPITAL

51/50 call: involuntary hospitalization commitment
Can also be voluntary
• Admission generally indicated if: 3 day (72 hours) hold
• Patient is psychotic
• Specific plan with high lethality #1 goal: talk them down
• 8-10 on scale Refuse- do involuntary hospitalization

• High suicidal intent

PET team: psychiatric emergency
• Hospitalize even without a plan team- would call if you can’t get
• If you had means to do it, would you? client to go voluntarily; if client bolts-
call 911

25% of therapists will lose a client Or family member to come get them
to suicide if PET takes too long

Includes homicidal ideation- self to harm or others

SUICIDE PREVENTION AND INTERVENTION

Treatment of
person’s current
mental disorder(s)

Current preventive Crisis intervention

efforts

Working with
high-risk groups
 Agree not to hurt/kill self- sign it

SUICIDE CONTRACTS

• http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf
• Frequently used, but Empirical basis limited (Garvey, Penn, & Campbell, 2016)

• Suicide contracts have been found to be ineffective - do safety plans instead - these are the steps I will take
 EMPIRICALLY VALIDATED METHODS

• Restricting access to lethal means

• Some school-based awareness programs
• Lithium, valproate (bipolar) and clozapine (psychosis)
• Follow up of patients who attempt suicide
• Promising therapies
• CBT, Dialectical Behavior Therapy (DBT),
• Electroconvulsive therapy - not around here
 CRISIS INTERVENTION AND SUICIDE PREVENTION

• 1-800-273-TALK (8255)
• The Crisis Text Line: text BRAVE to 741741
• You can also connect with the Crisis Textline and National Suicide Prevention Lifeline over Facebook Messenger.
• http://www.suicidepreventionlifeline.org/
• My3 Suicide Prevention App
• Focus on
• Maintaining supportive and highly directive contact with person over short period of time
• Helping person realize that acute distress is impairing his or her ability to assess the situation accurately
• Helping the person see that the present distress and emotional turmoil will not be endless
 WHAT TO DO AS A FRIEND OR FAMILY MEMBER
• Communicate
• Ask directly if your friend is thinking about suicide.
• Be willing to listen. Allow their expressions of feelings, and accept those feelings. Be non-judgmental. Don't debate
whether suicide is right or wrong, or whether feelings are good or bad. Don't lecture on the value of life. Focus on
being present with their feelings.
• Check in with your friend regularly. Be available. Show interest/support. Schedule times to talk for the next week when
you will both be available, to see how they are doing.
• Don't act shocked. This will put distance between you.
• Don't be sworn to secrecy. Seek support.
• Offer hope that alternatives are available but do not offer glib reassurance.
• Take action.
• Remove means, such as guns or stockpiled pills
• Get help from agencies specializing in crisis intervention and suicide prevention.
• Encourage (and offer to accompany) your friend to seek help and support from a crisis specialist, therapist, doctor
and/or clergy member. o Show them the safety or “crisis coping plan” on the Lifeline web site, and talk together about
your friend can use this to help him/her to cope in these difficult moments.
 CONTROVERSY: RIGHT TO DIE?

• How to Die in Oregon

• Right to Die Debate CBS News- Dr. Kevorkian
• 60 minutes-Assisted Suicide
PERSISTENT DEPRESSIVE DISORDER

• Used to be dysthymia, now it’s PDD

• Ongoing level of depression, not as severe as major
• Symptomatology very similar to MDD
• Everything more mild; if suicidality, very fleeting thoughts
• Difference is severity/intensity and timeframe
• Have for more days than not - lingering
• Minimum timeframe of 2 years
• In teenagers/children: 1 year