ITEMS IN AFP WITH MESH TERM:
Approaching the Suicidal Patient - Article
ABSTRACT: The suicide of a patient can be devastating to the family and to the family physician. The patient's death may shake the physician's confidence, undermine any willingness to work with patients with a mental illness, and provoke professional and legal review. In an attempt to help the family physician prevent suicide, this article reviews known risk factors and offers a strategy for assessing these factors in individual patients. The authors outline interventions that fit the existing level of risk and provide suggestions for the physician in the event of a completed suicide.
Childhood and Adolescent Depression - Article
ABSTRACT: Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies.
A Potentially Suicidal Patient - Curbside Consultation
Screening for Suicide Risk - Putting Prevention into Practice
ABSTRACT: Obsessive-compulsive disorder is an illness that can cause marked distress and disability. It often goes unrecognized and is undertreated. Primary care physicians should be familiar with the various ways obsessive-compulsive disorder can present and should be able to recognize clues to the presence of obsessions or compulsions. Proper diagnosis and education about the nature of the disorder are important first steps in recovery. Treatment is rarely curative, but patients can have significant improvement in symptoms. Recommended first-line therapy is cognitive behavior therapy with exposure and response prevention or a selective serotonin reuptake inhibitor. The medication doses required for treatment of obsessive-compulsive disorder are often higher than those for other indications, and the length of time to response is typically longer. There are a variety of options for treatment-resistant obsessive-compulsive disorder, including augmentation of a selective serotonin reuptake inhibitor with an atypical antipsychotic. Obsessive-compulsive disorder is a chronic condition with a high rate of relapse. Discontinuation of treatment should be undertaken with caution. Patients should be closely monitored for comorbid depression and suicidal ideation.
Care of the Returning Veteran - Article
ABSTRACT: Of the 23.8 million military veterans living in the United States, approximately 3 million have served in Operation Enduring Freedom or Operation Iraqi Freedom. The injuries and illnesses that affect veterans returning from combat are predictable. Blast injuries are common and most often present as mild traumatic brain injury, which is synonymous with concussion. Family physicians caring for returning veterans will also encounter conditions such as posttraumatic stress disorder at rates higher than those in the general population. The symptoms associated with posttraumatic stress disorder and mild traumatic brain injury often overlap and can present concurrently. Treatment of traumatic brain injury should be based on symptoms and guided by clinical practice guidelines from the U.S. Department of Veterans Affairs and Department of Defense. Family physicians should understand the range of post-war health concerns and screen returning service members for posttraumatic stress disorder, substance abuse, suicidality, and clinical depression. Family physicians are well positioned to offer continuity of care for issues affecting returning service members and to coordinate the delivery of specialized care when needed. (Am Fam Physician. 2010;82(1):43-49. Copyright © 2010 American Academy of Family Physicians.)
ABSTRACT: Suicidal ideation is more common than completed suicide. Most persons who commit suicide have a psychiatric disorder at the time of death. Because many patients with psychiatric disorders are seen by family physicians and other primary care practitioners rather than by psychiatrists, it is important that these practitioners recognize the signs and symptoms of the psychiatric disorders (particularly alcohol abuse and major depression) that are associated with suicide. Although most patients with suicidal ideation do not ultimately commit suicide, the extent of suicidal ideation must be determined, including the presence of a suicide plan and the patient's means to commit suicide.
Self-Injurious Behavior in an Adolescent - Curbside Consultation
ABSTRACT: The diagnosis of depression in older patients is often complicated by comorbid conditions, such as cerebrovascular disease or dementia. Tools specific for this age group, such as the Geriatric Depression Scale or the Cornell Scale for Depression in Dementia, may assist in making the diagnosis. Treatment decisions should consider risks associated with medications, such as serotonin syndrome, hyponatremia, falls, fractures, and gastrointestinal bleeding. Older white men with depression are at high risk of suicide. Depression is common after stroke or myocardial infarction, and response to antidepressant treatment has been linked to vascular outcomes. Depression care management is an important adjunct to the use of antidepressant medications. Structured psychotherapy and exercise programs are useful treatments for select patients.