Depressive Disorders Lecture Notes PDF

Don’t be sad. Complete your attendance quiz. 2/4/25 1  Depressive Disorders Behavioral Health PHA 535 Dr. Levy Spring 2025 2/4/25 2  Instructional Objectives Week...

Don’t be sad. Complete your attendance quiz. 2/4/25 1  Depressive Disorders Behavioral Health PHA 535 Dr. Levy Spring 2025 2/4/25 2  Instructional Objectives Week Unit or Instructional Objectives Module Week 4 Define depressive disorders and differentiate their subtypes. Lecture 7 &8 Week 4 Analyze the diagnostic criteria for major depressive disorder, Lecture 7 persistent depressive disorder, and premenstrual dysphoric &8 disorder. Week 4 Identify and evaluate risk factors, signs, and symptoms of suicidal Lecture 7 and homicidal behaviors. &8 Week 4 Develop and apply treatment and management strategies for Lecture 7 depressive disorders and crisis behaviors. &8 2/4/25 3 Essentials of Diagnosis In most depressions Mood varies from mild sadness to intense despondency and feelings of guilt, worthlessness, and hopelessness Difficulty in thinking, including inability to concentrate, ruminations, and lack of decisiveness Loss of interest, with diminished involvement in work and recreation Somatic complaints, such as disrupted, lessened, or excessive sleep; loss of energy; change in appetite; decreased sexual drive 2/4/25 4 Essentials of Diagnosis In some severe depressions Psychomotor retardation or agitation Delusions of a somatic or persecutory nature Withdrawal from activities Physical symptoms of major severity (eg, anorexia, insomnia, reduced sexual drive, weight loss, and various somatic complaints) Suicidal ideation 2/4/25 5 General Considerations about Depression Sadness and grief are normal responses to loss; depression is not Depression may be the final expression of Genetic factors Developmental problems (negative childhood events) Psychosocial stresses (divorce, unemployment) Persistent depressive disorder (dysthymia) is a chronic depressive disturbance with symptoms generally milder than in a major depressive episode 2/4/25 6 Demographics Up to 30% of primary care patients have depressive symptoms The COVID-19 pandemic has increased the risk of depression One meta-analysis of studies of community-based prevalence of depression found a seven-fold increase in depression in some heavily impacted communities in Europe and Asia US national surveys show a three-fold increase in the prevalence of depressive symptoms, with risk factors including lower income, < $5000 in savings, and exposure to stressors 2/4/25 7 Clinical Findings Symptoms and Signs There are four major types of depression, with similar symptoms in each group 1. Adjustment disorder with depressed mood 2. Depressive Disorders A. Major depressive disorder (this is where we are going to spend much of our discussion) B. Dysthymia 3. Mood disorders secondary to illness and medications 2/4/25 8  Adjustment disorder with depressed mood Depressed mood in reaction Adjustment disorder occurs Symptoms range from mild to identifiable stressor or within 3 months of the sadness, anxiety, irritability, adverse life situation (eg, stressor and causes worry, lack of concentration, death of a person [grief significant impairment in discouragement, and reaction], divorce, financial social or occupational somatic complaints to frank crisis loss) functioning depression 2/4/25 9  What are somatic complaints? Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness A person is not diagnosed with somatic symptom of breath, to a level that results in major distress disorder solely because a medical cause can’t be and/or problems functioning. The individual has identified for a physical symptom. The emphasis excessive thoughts, feelings and behaviors is on the extent to which the thoughts, feelings relating to the physical symptoms. The physical and behaviors related to the illness are excessive symptoms may or may not be associated with a or out of proportion. diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness). 2/4/25 10 Diagnosis of somatic symptoms A diagnosis of somatic symptom disorder requires the person experiencing One or more physical symptoms that are Ongoing thoughts that are out of proportion with the distressing or cause seriousness of symptoms disruption in daily life. Excessive thoughts, feelings or behaviors related to the Ongoing high level of anxiety physical symptoms or health about health or symptoms concerns with at least one of the following: At least one symptom is constantly present, although Excessive time and energy there may be different spent on the symptoms or symptoms and symptoms health concerns. may come and go. 2/4/25 11  Depressive Disorders Major depressive disorder (MDD) A syndrome of mood, physical and cognitive symptoms that occurs at any time of life Loss of interest and pleasure (anhedonia); withdrawal from activities Feelings of guilt and worthlessness; anxiety Poor concentration and cognitive dysfunction Chronic fatigue and somatic complaints Loss of sexual drive Thoughts of death 2/4/25 12  A.The DSM-5 criteria for MDD require 5 of the following 9 criteria (1 of which is depressed mood or anhedonia) for at least 2 weeks: A. Depressed mood most of the day, nearly every day B. Anhedonia with “marked diminished interest or pleasure in all or almost all activities” C. Significant appetite or weight change (> 5% DSM 5 Criteria for of body weight in 1 month not associated with dieting) MDD D. Sleep disturbance (insomnia or hypersomnia) E. Psychomotor agitation or retardation F. Fatigue G. Feelings of worthlessness or excessive or inappropriate guilt H. Impaired concentration I. Suicidal ideation 2/4/25 13  B. These criteria must be associated with significant distress or impaired functioning and not be secondary to substance abuse or another medical condition; in addition, there should be no prior history of mania (which would be diagnostic of a bipolar disorder). C. Minor depression requires 2–4 of the above symptoms, including anhedonia or depressed DSM 5 Criteria for mood for > 2 weeks. D. There are multiple validated screening tools MDD for depression, including the 2-item Patient Health Questionnaire (PHQ-2), the 9-item Patient Health Questionnaire (PHQ-9) and the Geriatric Depression Scale. E. Severity can be estimated using the Hamilton Rating Depression Scale (SEE PDF). Scores of ≤ 18 are classified as mild to moderate, 19–22 as severe, and ≥ 23 as very severe depression. 2/4/25 14  The sadness that accompanies major loss (grief), as in bereavement, may be difficult to distinguish from MDD and the 2 may coexist. Profound sadness, anorexia, insomnia, and weight loss may occur. Features that suggest grief (rather than MDD) include: A. The ability to have periods of Grief vs MDD happiness or pleasure in grief that is often absent in MDD. B. Sadness in grief is often episodic rather than pervasive and constant. C. In grief, the focus of sadness is typically on loss rather than self- loathing or worthlessness seen in MDD. 2/4/25 15  Patient Health Questionnaire PHQ-9 PHQ-2 2/4/25 16  Patient Health Questionnaire Scores PHQ-2 PHQ-9 2/4/25 17 Subcategories of MDD Psychotic major depression symptoms (delusions, paranoia) more common in depressed persons > 50 years old; paranoid symptoms may range from general suspiciousness to ideas of reference with delusions Major depression with atypical features is characterized by hypersomnia, overeating, lethargy, and mood reactivity where mood brightens in response to positive events or news Melancholic major depression is characterized by a lack of mood reactivity seen in atypical depression, the presence of a prominent anhedonia, and more severe vegetative symptoms Major depression with a seasonal onset (seasonal affective disorder) occurs more commonly in the fall and winter months; believed due to decreased exposure to full-spectrum light; common symptoms include carbohydrate craving, lethargy, hyperphagia, and hypersomnia Major depression with peripartum onset occurs during pregnancy or starts up to 4 weeks after delivery 2/4/25 18  Depressive Disorders Dysthymia Sadness, loss of Symptoms are interest, and generally milder but Chronic depressive withdrawal from longer-lasting than disturbance activities over two or those in a major more years depressive episode 2/4/25 19  Depressive Disorders Depressive Premenstrual symptoms occur dysphoric during the late luteal disorder phase (last 2 weeks) of the menstrual cycle 2/4/25 20 Depressive Disorders 2/4/25 Bipolar Disorder We have an entire lecture dedicated to this specific disorder. 21 Depressive Disorders Mood Disorders Secondary to Illness and Medications Any illness can cause significant depression Drug-induced depression Corticosteroids commonly associated with depression and hypomania or psychosis Older antihypertensive medications (eg, reserpine, methyldopa, guanethidine, and clonidine have been associated with depressive syndromes) Many other medications have been associated with depressive symptoms, including digitalis, antiparkinsonian medications, retinoids, interferon, disulfiram, and anticholinesterase medications Withdrawal of stimulants can result in depressive syndrome Alcohol, sedatives, and opioids 2/4/25 22  Mood disorders Bipolar disorder or cyclothymia Adjustment disorder with Differential Depression may be a part of any illness, either reactively or as a secondary symptom depressed mood Psychotic major depression Diagnosis Schizophrenia Major depression with atypical features Partial complex seizures Melancholic major depression Organic brain syndromes Persistent depressive disorder Panic disorders (dysthymia) Anxiety disorders Premenstrual dysphoric disorder Major depression with Thyroid dysfunction and other peripartum onset: occurs during endocrinopathies pregnancy or starts up to 4 Malignancies weeks after delivery Strokes, particularly dominant Drug-induced depression hemisphere lesions Seasonal affective disorder Carbohydrate craving, lethargy, hyperphagia, hypersomnia 23  Depression Assessment 2/4/25 25  Anhedonia Anhedonia is the inability to feel What are the signs of anhedonia? enjoyment or pleasure. People Signs of anhedonia may include: struggling with anhedonia aren’t motivated to seek out enjoyable Lack of joy and/or emotion activities like seeing friends or Lack of energy to socialize going for a walk, and they don’t Boredom enjoy them if they do. Anhedonia is a symptom of depressive Apathy disorders as well as some other Seclusion mental health conditions, such Insomnia as bipolar disorder and PTSD. 2/4/25 26 PHYSICAL EXAMINATION 2/4/25 27  Sample new patient Patient Name: John Doe DOB: 06/15/1985 Date of Visit: 02/03/2025 Chief Complaint: "I've been feeling down and unmotivated for the past few months." S: Subjective History of Present Illness: John Doe is a 39-year-old male presenting with complaints of persistent low mood, fatigue, and lack of motivation for the past four months. He reports difficulty concentrating at work and decreased interest in previously enjoyable activities, including socializing and exercising. He denies any known triggers but states that stress from work has been overwhelming. He has had difficulty falling asleep and wakes up feeling unrested. He reports a loss of appetite with a 5-pound weight loss over the past two months. He describes feelings of worthlessness and occasional thoughts that life is not worth living but denies any active suicidal ideation, intent, or plan. No prior history of depression or mental health treatment. No known history of manic or hypomanic episodes. No history of psychotic symptoms. 2/4/25 28  Sample new patient Social History: Occupation: Financial analyst, reports increased work stress Living situation: Lives alone, divorced one year ago Support system: Limited social support, estranged from family Alcohol/Drug use: Drinks 1-2 beers on weekends, denies illicit drug use Exercise: Previously ran 3x/week, now no exercise No prior psychiatric hospitalizations or therapy Past Medical History: Hypertension (well-controlled) No prior psychiatric history Medications: Lisinopril 10 mg daily Allergies: NKDA 2/4/25 29  Sample new patient Family History: Father: Hypertension, deceased from MI at 65 Mother: Depression, history of suicide attempt No known bipolar disorder or schizophrenia in family Review of Systems: General: Fatigue, unintentional weight loss HEENT: No changes in vision, recurrent headaches, nasal or throat issues Cardiovascular: No murmurs, palpitations, chest pain Pulmonary: No cough, SOB, wheezing GI: Decreased appetite, no nausea or vomiting Endocrine: No hot or cold intolerance. No excessive thirst, hunger or urine output. Psychiatric: Depressed mood, anhedonia, insomnia, difficulty concentrating, feelings of worthlessness, passive thoughts of death but denies intent or plan Neurologic: No headaches, dizziness, or memory impairment 2/4/25 30  Sample new patient O: Objective Vitals: BP: 122/78 mmHg; HR: 72 bpm; RR: 16 breaths/min; Temp: 98.2°F; SpO2: 98% on room air; BMI: 24.5 Physical Exam: General: Well-groomed, appears tired but cooperative Neck: No signs of thyroid enlargement Cardiovascular: Regular rate and rhythm, no murmurs Respiratory: Clear to auscultation bilaterally Abdomen: Positive BS throughout. Nontender, no masses. Neurological: Alert and oriented x3, no focal deficits Psychiatric: Mood: Depressed Affect: Restricted Thought process: Logical, goal-directed Thought content: No delusions or hallucinations, denies active suicidal or homicidal ideation Insight/Judgment: Fair 2/4/25 31 2/4/25 32  Types of Affects 2/4/25 33  Sample new patient A: Assessment 39-year-old male with symptoms consistent with major depressive disorder (MDD), moderate severity. Symptoms meet DSM-5 criteria for MDD, including depressed mood, anhedonia, sleep disturbances, fatigue, difficulty concentrating, feelings of worthlessness, and passive thoughts of death lasting for more than two weeks. No manic or psychotic symptoms. No current safety concerns. Differential Diagnoses: 1.Major Depressive Disorder (MDD) – most likely given symptom duration and severity 2.Persistent Depressive Disorder (Dysthymia) – less likely as symptoms are more episodic 3.Adjustment Disorder with Depressed Mood – could be contributing, given recent stressors 4.Hypothyroidism – to be ruled out with TSH 5.Vitamin B12 Deficiency – possible given fatigue and concentration issues 2/4/25 34  Sample new patient P: Plan 1.Pharmacologic: 1. Start Sertraline 25 mg PO daily, increase to 50 mg after one week if tolerated 2. Discussed potential side effects (GI upset, sexual dysfunction, activation) 2.Non-Pharmacologic: 1. Referral for cognitive-behavioral therapy (CBT) 2. Encourage daily exercise, even in small increments 3. Sleep hygiene counseling 4. Recommend journaling or mindfulness techniques 3.Lab Work-Up: 1. TSH, Free T4 (to rule out thyroid dysfunction) 2. CBC, CMP, Vitamin B12 (to rule out metabolic causes) 4.Safety Planning: 1. No acute safety concerns; patient denies suicidal intent 2. Provided crisis hotline information and advised to call if symptoms worsen 5.Follow-Up: 1. Follow-up in 2 weeks to assess medication tolerance and symptom improvement 2. Immediate return if worsening depressive symptoms, suicidal thoughts, or medication side effects 2/4/25 35  Sample established patient Patient Name: Jane Doe DOB: 03/15/1987 Date of Visit: 02/03/2025 S – Subjective Chief Complaint: "I’ve been feeling really down and unmotivated for the past few weeks." HPI: Jane Doe is a 37-year-old female with a history of major depressive disorder (MDD) presenting for follow-up regarding worsening depressive symptoms over the past month. She reports persistent low mood, anhedonia, low energy, difficulty concentrating, and insomnia (difficulty falling and staying asleep). Appetite is decreased, with an unintentional weight loss of 5 lbs over the past month. She notes increased stress at work but denies recent major life changes. No recent medication changes. She denies suicidal ideation, homicidal ideation, or self-harm thoughts. Psychiatric History: Diagnosed with MDD at age 25 Previous hospitalizations: None Past medications: Previously on fluoxetine, discontinued due to side effects Current medication: Sertraline 50 mg daily, started 6 months ago ROS (Review of Systems): General: No fever, chills, or night sweats. Reports fatigue and unintentional weight loss (5 lbs). HEENT: No headaches, vision changes, or sore throat. No sinus congestion. Cardiovascular: No chest pain, palpitations, or edema. Respiratory: No cough, dyspnea, or wheezing. Gastrointestinal: Appetite decreased, no nausea, vomiting, diarrhea, or constipation. Genitourinary: No dysuria, hematuria, or changes in urinary frequency. Musculoskeletal: No joint pain or swelling. Reports mild muscle tension in shoulders. Neurologic: No dizziness, syncope, numbness, or weakness. No tremors. Endocrine: No heat/cold intolerance, no polyuria or polydipsia. Psychiatric: Reports low mood, anhedonia, fatigue, insomnia, decreased concentration. Denies suicidal ideation, hallucinations, or paranoia. 2/4/25 36  Sample established patient O – Objective Vitals: BP: 118/76 mmHg; HR: 72 bpm; Temp: 98.1°F; RR: 16/min; SpO₂: 98% Physical Exam: General: Well-nourished, appropriately dressed, cooperative but appears fatigued. HEENT: No conjunctival pallor. No oropharyngeal abnormalities. No lymphadenopathy. Neck: No thyromegaly or masses. No cervical lymphadenopathy. Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. No peripheral edema. Respiratory: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi. Gastrointestinal: Soft, non-tender, non-distended. No hepatosplenomegaly. Normal bowel sounds. Musculoskeletal: No joint swelling or deformities. Normal range of motion. Neurologic: Alert and oriented x3. No focal deficits. Reflexes 2+ bilaterally. No tremors. Psychiatric: o Mood: Depressed o Affect: Restricted o Speech: Normal rate and tone o Thought process: Logical, goal-directed o Insight/Judgment: Intact o Suicidal/Homicidal Ideation: Denied o Hallucinations/Delusions: None 2/4/25 37  Sample established patient A – Assessment Major Depressive Disorder (F32.1 – Moderate MDD, without psychotic features) Persistent depressive symptoms despite current medication Insomnia and poor appetite noted No immediate safety concerns 2/4/25 38  Sample established patient P – Plan 1. Medication Adjustment: Increase sertraline to 75 mg daily, reassess in 2 weeks for efficacy/tolerability. 2. Sleep Hygiene Counseling: o Establish a regular sleep schedule o Limit screen time before bed o Consider melatonin 3 mg PRN if needed 3. Therapy Referral: Recommend cognitive-behavioral therapy (CBT), referral placed. 4. Labs Ordered (to rule out organic causes of fatigue/mood changes): o TSH, Free T4 (rule out hypothyroidism) o CBC (rule out anemia) o CMP (check for metabolic imbalances) o Vitamin D, B12 (evaluate for deficiencies) 5. Follow-up: o Schedule follow-up in 2-4 weeks to reassess symptoms and medication response o Instruct patient to call if symptoms worsen, especially suicidal thoughts 6. Emergency Plan: o Provided crisis hotline information o Instructed to go to ER if suicidal thoughts develop 2/4/25 39 Mini-Mental State Examination (MMSE)  Diagnosis Laboratory Tests Complete blood count Serum thyroid-stimulating hormone Toxicology screen may be indicated Metabolic Panel emp · Comprehensive 2/4/25 41  Treatment Medications Milder forms of depression Usually do not require medication therapy Can be managed by psychotherapy and the passage of time Antidepressant medication is often effective for severe depression 2/4/25 42  Treatment Psychotic depression Treat with a combination of an antipsychotic and an antidepressant (eg, selective serotonin reuptake inhibitors (SSRIs) at usual doses) Mifepristone may have enhanced activity against psychotic depression Major depression with atypical features or seasonal onset Treat with bupropion or an SSRI Monoamine oxidase inhibitors (MAOIs) may be used if more benign antidepressant strategies prove unsuccessful Melancholic depression May respond to electroconvulsive therapy (ECT), tricyclic antidepressants (TCAs), and serotonin–norepinephrine reuptake inhibitors (SNRIs), which are preferable to SSRIs (but are still effective in many cases) 2/4/25 43  Treatment Selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and atypical antidepressants SSRIs generally well tolerated SNRIs may also be beneficial in pain conditions (eg, neuropathy and fibromyalgia and stress incontinence) Most are activating and should be given in the morning; some patients may experience sedation with paroxetine, fluvoxamine, and mirtazapine requiring that the medication be given at bedtime Clinical response varies from 2 to 6 weeks Side effects Common side effects are headache, nausea, tinnitus, insomnia, nervousness Abnormal bleeding; sertraline and citalopram appear to be the safest agents in this class when used with warfarin Sexual side effects (eg, erectile dysfunction) are very common and may respond to sildenafil, tadalafil, or vardenafil; adjunctive bupropion (75–150 mg orally daily) may enhance sexual arousal "Serotonin syndrome" may occur when SSRIs are taken in conjunction with monoamine oxidase inhibitors or selegiline 2/4/25 44 Treatment SSRI continue With the exception of paroxetine, SSRIs should be tapered over weeks to months to avoid a withdrawal syndrome Most studies show that SSRIs are not associated with birth defects; paroxetine, however, should be avoided during pregnancy; use of SSRIs should be weighed against the risks of an untreated depression in the mother 2/4/25 45 Treatment Mainstay of treatment Side effects (principally anticholinergic) before SSRIs Tricyclic Amitriptyline 100 mg is Plasma drug levels may equivalent to atropine 5 mg antidepressants be helpful when clinical Use cautiously in older men (TCAs) response is disappointing with prostatic hyperplasia Constipation, confusion, heat Most common cause of stroke, orthostatic treatment failure is an hypotension, xerostomia inadequate trial; a full trial Class I antiarrhythmic consists of a therapeutic effects; altered rate, rhythm, daily dosage for at least 6 and contractility, particularly in patients with preexisting weeks cardiac disease, such as bundle-branch or bifascicular block Lower seizure threshold Overdose can be serious 46  Commonly cause orthostatic hypotension and sympathomimetic effects of tachycardia, sweating, and tremor Treatment Third-line agents due to dietary restrictions and drug–drug Monoamine interactions oxidase inhibitors Potential for withdrawal syndromes requires gradual tapering of antidepressants (MAOIs) Drug selection should be influenced by any history of prior responses 2/4/25 47 Overview of treatment for depression. (Reproduced from Agency for Health Care Policy and Research: Depression in Primary Care. Vol. 2: Treatment of Major Depression. United States Department of Health and Human Services, 1993.) Citation: Depression, Papadakis MA, McPhee SJ. Quick Medical Diagnosis & Treatment 2024; 2024. Available at: https://accessmedicine.mhmedical.com/content.aspx?sectionid=282395461&bookid=3388&Resultclick=2 Accessed: February 03, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved  Therapeutic Procedures Electroconvulsive therapy (ECT) Most effective (45–85%) treatment for severe depression; most effective treatment for psychotic depression, with remission rates between 60% and 90% When medical conditions preclude the use of antidepressants, with nonresponsiveness to these medications, and for extreme suicidality Remission rates in treatment-resistant depression are lower (around 48%) Most common side effects are headache and memory disturbances, which are usually short-lived Serious complications occur in less than 1 in 1000 cases 2/4/25 49  Therapeutic Procedures Phototherapy Used in major depression with seasonal onset Indirect eye exposure to a light source > 2500 lux for 2 hours daily or >10,000 lux for 20 minutes daily 2/4/25 50 Therapeutics Procedures Repetitive transcranial magnetic stimulation (rTMS) Delivers electromagnetic pulses to the prefrontal cortex Approved by the FDA for individuals who have not tolerated or responded to at least one or more standard antidepressant medications Traditionally delivered in a course of 30 sessions over 6 weeks While not as effective as ECT, rTMS neither requires general anesthesia nor produces cognitive side effects A rapid acting form of rTMS is delivered over 5 days, termed “SAINT” (Stanford Accelerated Intelligent Neuromodulation Therapy) 2/4/25 51  Therapeutics Procedures Vagus nerve stimulation Psychological Has shown promise in about one-third Medication and psychotherapy are of extremely refractory cases more effective than either modality FDA approved alone Effects plateau around 18 months to Psychotherapy is seldom possible in 2 years and are durable at 5 years the acute phase of severe depression Cognitive behavioral therapy can prevent relapse and the need for long- term medication when tapering off medication Mindfulness-based cognitive therapy is as effective as maintenance medication in preventing relapse 2/4/25 52  Therapeutic procedures Social Behavioral In depressions Desensitization may be used in involving alcohol abuse, early problems such as phobias involvement in recovery where depression is a by- programs is important to product therapeutic success Motivating depressed patients Family, employers, and friends to engage in pleasurable can help mobilize the patient activities is useful who experiences no joy in daily Exercise improves depressive activities and tends to remain symptoms uninvolved and to deteriorate 2/4/25 53  Outcomes Follow-Up Complications-Suicide Medication trials should be monitored Women make more suicide attempts than every 1–2 weeks until 6 weeks, when men, but men > 50 years are more likely to the effectiveness of the medication complete suicide can be assessed The suicide rate in the younger population, If successful, medications should be aged 15–35, is rising continued for 6–12 months before Patients with cancer, respiratory illnesses, tapering is considered AIDS, and hemodialysis have higher suicide Medications should be continued rates indefinitely in patients with their first Alcohol use is a significant factor in many episode before age 20, more than two episodes after age 40, or a single suicide attempts episode after age 50 Adults with untreated depression are at higher Tapering of medications should occur risk for suicide than those who are treated gradually over several months sufficiently to reduce symptoms Suicide rates are higher in patients with previous suicide attempts, a family history of suicide, psychiatric illness (eg, panic disorder, anxiety, severe depression), and severe 2/4/25 medical illness 54  Outcomes Prevention Prognosis Patients at risk for suicide should receive medications in small quantities Patients frequently respond well to a Although TCAs and SSRIs are associated full trial of drug treatment with an increased incidence of suicide However, at least 20% of attempts, the risk of a completed suicide is much higher with TCA overdose patients will have a more A useful question to assess for suicide chronic illness lasting > 2 years risk is to ask the person how many hours At least 80% of patients who per day he or she thinks about suicide; if it is > 1 hour, the individual is at high risk have a single major depressive Suicide risk can be assessed using an episode will have one or more instrument such as the Columbia-Suicide recurrences within 15 years of Severity Risk Scale the index episode (https://cssrs.columbia.edu/wp- content/uploads/C-SSRS_Pediatric- SLC_11.14.16.pdf) Guns and drugs should be removed from the patient's house High-risk patients should be asked not to drive The National Suicide Prevention Lifeline, 1- 800-273-8255, may be of assistance 2/4/25 55  Outcomes When to Refer When to Admit When depression is refractory Patients at risk for suicide to antidepressant therapy Complex treatment When depression is moderate modalities are required to severe When suicidality or significant loss of function is present With active psychosis or history of mania 2/4/25 56 2/4/25 57 Thank you for your attention. Any questions?