Depression & Suicide Prevention

1. Depression & Suicide Prevention Dr Kirthi Kumar Psychiatrist Mercy Mental Health Program Wyndham Private Clinic South West Specialist Centre Harvester Private Consulting

2. Content Significance Overview of depression Depression in men Management Extent of suicide Risk factors Management Prevention

3. Significance of depression Misconceptions Under recognised Medical profession have a duty to identify depression One of the leading causes of disability worldwide Prevalence rates – anxiety (9.7%), affective disorders (5.8%), D & A (7.7%)

4. Significance Most episodes are managed by GPs 85% of antidepressant prescriptions are by GPs 4th most commonly managed problem in general practice (McManus MJA 2000) 2nd highest contributor of global disease by 2020 (Harvard University Press 1996)

5. What is depression Major depression Bipolar depression Dysthymia Adjustment disorder PTSD Substance use disorders Personality disorders Organic depression Post psychotic depression

6. Depression Vs Unhappiness

7. Case 1 43 y o, male working as an admin officer presents sadness, amotivation to work, apprehension, frustration, helplessness, impaired sleep of 3months duration in the context of apparent work place harassment and bullying by management for the last 5months. Gives a history office adapting new technology about 5months ago which he could not cope as he was computer illiterate due to dyslexia. He has not been able to cope with performance review. Manager has told given him 2months time to ‘pull up his socks’ Patient has been feeling the threat of job loss.He has no past, family history. No major adverse personal or childhood events. On mental status examination, comes across as with depressed mood, non reactive affect with reduced range, preoccupied with state of affairs, apprehensive. Expresses helplessness. Not suicidal. No psychotic or cognitive features. He is insightful. Diagnosis: Adjustment disorder with depressive and anxiety symptoms

8. Case 2 45 y o single mother of two kids. Separated 8 years ago. Works part time in a supermarket. Presents with a 4 year history of sadness of mood, reduced motivation, does not enjoy much, fatigue, minimal socialisation, eats well, lack of sound sleep. No death wishes or suicidality. No psychotic symptoms. Has been on antidepressants for 3 years. Has not improved much nor has deteriorated. Functionally, drops kids off to school and attends work till 3 pm. Cooks for kids and self. Cleans the house once a week. Drives adequately. No drug and alcohol history. MSE, stated age; well attired, talks slowly. No PMA ↓, depressed mood but laughs at times. No psychotic or cognitive pathology. Insightful Diagnosis: Dysthymia

9. Case 3 30 y o mother of 1 (2 y o), married house wife. Reports 3 months of low mood, reduced interest, lack of pleasure, fatigue, increased effort, minimal appetite, loss of weight (5 kgs), poor quality of sleep, frequent disagreement with husband. Has been neglecting household chores, has occasionally thought of suicide but no plans or intent. Past history of PND, sister and mother have depression on treatment. Unable to identify overt reasons but wonders if her husband is not caring and son is demanding. MSE: looks tired, walks slowly, low tone of speech, worthless, fleeting suicidal thoughts, depressed mood, passively smiles at times, fearful of what people think around her. No psychotic or cognitive pathology. Some social judgement impairment. Insightful. Diagnosis: Major depression Recurrent depressive disorder

10. Treatment of depression Medications alone Psychotherapy alone Combined medications and psychotherapy ECT

11. Course of depression Average episode ► 9 months Most episodes remit in 2 years No prophylaxis ► 50% have another episode RDD with >3 episodes ► 70-80% will have another episode within 3 years Increasing number of episode ► ↑ risk of suicide, chronicity and disability

12. When to refer Severe symptoms Depression and physical comorbidity Depression and personality challenges Non response to treatment Suicidality Psychotic depression Bipolar depression Inability to treat Patient requests Legislative requirement.

13. Depression in Men Good at hiding Higher rate of under recognition Higher rate of physical symptoms → fatigue, pain, loss of weight Irritability Higher preexisting D & A issues, antisocial behaviour Better coping strategies such physical activities, instruments

14. Suicide Variable attitude towards suicide Way to end the suffering Suicidal thoughts = underlying pathology Planned or impulsive ‘Chronic suicide’

15. 2nd leading cause of death < 30 y o after MVA. Highest in Eastern European countries (0.027%) Lowest in Latin American and Muslim countries (0.0065%) Australia ranked 13th (WHO 1996) ♂ = 23.7/100,000 ♀ = 3.7/100,000

16. Global suicidal behaviour

17. Causes of Suicide, WHO 1997 (in %)

18. Risk factors - static Past suicide/DSH attempts Psychiatric diagnosis Substance abuse Family history – suicide/self harm Male Younger group (16-25) Older age > 75 Victim of child abuse Victim of violence as adult

19. Suicide risk factors – static (2) Major physical illness Social isolation Multiple psychiatric conditions Significant anniversary

20. Suicide risk factors - dynamic Current intent or plan (self harm/suicide) Hopelessness Active symptoms Expressing distress Lack of impulse control Low frustration tolerance Active D & A use Recent stress

21. Suicide risk factors – dynamic (2) Recent psychiatric admission Recent loss of relationship (separation, divorce, death) Retirement Access to method Poor adherence to treatment Lack of treatment response Insomnia Hostility Concerned family/carers

22. Risk factors • Sex: ♂ complete more than ♀ (about 4:1) • Age: Highest for 15-24 y o, > 60 y o • Depression • Past Attempt • Ethanol & Drug abuse • Rational thinking is impaired • Support networks (limited) • Organised plan • No Spouse • Sickness • Experiences of adversity • Sexual abuse • Co morbidity • Anxiety disorder • Personality disorders • Event: stressful

23. Risk factors - occupational Higher the social state, higher the risk (??) Physicians, especially ♂ Among physicians psychiatrists, ophthalmologists, Anesthetists Musicians, dentists, law enforcements officers, lawyers & Insurance agents Unemployment

24. Protective factors Positive self esteem Adequate problem solving Spirituality Supports Children Adequate self control Pregnancy Sense of responsibility (towards family/pets)

25. Level of risk No risk factors = absent Static + protection = low Static = some risk - moderate Static + dynamic = moderate to high

26. Risk prevention Must be offered to every patient A routine practice Share the knowledge, improve the knowledge 2nd opinion when in doubt Combined approach – clinician + patient + carer

27. Suicide management – low risk Routine clinical care Crisis management plan in place Triage contact details provided Ascertain patient’s ability to understand crisis plan; involve others if needed

28. Suicide risk management - moderate Treat (initiate/optimise) mental disorder Alert triage if necessary Refer to mental health follow up Check if someone can stay with patient Crisis management plan discussed Review again within a week

29. Suicide management - high As per management of moderate risk + Contact triage for further input Admission if needed Involve the carers Notify other clinicians (psychologist/nurse/social worker) +

30. Suicide prevention General public - helps to identify risk - encourages help seeking - reduces stigma General practitioners - most suicidal patients contact GP within a month prior to death - if unrecognised, untreated the risk worsens - opportunity to make a difference Gate keepers (eg, PCA, school cousellors, priests) - increase awareness - gate keepers are 1st point of contact to many - lesser level of stigma; more attached to gate keepers

31. Prevention (2) Screen for mental illness, D & A use, suicidal behaviour Include youth, juvenile offenders, high school students Use screening instruments Treat underlying conditions - a health care plan - medications - psychotherapy (CBT, DBT, problem solving, IPT) - family therapy - post suicide attempt follow up

32. Prevention programs Multimodal approach Must be repetitive to be effective Must be part of orientation in health care Must include information on - improving help seeking behaviour - access to care - reducing stigma