martes, 17 de mayo de 2011

CHAPTER 3. THE DEPRESSED AND SUICIDAL PATIENT


Depression develops in fifteen to twenty-five percent of the adult population at some time in life, so you can see that depression is one of the most common illnesses a physician encounters. Unfortunately, many primary care physicians overlook this problem allowing it to remain untreated. The purpose of this chapter is to alert the general physician to the significance and clinical spectrum of depressive illness. Suicide is a frequent concomitant ofdepression, so we'll be discussing it, too.

Theories about the etiology of depression began with the "black bile" theory of the ancient Greeks which stated that too much bile causes changes in affect. Today's leading theories are somewhat more sophisticated versions of the ancient one. Theories that certain neurotransmitters, particularly norepinephrine and serotonin, are relatively depleted or inactivated in certain areas of the brain in patients with severe depression may seem bilious. However, they offer great promise in understanding the etiology of this illness. Depressed patients often have low levels of metabolites of serotonin and norepinephrine. Also, the fact that depressed patients occasionally have altered dexamethasone suppressing capability (a dose of dexamethasone does not inhibit cortisol secretion the way it normally does), suggests that endocrine factors may playa role in depression.
Attempts at classifying the clinical syndromes or types of depression have met with variable success. Certain dichotomies have been used to describe the ends of the depressive spectrum. For instance, in psychotic (as opposed to neurotic) depression, there is a loss of reality testing. Exogenous depression occurs in response to an identifiable stress, whereas the cause is not apparent in endogenous depression. Depression may be primary or secondary (some people, for example, get depressed secondary to another illness). Unipolar depression is depression alone, whereas bipolar depression is depression alternating with mania. Depression may be major or minor. We think that it is most useful clinically to consider depression as occurring along a continuum of mild to severe.
Severe depression may occur anytime in the lifespan and is more common in women than in men. It is termed Major Depression in DSM IV if symptoms are present most of the time, every day for 2 or more weeks.
Let us use the mnemonic, JOIMAT, from the previous chapter and run through a mental status examination in a severely depressed patient.
J: Judgment may be impaired, particularly with respect to a patient's view that his situation is hopeless.
0: Orientation is usually normal, but in a severely depressed patient, time orientation may be abnormal.
I: Intellectual functioning may seem impaired, because attention and concentration are also impaired. Recall that intellectual functioning is also impaired in dementia. It is important to include dementia in the differential diagnosis of depression.
M: Memory may appear impaired in depression because depressives have trouble concentrating.
A: Affect is, of course, depressed, and often there is a history of crying spells. Extremely depressed patients may have slowed movements and almost blank expressions. This is usually called psychomotor retardation, but if severe enough might be called catatonia!
T: Thought content may include ideas of hopelessness or helplessness. Suicidal ideation mayor may not be present. Delusional thinking, such as paranoia or believing that the patient's internal organs are rotting, may occur. Behavioral symptoms, also referred to as vegetative signs of depression, are critical to the diagnosis. These include a history of weight loss and decreased appetite, and disturbed sleeping (either difficulty remaining asleep or early morning awakening). Classically, the severely depressed patient awakens at 2-4 a.m. and is unable to return to sleep. Depression and anxiety are often most intense in these early morning hours. The intern gets up at 2 a.m., because his beeper goes off. He has trouble returning to sleep, because he's angry, not because he's depressed. Other behavioral symptoms include decreased sexual interest and slowed motor movements. Constipation is a classic physiological or behavioral symptom of depression.
When the diagnosis is unclear, a personal history of recurrent depression or a family history of depression or manic-depressive illness can help corroborate the diagnosis. Alcoholism in the patient or his relatives can also support the diagnosis. These are risk factors for depressive illness.
It's worth repeating that making this diagnosis is important, because depression is debilitating. Untreated depression usually lasts up to one year. As many as fifteen percent of patients with severe depression may ultimately commit suicide. Despite this, depression is an illness that responds well to appropriate treatment. Ninety to ninety-five percent of depressed patients respond to either antidepressants or electroconvulsive treatments and show a significant remission of symptoms.
At the other end of the spectrum are the mild cases of depression. In mild depressions, jUdgment, orientation, intellectual functions, and memory are rarely impaired. Thought content may include ideas of self-depreciation or guilt (as in more severe depression), but extreme hopelessness or helplessness and psychotic thinking are not present. Vegetative signs also contrast with severe depression in that weight loss is unusual; weight gain is actually more common. Sleep disturbances occur at sleep onset, and psychomotor retardation is not present. Mild depression is more common in the afternoon and evening hours as opposed to the early morning hours. Constipation is unusual, but diarrhea occasionally occurs. Sexual interest is usually impaired in mild depression, too. Treatment with antidepressants is probably as effective as in severe depressions and patients more often request medications, since the newer drugs have fewer troubling side effects. Psychotherapy is often an appropriate treatment, whether the illness is mild or severe. Dysthymia is the official term for mild to moderate depression which is intermittent over 2 years or more. Dysthymia also responds to antidepressants.
Patients often come to psychiatrists with the simple complaint of "depression." Other frequent presenting symptoms include fatigue, crying spells, difficulty sleeping, and lack ofinterest in one's usual pursuits. These are the vegetative signs of depression. Unfortunately, depressed patients sometimes present symptoms in confusing ways. For example, depressed children might arrive at your office with a complaint of hyperactivity or antisocial behavior. Elderly depressed patients might complain of memory impairment. Somatic complaints (lower back pain) can herald a depressive decompensation.
A number of medical illnesses figure in the differential diagnosis of depression. Among these, hypothyroidism is very common. All patients being evaluated for depression should be asked about other symptoms of hypothyroidism (cold intolerance, hair loss, weight gain).
Cancer of the pancreas frequently causes depression. The reason for this is unknown. Both Addison's disease and Cushing's syndrome can cause depressive features. Certain drugs cause depression (reserpine, alphamethyldopa, propranolol); even viral illness can cause patients to become depressed.
The psychiatric differential diagnosis is equally important.
  1. Schizophrenics feel depressed sometimes, especially several weeks to several months after their first decompensation. However, they also suffer from hallucinations, bizarre delusions, and loose associations.
  2. Demented patients experience memory impairment and disorientation. Severely depressed patients can appear demented. This syndrome is called pseudodementia. Occasionally, dementia has to be diagnosed after a trial of antidepressant therapy has failed.
  3. Bipolar patients may be floridly depressed, but also have a history of manic episodes.
  4. Normal grief can be very difficult to distinguish from depression. Grief is such a ubiquitous and important response to loss that we will now digress and discuss it.

Grief

Grief follows the perception of a loss. Usually, the loss is a relative or close friend. People will also grieve over the loss of a limb, loss of body functioning, or loss of self-esteem (as in losing ajob). Depressed people may develop their illness in the absence of an actual loss; they seem more likely to suffer vegetative signs than those who are bereaved.
There are characteristic stages in grief reactions. People who are grieving experience shock; that is, they initially feel emotionally overwhelmed by their loss. This is usually followed by anger, denial, sadness, and then some form of resolution in which the lost relative, friend, or limb is gradually given up. Grieving typically lasts for about a year.
Pathological grief occurs when grief is intolerable. Watch for these signs to make a diagnosis of pathological grief.
  1. Ifa surviving relative develops symptoms of the deceased relative, this is a manifestation of pathological grief. For example, a grieving widower whose wife died ofcolonic cancer might develop stomach aches as a sign of pathological grief.
  2. Suicidal ideation and behavior is also on the pathological scale of grief reactions.
  3. Psychosomatic reactions (ulcerative colitis, rheumatoid arthritis, etc.) and hyperactivity also are aberrant reactions of grief.
4. Grief lasting longer than 2 years is pathological.
Grieving people do feel depressed and unhappy for a period of time. In the end, the distinction between grief and depression can be difficult. Table 4 summarizes these two clinical states.

Suicide

The evaluation of the suicidal patient is one of the most difficult tasks faced by the psychiatrist. Although fifteen percent of patients who are severely depressed may commit suicide, significant numbers of suicides occur in the absence of depression. The setting of a suicidal act is usually one in which a person experiences intense stress. Such stress leads to affects or feelings which are completely intolerable to the patient. If the person sees no solution to the circumstances causing these intolerable affects, suicide begins to appear as "the only solution" to the situation. This is the time of suicidal crisis and can last a few hours to a few days. If assistance is provided, this suicidal crisis can be overcome. The patient's situation may require hospitalization or family support; the priority of this phase of the illness is to safeguard the patient.
TABLE 4
TABLE 4
Depression
Grief
Loss
+/-
+
Thought
guilt, self-deprecation
thoughts of lost relatives/ hallucinations of the deceased relative are sometimes normal. Guilt.
Timing
6-12 mos. +
1-24 mos. following a loss
Depressive Vegetative Signs
Usual
Less Common
Depressive Vegetative Signs Usual Less Common
A three to nine month period of heightened vulnerability to suicide follows. This post-crisis phase should involve continuous monitoring of the patient. During this phase of the illness, the patient's underlying problems should be treated. For example, if he is depressed, antidepressants are usually indicated. Ifhe has poor coping skills, efforts should be made to teach him new ways of dealing with stress.
The problem during the acute and subacute phases is how to decide the actual risk for suicide attempt. No easy answer exists, but a variety of demographic and psychological data can be elicited to help you decide. Just remember SUICIDAL (fig.5)!
S: The Sex of the patient is important. More men commit suicide; more women than men attempt suicide. Availability of Significant others is also important. Married patients are less likely to commit suicide than single ones, and divorced patients are at higher risk than married ones. The quality of personal relationships is also important. A patient's feelings of loneliness or isolation from important people in his or her life may lead to suicidal thinking.
U: Unsuccessful, previous attempts, contrary to popular wisdom, make it more likely that an additional suicide attempt will end in death. An accurate history about previous attempts is crucial. It should include the means previously used (to assess their lethality), the presence or absence of other people at the time(s) of the attempt(s), the patient's distance from medical help at the time(s),

Fig. 5.
the presence or absence of loss of consciousness, and the length of stay(s) in the hospital following the attempt(s).
I: Identification with family members who have committed suicide in the past may make suicide a more acceptable option to some patients.
CI: Chronic Illness, psychological or medical, and/or recent onset of severe illness is an increased risk factor for completed suicide. Patients with depression, psychosis, and panic disorder are definitely at higher risk.
D: Depression significantly increases the risk of suicide as does drug abuse.
A: The Age of the patient is important. A simple rule of thumb is that older men are at greater risk for suicide. Young schizophrenic males are at high risk. Alcohol use is also common in successful suicides. A patient acutely intoxicated with Alcohol or other substance will be more impulsive and more likely to kill himself. Chronic alcoholism is also a risk factor for suicide. The patient's Alliance or therapeutic relationship with the people who are evaluating his suicidal potential should be considered. Patients who are assessed to be most isolated and out of touch with other people are at greatest risk.
L: Lethality of suicidal method is an important factor in the assessment. The use of guns, hanging, and jumping from high places are the most lethal means. Greater caution is therefore indicated with these patients. Drug overdoses and wrist cutting are generally less lethal. Recent Losses (death, divorce, loss of job) are also critical factors in assessing potentially suicidal patients.
Assessing suicidal potential involves the consideration of many factors. Complicating this assessment is the fact that some patients attempt suicide to manipulate "significant others." Usually, such patients are managed differently than others. It is safer, however, to assume that they are genuinely suicidal at first. If you're certain they are manipulative and don't really want to die, then hospitalization, giving in to the patient's threats, and even psychiatric treatment may not be indicated. These are tough cases, though, and consultation with a psychiatrist or psychiatric colleague is recommended before making these difficult treatment decisions.
Physicians in primary care will see the majority of depressed and suicidal patients. A significant number of patients who commit suicide have seen a doctor in the preceding several months. This suggests that they want help but can't ask for it directly. Remember SUICIDAL and you'll save lives!
(See Chapter 13 for treatment approaches).