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Diagnosing Depressive Disorders
 

SUICIDE RISK ASSESSMENT

One of the most critical tests of clinical judgement in the management of depression and to a lesser extent, anxiety disorders, is gauging the severity of the illness. In severe depression and certain severe anxiety disorders, thoughts of death, death wishes and suicidal ideas are the most serious symptoms of all because there is a real chance they will be successfully acted upon. Accurate assessment of the likelihood of a patient committing suicide is therefore vital if suicide is to be prevented.

This task can be made somewhat easier if physicians remain alert to the major risk factors felt to be predictive for suicidal intent. Under the acronym of SAD PERSONS, each factor listed in the SAD PERSONS scale is felt to increase the likelihood of a patient attempting suicide. With gentle and empathetic probing, physicians should assess patients for the presence or absence of each of these risk factors, and in so doing, decide how likely it is that the patient will commit suicide. The best approach is to ask the patient directly, using questions such as:

 

• Do you have any hope for the future?
• Do you ever have thoughts of death?
• If you died in your sleep, would that be all right with you?
• Have you ever thought of killing yourself?
• Have you formulated a plan for committing suicide?
• What stops you from trying to kill yourself?

 

 

 

 

 

When probing for the answers, it is vital not to be judgemental. It is also important not to use euphemisms for suicide, or ask the question obliquely as in, "You aren't thinking of doing anything rash, are you?" The term "harming yourself" likewise should not be used. To the depressed person, killing themselves is not the same as harming themselves. They are in pain and suicide for them is a way out of that pain - a solution that for them is not, in fact, "harmful". If the patient is at high risk for suicide, it is imperative to intervene immediately, including securing an emergency psychiatric consultation or hospitalizing the patient if possible.

Patients who are assessed to be less likely to commit suicide still require regular monitoring, while any potentially lethal medications including the tricyclic antidepressants should be avoided in favor of less lethal antidepressants. Keep in mind that one week's supply of a TCA is enough to kill a patient if taken in deliberate overdose. 1200 mg is considered the minimum lethal dose. TCAs possess Type 1A antiarrhythmic activity, which may increase the risk of sudden death.

Hence, limiting the amount of medication prescribed may not be adequate precaution against a strong desire to commit suicide by overdose. It is important to keep in mind that mood is often the last symptom of depression to improve under medication; thus, the risk of suicide is in fact greater in the early stages of treatment, as the patient may now have enough energy to follow through with a suicide plan, while mood may still be unchanged.

Although the newer antidepressant medications are safer in overdose, depressed patients should be carefully monitored to guard against deliberate overdose and suicidal intent. As patients continue to respond to treatment, it is helpful to initiate discussion about lifestyle issues: decreasing caffeine and alcohol intake, increasing physical activity levels, good sleep hygiene, using relaxation techniques and dealing with on-going crises that may be contributing to the depressed mood. [see Good Sleep Habits: Advice for Patients]

Finally, it should not be forgotten that according to one study, 50% of patients who committed suicide saw their family doctor or psychiatrist within two weeks of their death. If a patient insists that they are not considering suicide, yet the index of suspicion is high, it can be helpful to ask patients why suicide is not an option. It may also be important to determine if the patient has thought about taking a family member "with them" in cases where suicide intent is real.

Please see:

Section I: "Making The Diagnosis"
CANMAT – Guidelines for the Diagnosis and Pharmacological Treatment of Depression
(1st Edition Rev., 1999)
P. 13

 

SAD PERSONS Scale

Sex: Women attempt suicide 3 times more often than men, but men succeed more than 3 times as often as women
Age: High risk groups include men 45 years of age or more and adolescents 19 years of age and younger
Depression: 10% to 20% of patients [hospitalized for depression] commit suicide
Previous attempt: Patients who have previously tried to commit suicide are 64 times more likely than the general population to attempt suicide again. This increased risk is also a lifetime risk and does not diminish with time.
Ethanol abuse: An estimated 15% of patients with a history of alcohol abuse commit suicide
Rational-thinking loss: The presence of psychosis increases the risk of suicide
Social supports lacking: Social isolation from friends, relatives or community increases suicidal motivation
Organized plan: Patients with a specific plan outlining a lethal available method are at increased risk
No spouse: In older patients, widows and widowers have the highest rate of suicide
Sickness: The presence of a chronic or severe illness increases the risk of suicide.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Good Sleep Habits: Advice for Patients

Once sleep disturbances associated with mood disorders have improved with medication, it is important for patients to adopt sensible sleep habits to optimize mood. Key common sense strategies to improve sleep and which can be recommended to patients include:

 
• Avoid stimulants: These include caffeine from all sources - coffee, tea, colas and nicotine from cigarettes. Small amounts of alcohol may improve sleep; too much alcohol can fragment sleep and lead to early morning wakening.
• Avoid heavy meals late at night: Especially important for people who are prone to heartburn, a heavy meal before bed can cause digestive havoc and interrupt sleep.
• Try warm milk: Milk contains tryptophan; since the brain makes sleep-promoting serotonin from tryptophan once tryptophan crosses from the blood stream into the brain, milk is a gentle promoter of sleep. Prescription tryptophan is also available in Canada.
• Exercise regularly: Exercise done too late at night is not recommended as it will serve to energize rather than fatigue. However, done earlier in the evening or during the day, health-promoting physical activity can significantly improve sleep. Although it doesn't have to be done outside, fresh air also tends to promote physical relaxation and in turn, improves sleep.
• Create a good sleep environment: A restless partner in a bed that is too small can be extremely disruptive. Make sure the bed is big enough so that you can sleep far enough away not to be disturbed (or try single beds for greater physical separation). A good mattress is a good investment; while the mattress doesn't necessarily have to be firm, it does have to be comfortable for your needs. Lights, TV and the radio should also be turned off prior to going to bed; otherwise, they may interrupt sleep later on.
• Keep regular sleep/wake hours: Among the most important of good sleep habits, going to bed and getting up at the same time every day - weekends included - is an important element in helping promote sleep.
• Discuss sleep problems with your doctor: Medical illnesses, as well as prescription and non-prescription medications taken to relieve symptoms, may interfere with sleep. Talk to your doctor, make sure he or she is aware of everything you are taking, and if everything else fails, a non-addicting hypnotic may be required for a limited period of time to relieve fatigue arising from poor sleep.

 

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Over one million Canadians suffer from some form of depressive illness.