Suicide Assessment & Tx of Suicidality
RF	SAD PERSONS ·       Sex (male) ·       Age ·       Depression ·       Previous attempt ·       EtOH or other substances use ·       Rational thoughts loss (psychosis) ·       Social support lacking ·       Organized plan ·       No spouse or significantly other ·       Sickness or injury
Assessment	Evaluate if pt has the idea: ·       Wish to die, not wake up (passive) ·       Thought of killing self (active) ·       Frequency, duration, intensity, controllability Evaluate if pt has intent: ·       Strength of intent to attempt suicide; ability to control impulsivity ·       Determine how close patient has come to acting on a plan (rehearsal, aborted attempts) Evaluate if pt has a plan: ·       Specific details: Method, time, place, access to means (e.g., weapons, pills), preparations (e.g., gathering pills, changing will) ·       Lethality of method Likelihood of rescue
Management	High imminent risk (ideation, intent and plan) ·       Ensure safety: Hospitalize immediately (involuntarily if necessary) ·       Remove personal belongings and objects in room that may present self-harm risk ·       Constant observation and security may be required to hold against will High non-imminent risk (ideation, intent and no plan to act near future) ·       Ensure close follow-up ·       Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain) ·       Recruit family or friends to support pt ·       Reduce access to potential means (secure firearms, medications)

MDD	·        ≥2 weeks ·       ≥5 of 9 of the following symptoms; depressed mood and SIGECAPS o   Loss of interest o   Sleeping o   Anhedonia o   Suicidal o   Low energy o   Appetite o   Concentration ❌ o   Psychomotor agitation o   No life-time history of mania o   Significant functional impairment
Dysthymia	·       Chronic depressed mood ≥2 years ·       ≥2 of the following: appetite disturbance, sleep disturbance, low energy, low self-esteem, poor concentration, hopelessness
Adjustment disorder w/ depressed mood	·       Onset within 3 months of identifiable stressor ·       Marked distress/ functional impairment ·       Can be with depressed mood (but does not meet the criteria of MDD)
Normal stress response	·       Not excessive or not out of proportion to severity of stressor ·       No significant functional impairment

Major Depression Disorder
Dx	·       ≥5 of the following Sx for ≥2 weeks: o   Depressed mood o   Loss of interest or pleasure o   Change in appetite or weight o   Insomnia or hyperinsomnia o   Psychomotor retardation or agitation o   Low energy o   Poor concentration or indecisiveness o   Thoughts of worthlessness or inappropriate guilt o   Recurrent thoughts of death or suicide ·       No hx of mania or hypomania ·       Not d/t substances or another medical conditions
Tx	·       Psychotherapy ·       Antidepressant medication If partial response to antidepressant: §  Add another💊w/ different MoA §  2nd-gen antipsychotic §  Psychotherapy §  Lithium Bupropion (NDIR) §  Appropriate for weight loss §  No sexual SE Special uses: ·       Pt wants to sleep better: Trazodone ·       Pt wants to GAIN weight: Miratzapine ·       Pt wanna quit smoking: Bupropion
Electroconvulsive Therapy	Indications ·       Treatment resistance ·       Psychotic features ·       Emergency conditions o   Pregnancy o   Refusal to eat or drink o   Imminent risk for suicide Safety ·       No absolute contraindication ·       Increased risk o   Severe CV disease, recent MI o   Space-occupying brain lesion o   Recent stroke, unstable aneurysm

When to stop tx for MDD?

·       MDD is a recurrent illness for most patients. ·       If no recurrence → 6 months of free sx → discontinue tx. ·       If ≥2 recurrence → maintainance therapy → longer than 6 ·       months ·       If pt is young, persistant residual sx → maintainance ·       therapy → longer than 6 months However, patients with a hx of highly recurrent illness (≥3 lifetime depressive episodes), chronic episodes (≥2 years), severe ongoing psychosocial stressors, or severe episodes (suicide attempts) are candidates for maintaining antidepressant tx indefinitely (forever).

	Serotonin Syn	Neuroleptic Malignant Syn	Malignant Hyperthermia	MAOI crisis
Hx	SSRI / TCA	Antipsychotics	Post-op, use of anesthetic	Tyramine ingestion
BP	⤴️	⤴️	–	⤴️
T	⤴️	⤴️	⤴️	–
Muscle	Tremor, Myoclonus	RIGIDITY	RIGID	–
DTR	⤴️	N	N	–
Other Sx	GI Sx Dilated pupils	Confusion	–

	Serotonin Syndrome
features	·       ⤴️ Serotonin Activity ·       Can happen w/: TCAs + SSRIs.
S/S	Vitals: ·       tachycardia ·       hypertension ·       hyperthermia, PEx: ·       agitation, ·       ocular clonus, ·       tremor, ·       akathisia, ·       hyperreflexia, ·       muscle rigidity, ·       dilated pupils.
Dx	Clx
Tx	1.     withdrawal of the offending agent 2.     benzodiazepines to tx agitation and tremor 3.     Cyproheptadine as an antidote

Serotonin Syndrome
?	·       Serotonergic medications, especially if combined (SSRI/SNRI, TCA, tramadol) ·       Drug interactions; Serotonergic medications and MAOI or linezolid ✳️ ·       Intentional overdose of serotonergic medications
Clx	·       Mental status (Anxiety, agitation, delirium) ·       Autonomic dysregulation (diaphoresis, HTN, tachycardia, vomiting, diarrhea) ·       Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)
Tx	·       STOPP of all serotonergic medications ·       Supportive care, ·       sedation with benzos ·       If supportive measures fail: Serotonin antagonist (cyproheptadine)

Dysthymia (Chronic Depressed Mood)
Clx	·       Chronic depressed mood ≥ 2 years ·       No Sx-free period >2 months ·       Presence of ≥ 2 of: o   Appetite: Poor ⤵️ or overeating ⤴️ o   Sleep: Insomnia ⤵️ or hypersomnia ⤴️ o   Energy: ⤵️ o   Self-esteem: ⤵️ o   Poor concentration o   Feeling hopeless (less severe than MDD)
Different Types	·       Pure dysthymic syndrome: criteria for MDD episode are NEVER ⊕. ·       Dysthymia w/ intermittent MDD episodes ·       Dysthymia w/ persistent MDD episodes: criteria for MDD episode are ⊕ throughout previous 2 years

MDD	Grief (bereavement)
• 5 of 9 Sx – 2 Weeks Period: (Sleep disturbances, appetite (⤴️ or ⤵️), low energy, psychomotor retardation, anhedonia, low mood, feeling guilt, difficulty in concentration, suicidal ideation) • Low mood or anhedonia must be ⊕ • May occur in response to a variety of stressors, including loss of loved one • Pt has social & occupational dysfunction	• Normal reaction to loss • Feelings of loss & emptiness • Sx revolve around the lost one • Functional decline temporary (intensity ⤵️ over time) & less severe • “Waves” of grief at reminders • Less common sx of worthlessness, self-loathing, guilt & suicidality • Thoughts of dying involve joining the deceased

Postpartum mood disorder
⏰	Disorder	Sx	Mother’s Feelings Toward Baby	Tx
2 weeks	Postpartum blues or baby blues	Sadness, mood lability, tearfulness	No negative feelings	Supportive usually self-limited
During pregnancy or after 4 weeks	Depressive disorder with peripartum onset	Depressed mood, weight changes, sleep disturbances, and excessive anxiety	May have negative feelings toward baby	Antidepressant medications
During pregnancy or after 4 weeks	Bipolar disorder with prepartum onset Brief psychotic disorder with peripartum onset	Symptoms of depression, mania along with delusions, hallucinations and thoughts of harm	May have thoughts of harming baby	Antipsychotic medication, lithium, and possible antidepressant

Bipolar Disorder

Manic episode: ·       Symptoms more sever ·       1 week unless hospitalized ·       Marked impairment in social or occupational  functioning or hospitalization necessary  ·       May have psychotic features; makes episodes manic by definition. Hypomanic episode ·        Symptoms are less severe ·       ≥ consecutive days ·       Unequivocal, observable change in functioning form patient’s baseline. ·       Symptoms not severe enough to cause marked impairment Or necessitate hospitalization ·       No psychotic features

Bipolar I: ·       Manic episodes ·       Depressive episodes common, but not required for diagnosis

Bipolar II: ·       Hypomanic episodes ·       ≥1 major depressive episodes required

Cyclothymic disorder: ·       At least 2 years of fluctuating, mild hypomanic and depressive symptoms that do not meet criteria for hypomanic episodes Or major depressive episodes

Bipolar
Nx	DSM-5?
S/S	·       Mania + Depression
Dx	·       Clx
Tx	1˚ ENSURE Pt SAFETY 2˚ Mood stablizer (Lithium)

Manic Episode
Clx	≥1 week of elevated or irritable mood and ⤴️ energy/activity ≥3 of the following sx: ·       Distractibility ·       Impulsivity/ indiscretion, risky behavior ·       Grandiosity ·       Flight of ideas/ racing thoughts ·       Increased need for sleep ·       Talkativeness/ pressured speech (DIGFAST mnemonic)
Severity	·       Impaired psychosocial function ·       +/- psychosis (hallucinations, delusions) ·       May require hospitalization
Tx	·       Antipsychotics (first-second-generation) ·       Lithium (avoid in renal disease) ·       Valproate (avoid in liver disease) ·       Combinations in severe mania (antipsychotic plus lithium or valproate) ·       Adjunctive benzodiazepines for insomnia, agitation

Dysthymia	Cyclothymia
light depression for 2 ys	·       light bipolar for 2 ys ·       have mariatel issues ·       can be borderline
respond to psychotherapy	Respond to lithium & psychotherapy

Lithium Toxicity
?	·      Overdose ·      Volume depletion (⤵️ GFR) ·      During interactions (ones that affect the kidney) o   Thiazide o   NSAIDs o   ACE inhibitors
Sx	·       Thyroid/ Nephrogenic DI ·       Acute o   GI: N/V, diarrhea o   Late neurologic sequelae ·       Chronic toxicity (neurologic) o   Ataxia o   Tremors/ fasciculations
Tx	1.     Discontinuing: lithium is recommended 2.     If you cannot: salt restriction and selected diuretics such as amiloride 3.     When to hemodialysis? o   Serum lithium level >4 o   Lithium level >2.5 + signs of significant lithium toxicity (e.g., SZ,AMS) o   Inability to excrete lithium (e.g., renal disease, decompensated heart failure.