Emergency Psychiatry: Acute EPS & Suicide : Fernando Entenza , MD General, Geriatric & Forensic Psychiatrist UCC SOM Behavioral Sciences I & II Coordinator Emergency Psychiatry: Acute EPS & Suicide
Emergency Psychiatry Presentations (addressed elsewhere) : Substance Intoxication and related complications √ Substance Withdrawal and related complications √ Delirium √ Behavior disturbances related to Dementia √ Acute Psychosis √ Acute Mania √ Acute Anxiety / Panic √ Physical, sexual, emotional abuse (child, spouse, elderly) √ Emergency Psychiatry Presentations (addressed elsewhere)
Acute Antipsychotic –Induced EPS : Acute Antipsychotic –Induced EPS
PowerPoint Presentation : TIMA: Antipsychotics Rx - Side Effects Algorithms Time of Onset 4 hours dystonia / 4 weeks parkinsonism 4 days any time 4 months
Acute Dystonia : Sudden, sustained involuntary muscle spam Usually within 7 days of initiation or rapidly raising the antipsychotic > 2 of the following Abnormal positioning of head or neck in relation to the body ( retrocollis , torticolis ) Jaw muscle spasms (difficulty opening mouth, grimacing) Impaired swallowing ( dysphagia ), speaking ( dysphonia ), or breathing (laryngeal-pharyngeal spasm) Thickened or slurred speech due to hypertonic or enlarged tongue Tongue protusion or dysfunction Oculogyric crisis (eyes deviated up, down or sideward) Abnormal positioning of limbs or trunk Risk factors Male gender < 30 years of age High doses of high-potency neuroleptics Acute Dystonia
PowerPoint Presentation : Antipsychotic Side Effects: Movement Disorders Parkinsonism Within a few weeks of Initiation or increase in the antipsychotic dose, or Reduction of a drug used to treat of prevent acute EPS (i.e. benztropine ) > 1 of the following Rigidity Cogwheel rigidity Continuous “lead pipe” rigidity Tremor Coarse, rhythmic, at rest , 3-6 cycles /sec, affecting limbs, head, mouth ( rabbit syndrome ), or tongue Akinesia / bradykinesia Decrease in spontaneous facial expressions, gestures, speech, or body movements Risk factors Elderly Female High potency dopaminergic receptor antagonists ( typicals ) Internet Videos: http://video.google.com.pr/videoplay?docid=1934113740141980787&ei=xxd2S4zMM5CElge0xvXtBw&q=parkinsonism&hl=en&view=3#
PowerPoint Presentation : Antipsychotic Side Effects: Movement Disorders Acute Akathisia Within 4 days of initiating or increasing the dose Complaint of restlessness > 1 of the following Fidgety movements or swinging of the legs Rocking from foot to foot while standing Pacing to relieve restlessness Inability to sit or stand still for at least several minutes Risk factors Middle age woman May also occur with antidepressants and sympathomimetics
Antipsychotic Side Effects: Movement Disorders : Antipsychotic Side Effects: Movement Disorders Tardive Dyskinesia (TD) Involuntary movements of the tongue, jaw, trunk, or extremities Total of > 3 months of exposure to antipsychotics (1 mo. if elderly) Present for > 4 weeks Onset during exposure or within 4 weeks from withdrawal from oral drug (8 weeks from Depot) Neurologic referral and consideration of reserpine use Any one of these patterns Choreiform (rapid, jerky, non-repetitive) Athetoid (slow, sinuous, rhythmical, writhing) Rhythmic (stereotypes) Risk factors Elderly Female Presence of a mood disorder Presence of a cognitive disorder Duration of exposure to dopamine receptor antagonists May appear to exacerbate with withdrawal or dose reduction of the dopamine receptor antagonist (“Withdrawal Dyskinesia ”) Internet Videos: http://www.encyclopedia.com/video/FUr8ltXh1Pc-tardive-dyskinesia.aspx http://www.encyclopedia.com/video/W_3bbpFjI68-tardive-dyskinesia-symptoms-aimsdvdcom.aspx http://www.encyclopedia.com/video/lfOGLpb1q24-treatment-of-tardive-dyskinesia-with.aspx
Antipsychotic Side Effects: Movement Disorders : Antipsychotic Side Effects: Movement Disorders Neuroleptic Malignant Syndrome (NMS) Severe muscle rigidity and elevated temperature associated with the use of a neuroleptic medication Plus > 2 of the following Diaphoresis Dysphagia Tremor Incontinence Changes in level of consciousness (confusion to coma) Mutism Tachycardia Elevated and labile blood pressure Leukocytosis Risk factors (10 -20% mortality rate) Anytime during antipsychotic treatment Higher potency dopaminergic receptor antagonists? Typical antipsychotics?
Management of Antipsychotic-Induced Movement Disorders : Management of Antipsychotic-Induced Movement Disorders Parkinsonism Reduce neuroleptic dose Anti-EPS treatment Anticholinergic / antihistaminergic : benztropine , trihexyphenidyl , diphenhydramine Reassess need every 2-4 weeks Consider changing antipsychotic to an agent with lesser EPS profile Acute Dystonia Immediate administration of anticholinergic or antihistaminergic agent Benztropine Diphenhydramine PO or IM Continue anticholinergic agent following acute episode and reevaluate periodically Consider antipsychotic dose reduction or change to agent with lesser EPS profile
Management of Antipsychotic-Induced Movement Disorders (cont.) : Management of Antipsychotic-Induced Movement Disorders (cont.) Acute Akathisia Reduce antipsychotic dose Start acute treatment with ß-blocker or benzodiazepine Consider changing antipsychotic to agent with lesser EPS profile Tardive Dyskinesia If mild, change to SDA If severe, change to Clozapine Neuroleptic Malignant Syndrome Discontinue antipsychotic Supportive measures: hydration!!! , temperature control Start dopaminergic agonist treatment with dantrolene or bromocriptine ; consider amantidine If antipsychotic treatment is required subsequently, use lowest dose possible and consider clozapine , or SDA, or lower potency agent
Suicide : Suicide
Definitions : SUICIDE Intentional act to ending one’s life Completed suicide Suicide attempt Nonfatal outcome but there was a clear intention to die Suicide gesture (pseudo or parasuicide ) Absent clear intention to die Primary or S econdary Gains: intention to sleep/escape momentarily, seek help, obtain attention, manipulate others Suicide ideation & impulses Thoughts, fantasies, or preoccupations contemplating death in general or self-inflicted death, and related (ego- syntonic or ego- dystonic )impulses Non-suicidal self-injury or self-mutilation Definitions SUICIDAL BEHAVIOR Passive Suicide Passive-resistant behaviors with potential lethal consequences, like starving or noncompliance with medical regimes, although suicidal intent may be difficult to determine Most frequently performed by elderly and chronically ill men
Theories of Suicide: Psychosocial Factors : Life experiences High levels of stress in the year leading up to the suicide act, intensified during the preceding week Younger individuals are more susceptible to interpersonal stressors Older individuals are susceptible to a broader range of stressors, like work, finances, illness, family Loss of parents through death, divorce or abandonment in early life Physical or sexual abuse Suicide behavior in relatives or friends Dysfunctional families Ineffective coping abilities Appropriate integration into society (Durkheim’s theory) Theories of Suicide: Psychosocial Factors
Durkheim’s Theory of Suicide: Integration into Society : Performed by persons who Egotistic Exhibit excessive individualism ( not strongly integrated ) or Have no meaningful social interactions, and thus, are isolated from the group (i.e. actress intolerant of aging) Anomic Have not experienced societal regulations ( disturbed integration ) and suddenly feel subject to intolerable limits (i.e. incarcerated sociopath) Altruistic Are excessively integrated and Sacrifice themselves for the greater good of society (i.e. a soldier sacrificing himself in battle) Fatalistic Feel regulated to such extremes that they have no hopes or dreams , and all opportunities for improvement seem blocked (i.e. dependent personality traits) Durkheim’s Theory of Suicide: Integration into Society
Theories of Suicide: Biologic : Serotonin dysregulation (lowered serotonergic activity) Lower CSF concentrations of 5-HIAA, a serotonin metabolite, in suicide attempters and completers, independent of their psychiatric diagnosis Decreased concentrations of serotonin in brain stem, particularly in the raphe nuclei, in suicide victims Decreased platelet monoamine oxidase (MAO) Inhibition of the serotonergic system is associated with aggressive behavior in animals and poor impulse control in humans (i.e. low CSF 5-HIAA in murderers) Physiologic stress response: elevated levels of CRF found in CSF Activated HPA axis is a contributor to glucocorticoid -mediated hipoccampal atrophy in major depression in patients Theories of Suicide: Biologic
Theories of Suicide: Genetic Vulnerability : For suicidal behavior Intronic polymorphisms (A218C or A779C) of the tryptophan hydroxylase 1 (TPH1) gene Associated with suicide attempts in mood disorders Insertion/deletion polymorphism (S-allele) of the serotonin transporter promoter gene (5-HTTLPR) Associated with Neuroticism Depressive disorders Violent behavior in mood disorders Repeated suicide attempts in alcohol-dependent populations For impulsive-aggressive personality traits that might induce the use violent methods in subjects with suicide risks Monoamine oxidase (MAO) gene Theories of Suicide: Genetic Vulnerability
Epidemiology : Epidemiology Worldwide 11 th leading cause of death US all ages 8 th leading cause of death 0.9% of all deaths are the result of suicide 1 completed suicide for every 25 attempts US youths aged 15-24 1 suicide/100-200 attempts for those 14-25 y/o 3 rd cause of death, behind accidents and homicides US adults aged 25-64 5 th cause of death US elderly aged 65+ US whites > nonwhites (2:1) Suicide Method #1 = Firearms (most lethal) Most common method in completed suicide (~ 55%) Preferred method of men Preferred method of young people Hanging Preferred by men Poisoning (one of the least lethal) Overdose is preferred by women The #1 suicide site in the world is the Golden Gate Bridge in San Francisco
Suicide Risk Factors 1: Gender & Age : Gender (M > F) Men Are less likely to attempt suicide But they are more likely to complete suicide (4 : 1) Are less likely to communicate their suicide intentions Women Attempt suicide more frequently than men (3:1) Suicide peaks after age 55 Young people 14-25 10/100,000 persons per year Late adolescent white males In youths aged 10-19 the sharpest rise has been in blacks, approaching the rate of whites Firearms account for 96% of this rise Elderly > 65 (highest risk) Attempt suicide less But have a higher rate of success at 25/100,000 = 1 in every 4 attempts Elderly white men are at highest risk of completing suicide at 31/100,000 persons per year Increasing since mid 1970s Among the highest rates world wide 70% depressed / 20% abusing ETOH x3 the rate of young people Suicide Risk Factors 1: Gender & Age Age Suicide pacts Most common among elderly couples and adolescents
Suicide Risk Factors 2 : Suicide Risk Factors 2 Psychosocial stressors (loss) Unemployment Retirement Physical limitations Financial problems Change in standard of living Cognitive decline Geographic relocation Loss of a relationship Social status Not married > married Recently widowed elderly Religion Non-catholic Poor or lacking support network Previous suicide attempt Family history of completed suicide Genetic factor corroborated by higher monozygotic than dizygotic twin concordance The genetic factor may lead to reduced ability to control impulsive behavior, just like psychiatric disorders do
Suicide Risk Factors 3: Psychiatric Illness : History of mental disorder is present in up to 90% of completed suicides % Attempt % Commit Major depressive disorder 20 Substance abuse Alcohol 2.2 - 3.4 The suicide rate of heroin addicts is 20 greater than that of the general population Bipolar disorder Schizophrenia Panic disorder All panic patients: 20 1.2 Only non- comorbid panic patients: 7 Childhood sexual or physical abuse The highest risk of suicide occur when depressive disorder and substance abuse were comorbid Suicides with Cluster B personality disorders were more likely to have substance-use disorders, previous non-fatal attempts, good health Suicide Risk Factors 3: Psychiatric Illness
Comparison of risk for suicide in the presence of selected psychiatric disorders Adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228 : Comparison of risk for suicide in the presence of selected psychiatric disorders Adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228 The 2 most prevalent mental disorders associated with suicide are major depressive disorder and substance abuse
Suicide Risk Factors 4: Ethnic & Other Groups : Suicide Risk Factors 4: Ethnic & Other Groups African American women have the lowest rates of suicide in the U.S. at all ages Puerto Rican males and females x 3 higher suicide rates if living in the mainland U.S., compared to peers living in PR 90% of Puerto Ricans residing in the U.S. who committed suicide were born in PR Mexican men and women Higher suicide rates if living in the U.S. when compared to those still living in Mexico U.S. region Highest rates in southwestern states and Florida Homes with firearms Highest rates of completed suicide
Suicide Risk Factors 5: Acute or Chronic Medical Conditions : Suicide Risk Factors 5: Acute or Chronic Medical Conditions Cancer Huntington’s disease Epilepsy HIV/AIDS CNS MS Peptic ulcer disease Spinal cord injury SLE ESRD - dialysis Mechanisms leading to suicide Pain Physical limitations Loss of independence Deteriorating course Direct physiological depressive effect Suicide risk associated with a physical problem is highest for individuals 55 – 59 y/o Medical patients exhibiting suicidal ideation are more likely to have had a hospitalization within the previous year The risk of suicide is highest during the period immediately following discharge Are we setting up false expectations about aging that cannot be met?
Medical Conditions (cont.) : Medical Conditions (cont.) HIV/AIDS Most vulnerable following diagnosis and at times of disease exacerbation CANCER Cancer patients are at increased risk during the first few months even if remission has been induced Those in remission who commit suicide are more likely to have Personal or family history of mental disorders Personal or family history of suicide Difficulty adapting to mutilating surgery ALZHEIMER AD pts are at risk if they have: Insight into memory deficits and the nature of the illness Awareness of the caregiver’s burden and stress A family that is unable to cope with the demands of providing care Participated in experimental drug protocols but with poor results College degree or higher education Worked as a professional Access to firearms Decreased brain serotonin levels
Comparison of risk for suicide with and without presence of selected medical illnesses Data adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228; McGirr A, et al. J Clin Psychiatry 2008;69:966-970; Harris EC, et al. Medicine (Baltimore) 1994;73:281-296 : Comparison of risk for suicide with and without presence of selected medical illnesses Data adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228; McGirr A, et al. J Clin Psychiatry 2008;69:966-970; Harris EC, et al. Medicine (Baltimore) 1994;73:281-296
Doctor-Assisted Suicide Debate : Doctor-Assisted Suicide Debate The case of 52-year-old Chantal Sebire had drawn headlines across France and revived a national debate about the right to die. Sebire's body was found at her home in the eastern town of Plombieres -les-Dijon in the Bourgogne region this afternoon. The cause of her death was not immediately known, Dijon prosecutor Jean-Pierre Allachi said. On Monday, a court in the city of Dijon rejected Sebire's request to be allowed to receive a lethal dose of barbiturates under a doctor's supervision. It refused the request for doctor-assisted suicide because of French law and out of concern for medical ethics. Sebire had told the court she did not want to endure further pain and subject herself to an irreversible worsening of her condition. Sebire's case caught France's attention when the media published heartbreaking before-and-after pictures that made her suffering instantly apparent. The tumour burrowed through her sinuses and nasal cavities, causing her nose to swell to several times its original size, and pushing one of her eye sockets out of her head. Sebire , a former schoolteacher who has children aged 29, 27 and 13, was diagnosed nearly eight years ago with esthesioneuroblastoma , a rare form of cancer. The illness had left her blind, and with no sense of smell or taste, her lawyer said. She could not use morphine to ease the intense eye pain because of the side effects. Sebire had said she would not appeal the decision rendered Monday and that she would find life-terminating drugs through other means.
Parasuicide : Suicide attempters ~ 40% of suicide attempters have made a previous attempt 13-35% will repeat the attempt during the next 2 years 3 subgroups of repeaters Very occasional repeater Several times repeated Chronic or habitual repeater The risk of a serious attempt increased with increasing psychiatric comorbidity A definitive psychiatric disorder is less likely in parasuicide attempters (~30%) Compared to 90% of serious suicide attempters ~ 1% who attempt suicide will commit suicide during the following year 1 out of every 8 to 50 attempters Indicators of subsequent completed suicide During the 1 st year after a suicide attempt Many previous attempts by violent methods Having a psychiatric disorder, including alcoholism Separated, divorced or widowed Living alone Leaving a suicide note Poor physical health Older and younger attempters Older women > younger women Parasuicide Subsequent completers
Warning Signs : Warning Signs Suicide ideation Suicide plan & intention Acts in furtherance of plans Searches information about suicide Searches or obtains access to means: firearm, rope, pill-hoarding , poison Makes amends with others Writes “goodbye” letter Lies about wellbeing Obtains or updates insurance Presence or increase in substance abuse Talking or writing about death, dying, or suicide Hopelessness Current problems seem unsolvable to the person Withdrawal from friends and family Finds “no reason for living” Reckless behavior Drastic mood changes “Sudden improvement”
When Should Suicide Risk Be Assessed? : At every initial psychiatric evaluation Whenever a patient presents in crisis to mental health services Whenever a change in the mental status exam is observed Whenever a patient is not improving with current treatment Whenever a patient experiences worsening of symptoms despite treatment Whenever a patient experiences a psychosocial stressor When Should Suicide Risk Be Assessed?
Evaluation: Ideation + Intent + Plan + Access + Prior Attempt : Suicide Plan & Access Presence of a specific and elaborate plan & method When, where, how How to not be prevented Access to the method and means Lethality of the method Real risk Risk believed by the patient Is it imminent? Is there a condition to be met? Is the person committed to the suicide plan or wish? If so, how strongly? Are there acts in furtherance ? Evaluation: Ideation + Intent + Plan + Access + Prior Attempt Suicide Intent & Acts Other risk factors Male gender Age: 14-25 or >65 Psychiatric condition: MD Painful or incapacitating physical condition Disproportionate hopelessness 1 st gen. PR immigrant Prior Suicide Behavior
Method Lethality : Lower Lethality Method Lethality Higher Lethality
Commitment / Intention : Lower Intention Commitment / Intention Higher Intention
General Recommendations : Voluntary versus involuntary psychiatric hospitalization for any patient at risk of suicide Partial hospitalization may be appropriate if there is only death ideation without suicide plans or intentions Confidentiality may be breeched Make your suicide assessment clearly visible for all treatment team members to be aware & warned Inpatient prevention strategies Inaccessible means (safety regulations regarding clothing, belongings, etc.) Observation Periodic unit checks, “visual observation”, 1:1 arm-length General Recommendations
Pharmacological Suicide-Prevention Interventions : Schizophrenia Clozapine Avoid TCAs ( tricyclics ) due to their low LD 50 properties Note FDA’s warning for all approved antidepressant treatments Antidepressants increased suicide thinking and behavior in children, adolescents and young adults under 24 y/o in short-term studies of MDD and other psychiatric conditions Benzodiazepines and barbiturates should be avoided due to overdose lethality Pharmacological Suicide-Prevention Interventions Preventive Measures Bipolar Disorder Lithium Major Depressive Disorder SSRI ECT
Psychotherapeutic Interventions : Modalities shown to reduce suicidal behavior and improve treatment adherence Cognitive Behavior Therapy Dialectical Behavior Therapy For Borderline Personality Disorder patients General recommendations Broaden the person’s perspective beyond the immediate distress Identify positive expectations Develop long-term personal goals Activate/enhance support network Include group interventions 24-hour availability during risk period Psychotherapeutic Interventions
Other Recommendations : Hospitalization Indications Lack of a strong and reliable support system History of impulsive behavior Suicidal plan of action Requirements to treat as outpatient instead Modify stressful environment Build support & alliance by recognizing their legitimate complaints and offering alternatives Commitment to call (contract for safety) Note : it is legally meaningless 24-7 availability by the psychiatrist Indications History of being unresponsive to antidepressants So severely depressed and suicidal as to require a faster-acting treatment plan Other Recommendations ECT
Suicide Survivors : Family members of suicide completers may develop Disbelief May be even of delusional intensity Anger at the patient Anger at the healthcare provider or the medical establishment in general Guilt May be even of delusional intensity Depressive disorders Family members of unsuccessful attempters Without treatment, the family will return to their usual patterns of behaviors These may have contributed to the attempt Identify and address these issues Suicide Survivors