Depression

Key Feature 8: In a patient with depression, differentiate major depression from adjustment disorder, dysthymia, and a grief reaction.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis

Key Feature 9: Following failure of an appropriate treatment in a patient with depression, consider other diagnoses (ex: bipolar disorder, schizoaffective disorder, organic disease).
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 10: In the very young and elderly presenting with changes in behaviour, consider the diagnosis of depression (as they may not present with classic features).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Elderly

Key Feature 5: In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (ex: pneumonia, appendicitis, depression).
Skill: Selectivity, Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Many patients who present with depressed mood meet the DSM-V diagnostic criteria for Major Depressive Disorder, which are as follows:

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. NOTE: Do not include symptoms that are clearly attributable to another medical condition. 
   1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (ex: feels sad, empty, hopeless) or observation made by others (ex: appears tearful). (NOTE: In children and adolescents, can be irritable mood.)
   2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
   3. Significant weight loss when not dieting or weight gain (ex: a change of more than 5% of body weight in a month), or a decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.)
   4. Insomnia or hypersomnia nearly every day.
   5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down.)
   6. Fatigue or loss of energy nearly every day.
   7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
   8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
   9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The episode is not attributable to the physiological effects of a substance or to another medical condition.
4. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
5. There has never been a manic episode or a hypomanic episode. NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

NOTE: Criteria 1-3 represent a major depressive episode.
NOTE: Responses to a significant loss (ex: bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.

The DSM-V diagnostic criteria for Major Depressive Disorder provides a footnote on differentiated grief from major depression, as follows:

"In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humour that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic rumination seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (ex: not visiting frequently enough, not telling the deceased how much he or he was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the deceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression."

The DSM-V diagnostic criteria for Persistent Depressive Disorder (Dysthymia) are as follows:

1. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. NOTE: In children and adolescents, mood can be irritable and duration must be at least 1 year.
2. Presence, while depressed, of two (or more) of the following:
   1. Poor appetite or overeating.
   2. Insomnia or hypersomnia.
   3. Low energy or fatigue.
   4. Low self-esteem.
   5. Poor concentration or difficulty making decisions.
   6. Feelings of hopelessness.
3. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria 1 and 2 for more than 2 months at a time.
4. Criteria for a major depressive disorder may be continuously present for 2 years.
5. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
6. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
7. The symptoms are not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition (ex: hypothyroidism).
8. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

NOTE: Because the criteria for a major depressive episode include 4 symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.

The DSM-V diagnostic criteria for Adjustment Disorders are as follows:

1. The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
2. These symptoms or behaviours are clinically significant, as evidenced by one or both of the following:
   1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
   2. Significant impairment in social, occupational, or other important areas of functioning.
3. The stress-related disturbance doe not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.
4. The symptoms do not represent normal bereavement.
5. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

If a patient is diagnosed with depression, but does not respond well to therapy, this could be due to a failure of therapy to treat the depression, or it could also be that the treatment is not effective because the diagnosis is not accurate. Other diseases that can be incorrectly diagnosed as depression include bipolar disorder, schizoaffective disease, and organic disease (see my last blog post), as they may present first with an episode of major depression prior to the onset of other signs and symptoms that suggest an alternative diagnosis. 

The DSM-V diagnostic criteria for Bipolar Disorder I are as follows:

1. Criteria have been met for at least one manic episode
2. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

The DSM-V further states, "For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes."

The DSM-V diagnostic criteria for Bipolar Disorder II are as follows: 

1. Criteria have been met for at least one hypomanic episode (Criteria 1–6 under “Hypomanic Episode” below) and at least one major depressive episode (Criteria 1-3 under “Major Depressive Episode” below).
2. There has never been a manic episode.
3. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
4. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-V diagnostic criteria for a Manic Episode are as follows:

1. "A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
   1. Inflated self-esteem or grandiosity.
   2. Decreased need for sleep (ex: feels rested after only 3 hours of sleep).
   3. More talkative than usual or pressure to keep talking.
   4. Flight of ideas or subjective experience that thoughts are racing.
   5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
   6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
   7. Excessive involvement in activities that have a high potential for painful consequences (ex: engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
3. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
4. The episode is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication, other treatment) or another medical condition. NOTE: A full manic episode that emerges during antidepressant treatment (ex: medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

NOTE: Criteria 1-4 constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder."

The DSM-V diagnostic criteria for a Hypomanic Episode are as follows:

1. "A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
2. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
   1. Inflated self-esteem or grandiosity.
   2. Decreased need for sleep (ex: feels rested after only 3 hours of sleep).
   3. More talkative than usual or pressure to keep talking.
   4. Flight of ideas or subjective experience that thoughts are racing.
   5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
   6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
   7. Excessive involvement in activities that have a high potential for painful consequences (ex: engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
4. The disturbance in mood and the change in functioning are observable by others.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
6. The episode is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication, other treatment) or another medical condition. NOTE: A full hypomanic episode that emerges during antidepressant treatment (ex: medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.

NOTE: Criteria 1-6 constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder."

The DSM-V diagnostic criteria for Schizoaffective Disorder are as follows:

1. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion 1 of schizophrenia. NOTE: The major depressive episode must include Criterion 1.1: Depressed mood. NOTE: Criterion 1 of schizophrenia is to have 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
   1. Delusions.
   2. Hallucinations.
   3. Disorganized speech (ex: frequent derailment or incoherence).
   4. Grossly disorganized or catatonic behaviour.
   5. Negative symptoms (i.e., diminished emotional expression or avolition).
2. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
3. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
4. The disturbance is not attributable to the effects of a substance (ex: a drug of abuse, a medication) or another medical condition.

In summary, while I have outlined diagnostic criteria for multiple psychiatric diagnoses, the most important point here is to know how to diagnose Major Depressive Disorder  as it is extremely common, to distinguish it from other common causes for depressed mood, and to consider other diagnoses that may present with depressed mood as part of their symptomatology prior to the emergence of the other symptoms that distinguish them from Major Depression.

Depression

Key Feature 6: In a patient presenting with symptoms consistent with depression, consider and rule out serious organic pathology, using a targeted history, physical examination, and investigations (especially in elderly or difficult patients).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 7: In patients presenting with depression, inquire about abuse:

1. Sexual, physical, and emotional abuse (past and current, witnessed or inflicted).
2. Substance abuse.

Skill: Clinical Reasoning, Patient Centered
Phase: History, Hypothesis generation

Immigrants

Key Feature 4b: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Inquire about a past history of abuse or torture.
Skill: Clinical Reasoning
​Phase: History

Rape/Sexual Assault

Key Feature 7: Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

In my last post, I discussed the messy relationship between medical illness and depressed mood. Even if we will never be able to find a clear relationship that one necessarily preceded the other, and in this setting, whether it necessarily even led to the other, it is always important to rule out other medical conditions when evaluating someone for depressed mood, just as it is important to evaluate mood when providing care for other medical illness. 

Beyond the focused psychiatric history (including characterising mood, presence of other psychiatric syndromes such as anxiety or psychosis, and inquiring about predisposing, precipitating, perpetuating, and protecting factors*), it is important to do a general review of systems (screening for other symptoms they may be experiencing), review their medical history, the medications they take (including anything over the counter), and any substances they use (consider use or withdrawal from substances as a potential cause of depressed mood). Physical examination will be informed by the history. Consider cardiorespiratory and neurological examinations, among others. According to the UpToDate article, "Unipolar depression in adults: Assessment and diagnosis" the indications to order investigations are as follows:

1. New onset depression (especially if the psychosocial context or precipitant is not clear)
2. Severe depression (particularly patients with melancholic or psychotic features)
3. Treatment-resistant depression

Commonly performed investigations in the otherwise asymptomatic person are as follows:

• Complete blood count
• Serum chemistry panels
• Urinalysis
• TSH
• B-hCG
• Urine tox screen
• Others as indicated by the history and physical examination

More extensive testing (ex: vitamin B12, folate, ECG) may be warranted based on an individual's risk factors, including having chronic medical conditions or being at increased risk for medical illnesses (this includes elderly or institutionalized patients and patients with self-neglect or substance use disorders). UpToDate also states, "Neuroimaging studies are typically reserved for patients whose evaluation suggests an increased likelihood of structural brain disease. These include focal neurologic signs on physical examination or persistent cognitive impairment. However, it is reasonable to obtain neuroimaging in older depressed patients, especially patients with new onset depression in later life."

*A factor that may contribute to depression and other mental health problems is a history of trauma, be it physical, sexual, emotional, or otherwise. This could have been something experienced by the person or a witnessed experience. It is important to ask about this when performing a mental health assessment (including screening for this in well-established primary care relationships, particularly in patients who are at increased risk, even in the absence of depression) along with a screen for other significant psychosocial factors that could be contributing. It is important to be aware of the fact that talking about trauma can be particularly traumatic in and of itself for patients, so patients may choose not to disclose information about a history of abuse. And that is okay. As the clinician, what's most important is that you've created space for the patient to share their experiences of trauma, so that if and when they are ready and want to share, you can try to help in their process of healing. 

Depression

Key Feature 2: Screen for depression and diagnose it in high-risk groups (ex: certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 3: In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient.
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, Treatment

Immigrants

Key Feature 4a: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Screen for depression (i.e., because they are at higher risk and frequently isolated).
Skill: Clinical Reasoning
Phase: History

Multiple Medical Problems

Key Feature 3: In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (ex: physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology.
Skill: Clinical Reasoning
Phase: Hypothesis generation

I was tempted to tack these learning objectives into a previous blog that fit, partly due to the urge to be lazy, but also because they really do mesh with so many patient situations I encounter. In previous blog posts, I have discussed the power of the social determinants of health to influence health status, which of course includes mental health. I have also talked about the bidirectional influence of mood and chronic pain, and I have talked about the importance of screening for postpartum depression. Without being too much of a bummer, depression is really everywhere. Or, without being too heavy, and recognising that I am skewed by seeing a greater proportion of the population who may be at increased risk for mental health concerns given their history medical issues, perhaps it is better to say that it can be anywhere. Certainly not everyone is depressed, but almost every single person in their lives has risk factors for depression or anxiety. On the flip side, some people are extremely resilient, and managing to deke out this omnipresent state despite a significant number of risk factors can be truly remarkable. Nevertheless, I think it is important to recognise, as a family physician, that any of my patients may be at increased risk for poor mental health if they present with ongoing health concerns. I may be the one person in the medical field who they are in contact with to do so.

I can't tell you the number of times patients have presented for bodily concerns and, once probed, reveal significant mood disturbance. After appropriate investigation for the other bodily concerns, depression, anxiety, or other psychiatric distress may in fact be the most likely etiology responsible for them. Alternatively, it could be a secondary to chronic physical discomfort, or it could be totally unrelated. In some patients, it may be all too intimately mumble-jumbled to really know. But does it matter? I would argue that it doesn't, and that whether it causes, contributes, results from, or is entirely separate from other somatic complaints, treating mental health concerns may have the possibility to alleviate or lessen the severity of other symptoms, or at the very least increase one's capacity to cope with them, and it deserves treatment as it's own disease process that decreases quality of life. It takes two seconds to ask, and patients are often so very honest. But yet clinicians often don't ask, at least when it is not their domain of care (ex: Emergency Room Physicians, Surgeons, Cardiologists, etc. etc. etc.). Partly, this makes sense. They are there to treat a specific issue and not the rest of the body. I can't imagine practicing medicine like that, although I appreciate specialists' commitment to ameliorating and improving the lives of the patients they serve in their way. As a Family Physician, screening and managing depression and anxiety, and other mental health concerns (ex: abuse, whether physical/emotional/sexual/financial etc. or self-inflicted such as via harmful use of prescribed or non-prescribed substances) is absolutely under my purview, and detecting and providing therapy for these issues could arguably be how I may have the greatest impact in my career given the prevalence of it. It is also intimately related to quality of life at least as much as any other disease process, and helping my patients achieve better quality of life is my purpose for doing what I do. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a multi-faceted approach to treatment
• Develop appropriate pharmacologic and non-pharmacologic management plans including follow-up for patients with common mental health disorders

Key Feature 4: After a diagnosis of depression is made, look for and diagnose other co-morbid psychiatric conditions (ex: anxiety, bipolar disorder, personality disorder). 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 5: In a patient diagnosed with depression, treat appropriately:

• Drugs, psychotherapy
• Monitor response to therapy
• Active modification (ex: augmentation, dose changes, drug changes)
• Referral as necessary

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

At this point in my residency, I don't yet have a panel of patients I follow up with regularly. However, because I have a once-weekly callback shift in my home family clinic, I occasionally am lucky enough to be able to follow up with the patients I've seen there previously. Today, on my callback shift, the 19 year old female I previously wrote a previous post about who was having suicidal ideation returned to clinic for her followup appointment. 

I did not delve into the quality of this patient's depression in that last post, but her depression was largely of the seasonal affective variety. For most depressive disorders, first line treatment is antidepressant medication and/or psychotherapy. This major depressive disorder is of a unique subtype, however, in that first line therapy includes light therapy, a totally different modality of treatment. Other first-line recommendations include going for walks outside (even when cloudy), aerobic exercise, and having good sleep hygiene, the latter two of which would probably be useful first-line recommendations for any subtype of depression. See the UpToDate article, Seasonal affective disorder: Treatment (2017), for more information.

This patient was already on a high-dose of an antidepressant and described feeling as though she wasn't getting relief from it (although she had been on it already for 4 years or so, so it was pretty hard to know for sure), I screened her for any other psychiatric symptoms suggesting an alternative diagnosis. She indeed did have anxiety, as she was frequently having panic attacks at night, but she denied ever having elevated or energetic periods in keeping with mania or hypomania, and she denied and on examination did not appear to have any symptoms or signs of psychosis, reducing the likelihood for having disorders associated with this such as schizophrenia or schizoaffective disorder. In my clinical opinion, it seemed as though the anxiety was largely interrelated with the depression, and since the treatment for both depression and anxiety are often similar, this didn't change too much about how we would develop a plan for her treatment.

As this patient was characterised as having suicidal ideation in that previous post, you're probably wondering, just as I was when I saw her name on the dayshift, how she was doing in this regard in followup. At this visit, she was still feeling as depressed as at the last, but she was feeling stable in that her mood was not worsening, and she still did not have any intent of acting on her suicidal thoughts. And again, she didn't think she would feel like she was going to consider acting on her suicidal thoughts anytime in the near future. Phewf. And although her energy was low, at this appointment she was feeling open to giving new therapies a chance - she felt she had nothing to lose at this point. So we went as multi-faceted in our therapeutic approach as I can imagine any disease treatment can get. The plan was as follows:

1. Antidepressant medication 
2. Light therapy
3. Cognitive behavioural therapy
4. Sleep hygiene
5. Aerobic exercise and going for walks
6. Reconnecting with old friends (although not specifically evidence-based, on history I learned that she had fallen out of touch with her closest friends, and I encouraged her to reach out to try to re-establish connections with them)
7. A doctor's note giving her a couple of days off work to give her a bit of respite and get herself organized regarding the above treatment modalities
8. Follow-up appointment in 4 weeks
9. Safety plan for when and how she should return for professional help should she begin to feel acutely worse
10. Consider changing or augmenting medication +/- referral for electroconvulsive therapy in the future if the above interventions are given a good try but turn out not to be sufficient

I wrote out the above list with unchecked boxes in front of each item and gave it to her once we drew up this mutually agreed upon plan. I won't get into the details regarding the specifics of each treatment on that list, but the plan was more nuanced than this of course. For example, we came up with a specific plan that was tailored for her in terms of how she was going to include more aerobic exercise in her life over the next month, and we discussed strategies that she could use to promote good sleep hygiene. And they were all agreed upon in in keeping with SMART goal criteria (specific, measurable, achievable, realistic, timely). You may be thinking that this is an extensive to do list for anyone to followup on, let alone someone who is feeling depressed with all of the demotivation that can come along with that. Certainly it is. However, she was already on a high dose of an antidepressant and using light therapy optimally (so she was simply continuing as usual with these two therapies). She also had a previous positive experience with psychotherapy in the past, so the idea of this option was well-received. 

I would love to know how she is doing at her 4 week follow-up appointment, and if the stars align, I may be in clinic that day to reassess. Until then, it has been a great reminder of the ways in which I can incorporate a multifaceted approach to treatment of illness and restoration of function.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Recognize, and appropriately respond to, the need for urgent and emergent intervention
• Assess a patient’s suicide risk, homicide risk and judgment
  

Crisis

Key Feature 2: Identify your patient’s personal resources for support (ex: family, friends) as part of your management of patients facing crisis.
Skill: Patient Centered, Clinical Reasoning
Phase: History, Treatment

Key Feature 3: Offer appropriate community resources (ex: counselor) as part of your ongoing management of patients with a crisis.
Skill: Patient Centered, Professionalism
Phase: Treatment

Key Feature 4: Assess suicidality in patients facing crisis.
Skill: Clinical Reasoning
​Phase: Hypothesis generation, Diagnosis

Key Feature 8: Negotiate a follow-up plan with patients facing crisis.
Skill: Clinical Reasoning, Communication
Phase: Treatment, Follow-up

Depression

Key Feature 1a: In a patient with a diagnosis of depression: Assess the patient for the risk of suicide.
Skill: Clinical Reasoning, Selectivity
Phase: History

Key Feature 1b: Decide on appropriate management (i.e., hospitalisation or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk). 
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Suicide

Key Feature 1: In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (ex: ideas, thoughts, a specific plan).
Skill: Clinical Reasoning
Phase: History

Key Feature 2: Given a suicidal patient, assess the degree of risk (ex: thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (ex: immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling).
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Treatment

Key Feature 3: Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (ex: return to the emergency department [ED], call a crisis hotline, re-book an appointment).
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

A 19 year old female presented to clinic for a yearly refill of her antidepressant. When I asked her what she takes it for, she said it was for depression and anxiety. She didn't elaborate. I probed further by  asking how her mood has been lately. She said it had been worsening over the past month or so but again was brief in her answer. By around this point I started to clue in to the fact that not only were her answers minimally detailed, she was also slow to speak them (psychomotor retardation). I asked her if she was having thoughts about self-harming or suicide. She responded to say she was having suicidal thoughts. She denied any homicidal ideation. I asked her if she had thought of a plan for committing suicide, and without time to think she answered very matter-of-factly, "Yeah I think about hanging myself. When I was younger I used to think I'd want to drown, but now I think hanging makes the most sense." I asked if she's been thinking about going through with it, and she said, "There are all these deaths that seem to be happening around me, even like celebrities and whatnot, and I think to myself how those people have the courage to do what I haven't been able to. But then I think to myself how that's just a temporary solution to a bigger problem sort of thing." I didn't quite understand what she meant by her last sentence, but I was a little relieved to hear she had a protective thought. Just how at risk was this patient of completing suicide?

In patients who endorse having suicidal thoughts, it's important to clarify 

1. Onset and frequency
2. Active vs passive (thinking about taking an action to commit suicide vs wishing death would happen to them such as wanting to die in an accidental car crash)
3. Organized plan +/- final arrangements (ex: suicide note) and whether they have the means (ex: have rope at home)
4. Intent: "Do you want to end your life?"
5. Past attempts (how, what happened) or practiced attempts
6. Provocative factors
   1. Predisposing factors
      1. Abuse (physical, sexual, verbal, emotional, financial)
      2. Neurological concerns (head trauma, dementia, stroke)
      3. Developmental issues
      4. Legal concerns
   2. Precipitating factors (ex: substance use, relationship distress)
7. Protective factors (coping mechanisms, supports)
8. Ambivalence: "I wonder if there is a part of you that wants to live, given that you came here for help?"

SADPERSONS mnemonic for risk-stratifying patients with suicidal ideation (1 pt for each if present)

1. Sex = male
2. Age < 19 or > 45
3. Depression 
4. Previous attempt or FHx
5. EtOH/substance use
6. Rational thinking loss (poor insight, impaired judgment)
7. Social supports lacking
8. Organized plan
9. No spouse
10. Sickness

• 0-4 = low risk
• 5-6 = medium risk
• 7-10 = high risk

​
According to the SADPERSONS suicidal ideation risk stratification mnemonic, this patient was low risk. Note that depression gives one point on the SADPERSONS scale, which is something important to note as it raises the point that suicidal ideation is not a phenomenon that is unique to patients with depression. According to the UpToDate article, "Suicidal ideation and behaviour in adults," "The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders including panic disorder, posttraumatic stress disorders, and delirium." This article also notes, "Anxiety disorders more than double the risk of suicide attempts (odds ratio 2.2), and a combination of depression and anxiety greatly increases the risk (odds ratio 17). Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase the risk regardless of the specific diagnosis."

Once you've got a patient in front of you who endorses suicidal ideation, what are your next steps? My approach to a patient that is risk-stratified for suicidal ideation (SI) as either low, medium, or high risk is as follows:

1. Low risk: Develop safety plan patient agrees to that includes:
   1. Setting up a follow-up appointment, preferably within 1 wk or so, ideally with the same primary care provider and a professional counselor
   2. Avoiding triggers including substances
   3. Not harming themselves, and to contact health care worker (or present to Emergency Department) or call crisis line if feelings return or intensify
2. Medium risk: My decision to admit to hospital +/- Form 1 in a medium risk patient depends on:
   1. The degree of social supports present
   2. Whether there is a loss of rational thinking (psychosis)
   3. Whether the patient is likely to encounter any acute SI precipitants (ex: substance use)
3. High risk = Hospitalization +/- Form 1

The 19 year old patient in the office agreed to follow-up in clinic in one week, agreed to avoiding triggers (aka precipitants) for her SI, and agreed to present to the ED or call a suicide crisis line before taking any action if she was having thoughts about completing suicide.

The Canadian Association for Suicide Prevention website has a list of local crisis centres organized by province on their home page. I provide both the CSAP website address and the province-wide crisis line (1-800-SUICIDE) to patients at risk of SI.