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Overview of Psychiatric Overview of Psychiatric DisordersDisorders
Douglas Jacobs, MDDouglas Jacobs, MDAssociate Clinical Professor of PsychiatryAssociate Clinical Professor of Psychiatry
Harvard Medical SchoolHarvard Medical School
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Overview of Clinical Context of Overview of Clinical Context of Spontaneous ReportsSpontaneous Reports SuicideSuicide
– clinical and demographic correlatesclinical and demographic correlates– clinical featuresclinical features
Suicidal BehaviorSuicidal Behavior– definitional issues as they relate to spontaneous reportsdefinitional issues as they relate to spontaneous reports
DepressionDepression– definitions - illness vs symptomsdefinitions - illness vs symptoms
relationship to medicationsrelationship to medications– relationship to suiciderelationship to suicide
Depression and Suicide in Ages 15-24Depression and Suicide in Ages 15-24– diagnostic issuesdiagnostic issues– epidemiology and risk factorsepidemiology and risk factors
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SUICIDSUICIDEE
Neurobiology
Severe MedicalIllness
Impulsiveness
Access To WeaponsHopelessness
Life Stressors
Family History
SuicidalBehavior
Personality Disorder/Traits
No apparentpsychopathology
Substance Use/Abuse
Psychiatric Illness
Co-morbidity
Suicide: A Multi-Factorial Event - AdultSuicide: A Multi-Factorial Event - Adult
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Incidence of SuicideIncidence of Suicide
30,000 suicides per year in the US30,000 suicides per year in the US
0.01% annual incidence rate (11.4/100,000) 0.01% annual incidence rate (11.4/100,000)
80% suicides are in males (4:1 m/f ratio) 80% suicides are in males (4:1 m/f ratio)
Third leading cause of death in the 15-24 age Third leading cause of death in the 15-24 age group representing 20% of suicides group representing 20% of suicides (approximately 6,000)(approximately 6,000)
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Suicide: Clinical FeaturesSuicide: Clinical Features
Associated with severe depressionAssociated with severe depression
Majority not in mental health treatmentMajority not in mental health treatment
75% have seen a physician in previous six months75% have seen a physician in previous six months
No one factor predictive of suicideNo one factor predictive of suicide
60% suicide on first attempt60% suicide on first attempt
No medication has ever been proven to cause suicideNo medication has ever been proven to cause suicide
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Profile of the Suicides in the Accutane Profile of the Suicides in the Accutane Medwatch ReportsMedwatch Reports 30,000 suicides per year in the 30,000 suicides per year in the
USUS
0.01% annual incidence rate 0.01% annual incidence rate (11.4/100,000) (11.4/100,000)
80% suicides are in males (4:1 80% suicides are in males (4:1 m/f ratio)m/f ratio)
Third leading cause of death in Third leading cause of death in the 15-24 age group the 15-24 age group representing 20% of suicidesrepresenting 20% of suicides
Associated with severe depressionAssociated with severe depression
Majority not in mental health Majority not in mental health treatmenttreatment
75% have seen a physician in 75% have seen a physician in previous six monthsprevious six months
No one factor predictive of suicideNo one factor predictive of suicide
60% suicide on first attempt60% suicide on first attempt
No medication has ever been proven No medication has ever been proven to cause suicideto cause suicide
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Definitional Issues - Suicidal BehaviorDefinitional Issues - Suicidal BehaviorSuicidal Ideation:Suicidal Ideation:
– A) nonspecific -- thoughts of death A) nonspecific -- thoughts of death – B) specific -- the thought of death includes B) specific -- the thought of death includes
an intent to die with a plan of action an intent to die with a plan of action
Prevalence of suicidal Prevalence of suicidal ideation = 2.6%ideation = 2.6%
Thoughts of death = 28.2% Thoughts of death = 28.2%
Suicidal ideation (definition B) is associated Suicidal ideation (definition B) is associated with a psychiatric with a psychiatric disorder, primarily depressiondisorder, primarily depression
Suicide Attempts:Suicide Attempts: – A) (U.S.) Potential or actual self-injurious A) (U.S.) Potential or actual self-injurious
behavior accompanied by intent to diebehavior accompanied by intent to die– B) (Europe) Parasuicide -- a self-harmful B) (Europe) Parasuicide -- a self-harmful
act with nonfatal outcome -- intent not act with nonfatal outcome -- intent not included in definitionincluded in definition
(U.S.) Current prevalence estimates: (U.S.) Current prevalence estimates: 0.3 to 0.8%0.3 to 0.8%– Male/Female ratio 1:3 (inverse of Male/Female ratio 1:3 (inverse of
suicides)suicides)– Attempts/completion 18/1Attempts/completion 18/1
Higher incidence of attempts in 15-24 age Higher incidence of attempts in 15-24 age population: 100/1 (parasuicide)population: 100/1 (parasuicide)
Serious suicide attempts indicative of severe Serious suicide attempts indicative of severe psychiatric illnesspsychiatric illness
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Ideators: 5,000,000*Attempters: 600,000*Completers: 31,284 (1995)
Suicide Ideators (2.6%)
Suicide Attempters
Completers
*estimate
Thoughts of death (28%)
Self Destructive Behavior
Overview of Suicidal BehaviorOverview of Suicidal Behavior
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Depression: EpidemiologyDepression: Epidemiology
Prevalent disorder 12% annually - 20 million peoplePrevalent disorder 12% annually - 20 million people
Undertreated and Underdiagnosed - Only 20% with Undertreated and Underdiagnosed - Only 20% with recent episodes in treatment; 40% lifetime. recent episodes in treatment; 40% lifetime.
20% appear in general medical practices; 50% 20% appear in general medical practices; 50% undiagnosedundiagnosed
Decreased age of onset since WW IIDecreased age of onset since WW II
Male/Female ratio 1:2Male/Female ratio 1:2
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Depression: The Illness VersusDepression: The Illness VersusDepressive Symptoms - (The Blues)Depressive Symptoms - (The Blues)
Essential distinction:Essential distinction: An An illnessillness A A normalnormal reactionreactionto life situationsto life situations
Prevalence:Prevalence: 12%12% 25%25%
Symptoms:Symptoms: Multiple: mood,Multiple: mood, Single: moodSingle: moodthoughts, bodilythoughts, bodilyfunctionsfunctions
Duration:Duration: Persists, episodicPersists, episodic TemporaryTemporary
Suicide Potential:Suicide Potential: Can result inCan result in Rarely producesRarely producessuicidesuicide suicidal thoughtssuicidal thoughts
Treatment:Treatment: Requires specificRequires specific Requires a goodRequires a goodmedical/psychiatricmedical/psychiatric listener and/orlistener and/ortreatmenttreatment time to healtime to heal
DepressionDepression The BluesThe Blues
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The Issue of Medications The Issue of Medications and “Depression”and “Depression”
Are medications that are reported to cause depression Are medications that are reported to cause depression (approximately 100) associated with diagnosed (approximately 100) associated with diagnosed depressive disorders or depressive symptoms?depressive disorders or depressive symptoms?
Case reports vs empirical evidenceCase reports vs empirical evidence
Majority of evidence suggests association with Majority of evidence suggests association with depressive symptoms and depressive symptoms and notnot depressive disorders depressive disorders
Clinical significance of depressive symptoms Clinical significance of depressive symptoms is minimalis minimal
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Adolescent Depression - Clinical FeaturesAdolescent Depression - Clinical Features Increased moodiness, irritability, argumentativenessIncreased moodiness, irritability, argumentativeness
Poor concentrationPoor concentration
Sleep and appetite changesSleep and appetite changes
Increased self-criticismIncreased self-criticism
Despair, sadness, emptinessDespair, sadness, emptiness
Loss of energyLoss of energy
Lack of interest in usual activities and friendsLack of interest in usual activities and friends
Increased talk of death and dyingIncreased talk of death and dying
Threats of suicideThreats of suicide
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Why Adolescent Depression Is UndiagnosedWhy Adolescent Depression Is Undiagnosed
Normal adolescents often moody, Normal adolescents often moody, frequently arguefrequently argue
Symptoms of depression overlap with traits of Symptoms of depression overlap with traits of normal adolescencenormal adolescence
Parents, teachers and other adults label it “troubled Parents, teachers and other adults label it “troubled teenage behavior”teenage behavior”
Adolescents conceal symptoms from parents and Adolescents conceal symptoms from parents and care giverscare givers
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Adolescent Depression - Relationship to Adolescent Depression - Relationship to Stressful EventsStressful Events
Depression can occur after a stressful event or Depression can occur after a stressful event or in teenagers who have not experienced a in teenagers who have not experienced a stressful event (50-50)stressful event (50-50)
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Suicide Rates for All Persons and Suicide Rates for All Persons and Persons Aged 15 to 24, U.S., 1900-1995Persons Aged 15 to 24, U.S., 1900-1995
0
2
4
6
8
10
12
14
16
18
Year 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995
Ages 15-24
All Ages
Adapted from: Rosenberg et al, 1987. The Emergence of Youth Suicide: An Epidemiologic Analysis and Public Health Perspective. Annual Review of Public Health, 8:417-44Updated from National Center for Health Statistics Center
YearYear
SuicideSuicideRateRate
(per 100,000)(per 100,000)
PSY 110, (1063), 7/18/00
Ages 15-24Ages 15-241950 = 41950 = 41980 = 12.31980 = 12.3
13.3513.35
11.911.9
1950 1980
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SUICIDESUICIDE
Neurobiology
Impulsiveness
Family History
SuicidalBehavior
Conduct Disorder
No apparentpsychopathology
Substance Use/Abuse
Psychiatric Illness
Co-morbidity
Age Specific Stressors
•Self-esteem/imageSelf-esteem/image
•Academic ProblemsAcademic Problems
•Disciplinary Crisis/ Disciplinary Crisis/ Humiliation Humiliation
Exposure to Suicide
Access To Weapons
Hopelessness
Severe Acne
Suicide: A Multi-Factorial Event - AdolescentSuicide: A Multi-Factorial Event - Adolescent
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Note: Cases 15, 29, 1, 61, 14, 8 (patient had 2 courses of Accutane,argues against impulsive rx to Accutane
No Apparent PsychopathologyNo Apparent Psychopathology
Psychological autopsy studies reveal risk factors:Psychological autopsy studies reveal risk factors:– subsyndromal psychopathologysubsyndromal psychopathology– past suicidalitypast suicidality– familial psychiatric disorderfamilial psychiatric disorder– legal/disciplinary problemslegal/disciplinary problems– presence of firearm (or other lethal method)presence of firearm (or other lethal method)
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Clinical Analysis of Clinical Analysis of Spontaneous ReportsSpontaneous Reports
Dr. JacobsDr. Jacobs
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Questions AddressedQuestions Addressed
Is there any pattern to suicide reports in relationship Is there any pattern to suicide reports in relationship to Accutane?to Accutane?– e.g., gender distribution and on/off Accutanee.g., gender distribution and on/off Accutane
What is the significance of the temporal association What is the significance of the temporal association with “depression”?with “depression”?
Does Accutane exacerbate underlying Does Accutane exacerbate underlying psychopathology and lead to suicide?psychopathology and lead to suicide?
Does Accutane cause impulsive suicides?Does Accutane cause impulsive suicides?
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Categories of Suicides in Categories of Suicides in Medwatch ReportsMedwatch Reports
Relationship to Accutane UseRelationship to Accutane Use
Concealment of symptomsConcealment of symptoms
Confounding factors e.g. pre-existing Confounding factors e.g. pre-existing psychiatric historypsychiatric history
No apparent psychopathologyNo apparent psychopathology
MiscellaneousMiscellaneous
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Suicide: On/Off AccutaneSuicide: On/Off Accutane
30 cases were on Accutane, including 4 that were on 30 cases were on Accutane, including 4 that were on over 6 monthsover 6 months
24 cases were off Accutane24 cases were off Accutane
10 unknown10 unknown
No evidence of predominance of on/off factorNo evidence of predominance of on/off factor
Gender -- total males = 53, total females = 11Gender -- total males = 53, total females = 11 total suicides consistent with known demographics total suicides consistent with known demographics on/off ratio the same, regardless of genderon/off ratio the same, regardless of gender
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On Accutane < 1 MonthOn Accutane < 1 Month Off Accutane 9 MonthsOff Accutane 9 Months
AnalysisAnalysis: No consistent relationship to Accutane: No consistent relationship to Accutane
Case Example: Relationship to AccutaneCase Example: Relationship to Accutane
22 year-old male22 year-old male
FirearmFirearm
No relevant findingsNo relevant findings
19 year-old male19 year-old male
FirearmFirearm
History of psychosisHistory of psychosis
School stressorsSchool stressors
Duration 6 monthsDuration 6 months
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““Depression” Occurring While Depression” Occurring While On AccutaneOn Accutane
17 out of 64 reports17 out of 64 reports
10 cases committed suicide on Accutane10 cases committed suicide on Accutane
7 cases committed suicide off Accutane7 cases committed suicide off Accutane
Only one case had psychiatric treatmentOnly one case had psychiatric treatment
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14 year-old male14 year-old male
Committed suicide 2 months Committed suicide 2 months on Accutaneon Accutane
Psychiatric History -- none Psychiatric History -- none reportedreported
No depression or suicidal No depression or suicidal ideation noted while on ideation noted while on AccutaneAccutane
Pre existing depression and Pre existing depression and suicidal ideation -- revealed by suicidal ideation -- revealed by diary found after suicidediary found after suicide
Depression with suicidal Depression with suicidal ideation requires psychiatric ideation requires psychiatric treatmenttreatment
AnalysisAnalysis: Depression and : Depression and suicidal ideation concealed suicidal ideation concealed from family and physicianfrom family and physician
Case Example Case Example – Concealment of Symptoms– Concealment of Symptoms
Case DescriptionCase Description Case AnalysisCase Analysis
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Prior Psychiatric History Related to Prior Psychiatric History Related to On/Off AccutaneOn/Off Accutane
Question: What is the impact of Accutane on Question: What is the impact of Accutane on this at-risk group for exacerbation of underlying this at-risk group for exacerbation of underlying illness leading to suicide?illness leading to suicide?
Results: 9 cases on AccutaneResults: 9 cases on Accutane 12 cases off Accutane 12 cases off Accutane
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Reports With Prior Psychiatric History Reports With Prior Psychiatric History That Represent “Controls”That Represent “Controls”
> 6 mo> 6 mo
9 mo9 mo
18 mo18 mo
6 yrs6 yrs
6 yrs6 yrs
8 yrs8 yrs
~ 10 yrs~ 10 yrs
10 yrs10 yrs
• None of these reports developed
symptoms of underlying illness while on Accutane
• Accutane did not precipitate symptoms in persons at-risk
• Suicide unrelated to Accutane
Analysis: Suicide related to underlying psychiatric disorder
8 mo8 mo
6 mo6 mo
4 mo4 mo
6 mo6 mo
3 mo3 mo
18 mo18 mo
6 mo6 mo
1 yr1 yr
Time OffDuration
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18 year-old male18 year-old male
On Accutane < 1 monthOn Accutane < 1 month
No history of depression, No history of depression, mood swings or stressorsmood swings or stressors
Suicide by inhaling pellets Suicide by inhaling pellets placed in a canister, placed in a canister, attached to tubing and a attached to tubing and a face maskface mask
Engaged in risky behaviorEngaged in risky behavior
Method suggestive of Method suggestive of “getting high”“getting high”
AnalysisAnalysis: Suicide intent : Suicide intent not established, possible not established, possible accidental deathaccidental death
Case DescriptionCase Description Case AnalysisCase Analysis
Case Example Case Example –– No Apparent No Apparent PsychopathologyPsychopathology
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Case DescriptionCase Description Case AnalysisCase Analysis
Case of Murder-SuicideCase of Murder-Suicide
Duration = 8 monthsDuration = 8 months
Off Accutane 4 monthsOff Accutane 4 months
Method = killed self and child by Method = killed self and child by drowning (child not drowning (child not exposed to Accutane)exposed to Accutane)
Prior history = post-partum Prior history = post-partum depressiondepression
Accutane stopped because Accutane stopped because of “delirium”of “delirium”
Hospitalization offered Hospitalization offered but refusedbut refused
Infanticide consistent with Infanticide consistent with psychotic depressionpsychotic depression
Post-partum depression occurs Post-partum depression occurs in manic-depressive illnessin manic-depressive illness
““Delirium” most likely was Delirium” most likely was psychotic episodepsychotic episode
AnalysisAnalysis: Events related to : Events related to severe underlying psychiatric severe underlying psychiatric disorderdisorder
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21 year-old male21 year-old male
Psychiatric historyPsychiatric history
Patient had been in and out of Patient had been in and out of substance abuse rehabilitation substance abuse rehabilitation treatmenttreatment
On Accutane, 6 monthsOn Accutane, 6 months
No report of depressive symptoms No report of depressive symptoms nor of drug relapsenor of drug relapse
Committed suicide 1 year off Committed suicide 1 year off AccutaneAccutane
Substance abusers are at-risk for Substance abusers are at-risk for mood disorders and impulsive mood disorders and impulsive behaviorbehavior
Accutane did not cause relapse, Accutane did not cause relapse, mood symptoms, or impulsive mood symptoms, or impulsive actionsactions
AnalysisAnalysis: Suicide was related to : Suicide was related to pre-existing psychiatric conditions pre-existing psychiatric conditions and happened a considerable and happened a considerable amount of time after discontinuation amount of time after discontinuation of Accutaneof Accutane
Case DescriptionCase Description Case AnalysisCase Analysis
Case Example Case Example –– Substance Substance Abuse/Impulsive BehaviorAbuse/Impulsive Behavior
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Summary of Clinical AnalysisSummary of Clinical Analysis
No alteration of gender distributionNo alteration of gender distribution
No impact of on/off AccutaneNo impact of on/off Accutane
No significant relationship to concurrent “depression”No significant relationship to concurrent “depression”
No exacerbation of underlying psychiatric disordersNo exacerbation of underlying psychiatric disorders
Lack of warning signs consistent with youth suicideLack of warning signs consistent with youth suicide
No evidence of impulsive factorNo evidence of impulsive factor