Diagnosis of Suicide
Suicide Diagnosis: Book Excerpts
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Diagnostic Tests for Suicide: Online Medical Books
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DEPRESSION:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there associated headache, papilledema, dementia, or focal neurologic signs? These findings would suggest a space-occupying lesion. This is something the clinician does not want to miss.
- Are there endocrine changes? A number of endocrinologic diseases may present with depression, including Cushing's disease, myxedema, hyperthyroidism, and menopause.
- Is there marked loss of appetite, weight, and libido? Endogenous depression, unipolar depression, and the depressive phase of manic-depressive psychosis may present with these findings. On the other hand, neurotic depressive reaction usually is not associated with significant loss of appetite, weight, or libido.
DIAGNOSTIC WORKUP
If the patient is suicidal, one should not hesitate to make a psychiatric referral or plan hospitalization immediately. To rule out organic causes, routine laboratory studies include a CBC, sedimentation rate, chemistry panel, VDRL test, and thyroid profile. If Cushing's syndrome is suspected, a serum cortisol and cortisol suppression test should be done. If menopause is suspected, order a serum FSH and estradiol level. A trial of estrogen therapy may be warranted. A CT scan of the brain should probably be done in all cases to exclude a brain tumor, especially if there is no response to treatment! Office tests to evaluate nonorganic depression include the Beck Depression Inventory and the Hamilton Depression Scale. A referral to a psychiatrist should also be considered early if the depression is severe or if there is suicidal ideation.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is all important. A triiodothyronine (T3) level, total thyroxine (T4) level, and free thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes, toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and 17-hydroxycorticosteroid level should be done on anyone suspected of having endogenous depression. (Possibly all depressed patients should get this screen.) Skull x-ray film, EEG, CT scan and even a spinal tap [to rule out multiple sclerosis (MS) and lues] may be worthwhile when other neurologic signs are present.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Depression:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what's bothering her. How does her current mood differ from her usual mood? Then ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (SeeSuicide: Caring for the high-risk patient.)
Ask the patient about her family — its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed, and whether anyone important to the patient has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she's feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.
Cultural cue
Patients who don't speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Violent behavior:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
During your evaluation, determine if the patient has a history of violent behavior. Is he intoxicated or suffering symptoms of alcohol or drug withdrawal? Does he have a history of family violence, including corporal punishment and child or spouse abuse? (See Understanding family violence.)
Watch for clues indicating that the patient is losing control and may become violent. Has he exhibited abrupt behavioral changes? Is he unable to sit still? Increased activity may indicate an attempt to discharge aggression. Does he suddenly cease activity (suggesting the calm before the storm)? Does he make verbal threats or angry gestures? Is he jumpy, extremely tense, or laughing? Such intensifying of emotion may herald loss of control.
If your patient’s violent behavior is a new development, he may have an organic disorder. Obtain a medical history, and perform a physical examination. Watch for a sudden change in his level of consciousness. Disorientation, failure to recall recent events, and display of tics, jerks, tremors, and asterixis all suggest an organic disorder.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fontanel depression:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Obtain a thorough patient history from a parent or caretaker, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant’s fluid intake and urine output over the past 24 hours, including the number of wet diapers during that time. Ask about the child’s preillness weight, and compare it to his current weight; weight loss in an infant reflects water loss.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Major depression:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing major depression.
The diagnosis is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms. A toxicology screening may suggest drug-induced depression.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Depression:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what’s bothering her. How does her current mood differ from her usual mood? Then ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (See Suicide: Caring for the high-risk patient, page 234.)
Ask the patient about her family—its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed and whether anyone important to her has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she’s feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.
Cultural Cue: Patients who don’t speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Violent behavior:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
During your evaluation, determine if the patient has a history of violent behavior. Is he intoxicated or suffering symptoms of alcohol or drug withdrawal? Does he have a history of family violence, including corporal punishment and child or spouse abuse? (See Understanding family violence, page 800.)
Watch for clues indicating that the patient is losing control and may become violent. Has he exhibited abrupt behavioral changes? Is he unable to sit still? Increased activity may indicate an attempt to discharge aggression. Does he suddenly cease activity (suggesting the calm before the storm)? Does he make verbal threats or angry gestures? Is he jumpy, extremely tense, or laughing? Such intensifying of emotion may herald loss of control.
If your patient’s violent behavior is a new development, he may have an organic disorder. Obtain a medical history, and perform a physical examination. Watch for a sudden change in his level of consciousness. Disorientation, failure to recall recent events, and a display of tics, jerks, tremors, and asterixis all suggest an organic disorder.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fontanel depression:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a thorough patient history from a parent or caregiver, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant’s fluid intake and urine output over the last 24 hours, including the number of wet diapers during that time. Ask about the child’s pre-illness weight, and compare it with his current weight; weight loss in an infant reflects water loss.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Depression:
History and mental status examination (MSE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Symptoms and signs. The diagnosis of major depression depends on a systematic assessment of psychiatric symptoms and signs (i.e., the history and MSE). At least five symptoms from the following list must be present most of the day, nearly every day, for 2 consecutive weeks or more: depressed mood; decreased interests or pleasure; weight or appetite change; sleep disturbance; psychomotor agitation or retardation; anergia; worthlessness or guilt; trouble thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plan, or attempt. One of the symptoms must be depressed mood or decreased interests. Although somewhat arbitrary, the following grouping of symptoms may facilitate their recall.
1. Mood—depressed mood: “How is your mood, your spirits?” “Sad,” “blue,” “down,” crying spells; the patient also may have irritability, anxiety, decreased mood reactivity, and decreased hedonic capacity.
2. Ideational or psychological—decreased interests: thoughts of worthlessness, helplessness, hopelessness, suicide; decreased ability to concentrate; and ruminative thinking (thoughts dwelling on depressive themes). Given the risk of suicide, all patients with clinically significant depressive symptoms should be asked about their suicidal thoughts (“Many people who are depressed have thoughts about dying, wanting to be dead, or wanting to kill themselves. What thoughts like this have you had?”) (Chapter 3.4).
3. Neurovegetative or somatic—change in appetite and weight: anorexia and weight loss are most common but hyperphagia and weight gain are possible; change in sleep (insomnia, especially early morning awakening is most common but hypersomnia is possible); decreased energy, decreased libido, psychomotor slowing or agitation; diurnal variation (in more severe cases, mornings are worse is the most common pattern).
B. Other factors. In addition to the symptoms that define the condition, other factors should be assessed:
1. Function. How is the depression affecting performance at work? Interpersonal relations? Attention to grooming and other activities of daily living?
2. Psychosocial stressors. Both acute life events and ongoing stressors may be relevant.
3. Prior depressive episode. Detailed information about previous episodes and their treatments will guide both prognosis and current treatment.
4. Family history may reflect genetic vulnerability toward the condition, and also can shape the patient’s perceptions about the illness and recommended treatments.
5. General medical history. Careful review of past and current illnesses and drugs (including alcohol and other recreational drugs) is needed to identify potential physiologic causes or contributors.
6. Other pertinent negatives. A past history of mania or psychosis suggests bipolar or schizoaffective disorder rather than major depression. Objective cognitive deficits (as opposed to merely subjective cognitive complaints) require further evaluation to determine the presence and cause of delirium or dementia, in which depressive symptoms are frequent.
Physical examination.
Any patient with severe depression sufficient to warrant treatment should have both a general screening physical examination, paying particular attention to signs of anemia and endocrinopathies (e.g., hypothyroidism) and a careful screening neurologic examination.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Suicidal Risk:
History.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The major risk factors for suicidal patients are being male, older, unemployed, unmarried, living alone, having a chronic illness, gay or lesbian, adolescent, and being in a socially alienated group (5). The two major risk factors for child suicide are conflict with parents and an undiagnosed psychiatric disorder. For youth, family and interpersonal conflict were the most prevalent reported precipitating event (4). Drinking alcohol, especially in combination with depression, increases the rate of death; 15% of alcoholics commit suicide. Patients with previous suicidal behavioral are at increased risk for subsequent suicide attempts. Is there a history of previous suicide attempts, explicit statement of suicidal ideas or feelings (such as, “I want to go to sleep and never wake up” or “I’m going away and you won’t have to worry about me anymore”), or development of suicidal plan? Some patients may also have a history of self-inflicted injuries, reckless behavior, and unexplained accidents. Clear indication of a suicide plan is the making of a will or distributing personal possessions. All these behaviors lead to increased suicide risk; it is important to assess for them.
Physical examination
Once a patient is identified as depressed (Chapter 3.3), the clinical interview and the mental status examination (MSE) are the primary methods for assessing severity of suicide risk. To assist the provider in assessing the risk of suicide, Table 3.2 identifies emotional and behavioral changes associated with suicide. When these finding are present, the clinician should assess the patient’s suicide risk.
Diagnostic assessment
All depressed patients need screening for conditions associated with increased suicide risk (Table 3.2). If the patient is depressed or has one or more conditions associated with increased suicide risk, ask specific questions for suicide assessment. These questions will not increase the patient risk of suicide, but rather will help guide development of a treatment plan. For patients with mild risk—experiencing passive or active suicidal ideation—contract for safety to establish a therapeutic relationship and identify the personal and professional resources for the patient and involved providers to contact if risk increases. The patient at medium risk—suicide plan without means to accomplish the plan—should return to the office frequently with a personal support person to continue to assess suicide risk, assess effectiveness of medication, and receive new prescriptions. Patients who have an active plan and means to carry out that plan are at high risk for suicide and should be transported to a hospital emergency room.
References
1. American Foundation for Suicide Prevention (1998). Suicide facts. www.afsp.org/
suicide
2. Beck AT, Kovacs M, Weissman A. Assessment of suicidal ideation: the scale for suicide ideation. J Consult Clin Psychol 1979;47:343–352.
3. Centers for Disease Control and Prevention. Suicide among children, adolescents, and youth: United States, 1980–1992. MMWR 1995a;44:289–291.
4. Centers for Disease Control and Prevention. Fatal and non-fatal suicide attempts among adolescents: Oregon, 1988–1993. MMWR 1995b;44:312–323.
5. Maxmen JS, Ward ND. Essential psychopathology and its treatment, 2nd ed. New York: WW Norton & Co, 1995:23–25.
6. American Foundation for Suicide Prevention. Suicide prevention resources (online). www.afsp.org
7. Ventura SJ, Anderson RN, Martin JA, Smith BL. Births and deaths: preliminary data for 1997. Natl Vital Stat Rep 1998;47(4):1–41.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Depression:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Dysthymia
❑ Major depression
❑ Adjustment disorder with depressed mood
❑ Seasonal affective disorder
❑ Bipolar disorder
❑ Drug-induced
❑ Grief
❑ Thyroid disease
❑ Dementia
❑ Stroke
❑ Paraneoplastic
Diagnostic Approach
Depression often presents in primary care settings masked in the form of somatic symptoms, such as anorexia, weight loss, fatigue, insomnia (especially early morning awakening), or difficulty concentrating. It is also common for the perception of symptoms produced by another organic cause to be heightened by depression. Depression becomes pathologic when it interferes with normal function.
Once depression is identified, it is critical to assess suicide risk. The best way to do this is to straightforwardly ask patient, if they have thought of harming themselves and if so, do they have a plan. Risk factors for suicide include living alone, prior suicide attempt, family history of suicide attempt or substance abuse, general medical illness, extreme hopelessness, psychosis, and substance abuse.
The SQ is a one-question screen: “Have you felt depressed or sad much of the time in the past year?”. The CAGE questionnaire is designed to identify drinkers who are alcohol-dependent or heavy drinkers (>8 drinks/day):
1) “Have you ever felt you should Cut down your drinking?” 2) “Have people Annoyed you by criticizing your drinking?” 3) “Have you ever felt bad or Guilty about your drinking?” 4) “Have you ever taken a drink first thing in the morning (Eye-opener)?”.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Depression, major:
Diagnosis
(Handbook of Diseases)
The DSM-IV-TR describes specific characteristics of patients with this condition. (See Diagnosing major depression.)
The diagnosis of major depression is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms. A toxicology screening may suggest drug-induced depression.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Violent behavior:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
During your evaluation, determine whether the patient has a history of violent behavior. Is he intoxicated or suffering symptoms of alcohol or drug intoxication or withdrawal? Does he have a history of family violence, including corporal punishment and child or spouse abuse? (See Understanding family violence.)
Watch for clues indicating that the patient is losing control and may become violent. Has he exhibited abrupt behavioral changes? Is he unable to sit still? Increased activity may indicate an attempt to discharge aggression. Does he suddenly cease activity (suggesting the calm before the storm)? Does he make verbal threats or angry gestures? Is he jumpy, extremely tense, or laughing? Such intensifying of emotion may herald loss of control.
If your patient's violent behavior is a new development, he may have an organic disorder. Obtain a medical history and perform a physical examination. Watch for a sudden change in his level of consciousness. Disorientation, failure to recall recent events, and display of tics, jerks, tremors, and asterixis all suggest an organic disorder.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Fontanel depression:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a thorough patient history from a parent or caretaker, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant's fluid intake and urine output over the past 24 hours, including the number of wet diapers during that time. Ask about the child's preillness weight, and compare it with his current weight; weight loss in an infant reflects water loss. Then perform a complete physical examination.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is all important. A
triiodothyronine (T3) level, total thyroxine (T4) level, and free
thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes,
toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and
17-hydroxycorticosteroid level should be done on anyone suspected of having
endogenous depression. (Possibly all depressed patients should get this
screen.) Skull x-ray film, EEG, CT scan, and even a spinal tap (to rule out
multiple sclerosis [MS] and lues) may be worthwhile when other neurologic
signs are present.
case presentation #14
A 62-year-old white woman is brought to your office because the family
has noticed that she is depressed. The patient has insomnia, frequent
nightmares, and weight loss over the past 6 months despite the fact that she
has a good appetite.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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