Suicide continues to be a growing public health issue, and suicidal behaviors have been identified as a critical problem in the military population, with the number of soldiers dying by suicide exceeding those killed in action. This study aimed to characterize the population with attempted or completed suicides at the South Texas Veterans Health Care System and to analyze differences between those 2 populations. Other outcomes included adherence to psychiatric medications 6 months before suicide attempt or completion and psychiatric hospitalizations, psychiatric emergency department visits, and “no-show” appointments to mental health providers. Data were collected from the Suicide Prevention and Application Network for patients from South Texas Veterans Health Care System who had attempted or completed suicide between September 1, 2011, and September 30, 2013. Those data were supplemented with data from the computerized patient-record system. A retrospective chart review was conducted to collect further information. Of 120 events included in the analysis, there were 97 attempts (81%) and 23 completions (19%). Men were significantly more likely to complete a suicide than women were (P = .025). Those that attempted suicide were more likely to have previous attempts compared with those who completed suicide (mean of 1.01 versus 0.17 respectively, P = .0035). The most frequent method for attempt was toxic ingestion (accounting for 61.9% of attempts), while the most frequent method of completing suicide was by using a firearm (87.0%); there was a statistically significant difference found between methods used for suicide attempt versus completion (P < .0001). Significantly more attempts than completions involved alcohol (21 versus 0 respectively; P = .013). Those on divalproex were less likely to complete suicide (16 attempts, 0 completions; P = .040). There were no differences between groups for the secondary outcomes studied. Characteristics associated with completion of suicide in this analysis include male gender and using a firearm, while having previous attempts, being on divalproex, or using alcohol are associated with being more likely to attempt rather than complete suicide. More information is needed on how to appropriately identify high-risk veterans, and suicide safety plans should be developed for these patients to minimize their risk.Abstract
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Suicide is a leading cause of death in the US. Many factors impact suicide and suicide prevention; however, improved awareness, recognition, and depression management account for some of the best suicide prevention strategies. A depression case management service, compared to usual care, was evaluated for its ongoing assessment of patients with depression and improvements in care. Case management demonstrates improved documentation of PHQ9 scores, response rates, and remission rates when compared to usual care. Additional benefits of case management are seen in improved suicide assessment and potential for intervention and access to care.Abstract
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The first published literature on the topic of antidepressants and suicidality dates back to the mid-1950s. Today, 10 years after the black-box warning was issued, this controversial topic is still debated. This article will review the data behind the black-box warning and its revision; address the subsequent impact the warning had on depression diagnoses, prescribing patterns, follow-up visits, and suicide rates in the United States; and summarize meta-analyses on this topic published since the revised warning was issued in 2007. A PubMed database search using the MeSH terms Antidepressive Agents and Suicide was conducted from January 2012 through October 2014 to identify articles published on the impact the Food and Drug Administration's black-box warning had on health care at a national level and from January 2007 through October 2014 using the same MeSH terms to identify meta-analyses on the current research regarding the link between antidepressants and suicidality. Search results for both topics were further limited to those articles published in English on human participants with the age criteria Child: Birth – 18 years, Adolescent: 13-18 years, or Young Adult: 19-24 years. Due to the black-box warning, depression diagnoses and antidepressant prescription issuance rates declined in young patients. It is still debated whether the black-box warning had an untoward effect on suicide rates. Most of the meta-analyses identified a small risk of suicidality in the populations studied. Because of the varying nature of the meta-analyses and the major limitation of the limited availability of prospectively collected suicidality data, an absolute risk is still yet to be determined. More studies on antidepressants conducted to prospectively identify suicidality in patients with Major Depressive Disorder and other varying diagnoses need to be completed to truly identify the incidence of suicidal behavior and ideation when initiating antidepressants. Albeit seemingly low, there is a risk of suicidality when initiating antidepressants; there is also risk in not treating depressed patients with antidepressants in whom they are indicated. Clinicians must be cognizant of this risk and monitor high-risk patients per the Food and Drug Administration–recommended guidelines.Abstract
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Suicidal thoughts and behaviors are highly associated with major psychiatric illnesses, including depression, schizophrenia, and substance related disorders.1 Suicide is a major cause of death in individuals with mood disorders, and mortality rates are markedly higher in this patient cohort compared with those without mental illness.2,3 The estimated lifetime rate of suicide in those with schizophrenia, major depressive disorder, and bipolar disorder are 6.0%, 14.6%, and 15.5%, respectively, as compared with 0.72% in the general population.4 A literature search was conducted for empirical evidence of affect of suicidality with electroconvulsive therapy. Available evidence suggests electroconvulsive therapy may reduce the risk of suicide in various patient populations. This review seeks to summarize a selection of the pertinent literature describing electroconvulsive therapy's effects on suicidality.Abstract
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Conducting an accurate suicide risk assessment (SRA) is no simple task as there are a number of factors that influence an individual's level of suicidality and his/her willingness to share this information. Therefore, it is imperative that practitioners adopt a systematic approach to conducting and documenting the foreseeability that a patient will commit suicide. PubMed was used to search for articles published in MEDLINE journals using the following keywords: suicide, risk assessment, measure, scale. Randomized trials and pilot, proof-of-concept publications investigating the use of specific SRA measurements were included in the review. The scales are described based on the prevailing opinions in psychiatry from the American Psychiatric Association's Textbook of Suicide Assessment and Management (2nd ed., 2012). Although various SRA scales exist, experts in the field have repeatedly concluded that there is not any one scale that can predict who will commit suicide to any useful degree. However, when used along with the clinical interview, standardized suicide risk factor components of clinical and research scales remain crucial to gaining information often omitted by patients regarding thoughts and preparation for suicide. A summary of the most widely cited scales and approaches used in SRA is provided. SRA remains a challenge largely due to the fact that suicidal behavior is multifactorial. As a result, risk formulation is a process that should involve both standardized measures and detailed clinical interviews repeated over time.Abstract
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The term suicidality describes the multitude of behaviors related to suicide: suicidal ideation, self-injurious behavior, suicide attempt, and completed suicide. Risk factors associated with increased suicidality in individuals include specific demographics, medical and psychologic conditions, socioeconomic status, family history, and major life events. In addition to baseline risk factors, there have been reports of numerous medications associated with increased suicidality in patients. Most of these medications are antiepileptics and antidepressants. Because of the contradictory risk posed by the exact medications prescribed to treat depression and psychologic conditions, the nonpsychotropic medications with reports of suicidality are often overshadowed. Medications with FDA-issued warnings were reviewed for inclusion. Further medications were identified through PubMed literature review. Eight medications with various indications were identified and evidence is assessed regarding risk of suicidality. This review evaluates the current literature for nonpsychotropic medications that have been implicated in treatment-emergent suicidality.Abstract
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Suicide is currently on the rise with rates increasing alarmingly during the past decade. There are many risk factors for suicidal behavior, and mental illness is at the top of the list. Although a variety of medications have been evaluated in the literature, lithium and clozapine continue to have the most evidence supporting their use in decreasing suicidality. It is clear that medications are indispensable regarding the reduction of suicidality; however, a holistic approach must be taken when caring for this patient population. This review focuses on the specific role that lithium and clozapine have in the reduction of suicidal behavior.Abstract
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The objective of this case summary is to evaluate the potential role of naltrexone in reducing compulsive behaviors in a psychiatric patient. Naltrexone is an opioid antagonist that is approved for the treatment of opioid dependence and alcohol dependence. Naltrexone has been studied in autism, self-injurious behavior, and trichotillomania, which indicates that it has a possible benefit in compulsive disorders. A hospitalized patient who exhibited compulsive behaviors received naltrexone therapy. Naltrexone was effective in reducing the patient's compulsive behaviors after a dosage increase. No adverse effects were noted in this patient. Literature sources have demonstrated mixed results with naltrexone therapy in treating a variety of compulsive disorders. Naltrexone was initially effective as an adjunctive treatment option in reducing compulsive behaviors in the psychiatric patient described in this case report; however, naltrexone's efficacy waned over time. Further investigation of the use of naltrexone in treating compulsive behaviors is needed to determine whether naltrexone is consistently effective when used as an adjunctive agent in treatment.Abstract
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