|
| A) | Depression is less common among the medically ill. | ||
| B) | Women have higher lifetime rates of depression than men. | ||
| C) | One in 5 Americans are afflicted by depressive disorders annually. | ||
| D) | Roughly 18.4% of all persons in the United States will have a diagnosable depression at least once in their lifetimes. |
In 2020, 18.4% of U.S. adults (one in five) reported having ever been diagnosed with depression. The prevalence of depression was higher in women, younger adults, and adults with lower education levels. Estimates of an ever diagnosis of depression ranged from 12.7% in Hawaii to 27.5% in West Virginia. Age-standardized county-level prevalence estimates ranged from 10.7% to 31.9%, with considerable state- and county-level variability [6]. Reports that focused on measures of current depression (i.e., during the prior two weeks) rather than on lifetime depression showed similar subgroup differences, including those observed both before and throughout the SARS-CoV-2 2019 (COVID-19) pandemic. Reporting from 2020 forward suggests that the COVID-19 pandemic contributed to a worsening mental health crisis in the United States, especially among adolescents and young adults [7,8,9]. Depression is more common in persons with medical illnesses, with 11% to 36% of general medical inpatients fulfilling diagnostic criteria for MDD [10,11,12,13]. Depression also is two to three times more likely in individuals with chronic diseases, including diabetes, arthritis, and cardiovascular diseases [14].
| A) | Being married | ||
| B) | Higher socioeconomic status | ||
| C) | Severe underweight in women | ||
| D) | Major life changes such as job loss or divorce |
Several demographic/socioeconomic, psychosocial, familial, medical, and psychologic factors are associated with higher risk for depression. Adverse early life events such as early childhood parental abandonment or death, or emotional trauma from physical, sexual or emotional abuse are major risk factors for depression and other psychiatric disorders in adulthood. In adulthood, recent loss (e.g., death, divorce), domestic abuse/violence, traumatic civilian (assault, serious car accident) or military (battlefield injury, witnessing death and dismemberment) events, and major life changes (e.g., job change, financial hardships) are all potential red flags for depression [21,32].
Women have greater risk of depression, with a lifetime prevalence almost twice that of men [33]. Among women, severe obesity (body mass index greater than 40) is strongly associated with depression [34]. Lower socioeconomic status and being single are also risk factors for both genders [32].
| A) | Stroke | ||
| B) | Dermatitis | ||
| C) | Chronic pain | ||
| D) | Myocardial infarction |
Certain neurologic disorders are risk factors, such as Parkinson disease, stroke, multiple sclerosis, and seizure disorders. Among persons with certain general medical conditions, such as cancer, diabetes, myocardial infarction, or stroke, 20% to 25% will go on to experience a major depressive episode (MDE) [22]. Chronic pain, medical illness, and persistent or severe psychosocial stress elevate the risk of MDD [32].
| A) | Substance abuse | ||
| B) | Past abuse experiences | ||
| C) | Excessive social involvement | ||
| D) | Previous history of a mood disorder |
As noted, peripartum women are particularly vulnerable to depression. Risk factors for peripartum depression include [21]:
Depression or anxiety during pregnancy
Previous history of a mood disorder
Poor social support
Stressful life events
Pre-pregnancy and gestational diabetes
Fragmented or poor sleep
Substance abuse
Current or past abuse experiences
Difficulty breastfeeding in the first two months postpartum
| A) | Less than 1% | ||
| B) | 15% | ||
| C) | 35% | ||
| D) | 50% |
After the initial onset of MDD, around 15% of patients have a chronic and unremitting course. An additional 35% recover but experience one or more future recurrent episodes, and roughly 50% of first lifetime onsets recover and do not have future MDE episodes [10,37]. The risk of recurrence becomes progressively lower over time as the duration of remission increases. Preceding severe depressive episodes, younger age, and previous multiple depressive episodes increase the risk of recurrence [10].
| A) | reduces recurrence. | ||
| B) | delays future recurrences. | ||
| C) | has no effect on recurrence. | ||
| D) | may increase the risk of a recurrence. |
Antidepressant medication can alter the disease course by reducing relapse rates, while premature antidepressant discontinuation is associated with marked increases in risk of relapse [38,39,40]. Relapse prevention is a clinical priority, and a collaborative care model with ongoing pharmacotherapy and/or psychotherapy and regular follow-up can improve treatment adherence and reduce the risk of depressive relapse [21,41]. A single episode of major depression is associated with a 50% chance of a subsequent episode, two episodes with a 70% chance, and three or more episodes with a 90% chance [42]. A greater number of depressive episodes predicts poor treatment response [22].
| A) | in the first three months of onset. | ||
| B) | three to six months after onset. | ||
| C) | six to nine months after onset. | ||
| D) | one year after onset. |
Depression is an illness with a potentially fatal outcome. Among persons with a mood disorder, 12% to 20% will ultimately die by suicide. The first three months is the period of highest risk for a first attempt, with the three months following the first attempt being the highest risk period for a second attempt [43].
| A) | Patient history | ||
| B) | Diagnostic criteria | ||
| C) | Psychometric findings | ||
| D) | Quantifiable measures |
Biologic measures of depression are not available for clinical practice, and diagnosis is made through psychometric findings, fulfillment of diagnostic criteria, patient history, and clinical impression [61].
| A) | appearance and affect. | ||
| B) | cognition and sensorium. | ||
| C) | mood and thought process. | ||
| D) | All of the above |
Assessment of the presence of depression can also be made through signs and symptoms of the following cognitive, affective, and behavioral domains [10,21,22].
Although most patients with MDD appear normal upon initial presentation, patients with severe symptoms can exhibit poor grooming and hygiene and changes in weight from previous contact. Psychomotor retardation may be present, reflected by a slowing or absence of spontaneous movement, flat affect, and sighs and long pauses. This represents a diminished reactivity in emotional expression. Some patients with MDD may display psychomotor agitation, reflected by pacing, hand wringing, or hair pulling [10,21,22].
Patients may appear tearful or sad and often report a dysphoric mood state expressed as sadness, heaviness, numbness, or irritability and mood swings, as well as a loss of interest or pleasure in their recreational or leisure activities, difficulty concentrating, or loss of energy and motivation. Feelings of worthlessness, hopelessness, helplessness, or other negative thoughts may pervade their thinking, and ruminative thinking is not uncommon in MDD. Eye contact may be absent [10].
In the context of MDD, psychotic thought processes are congruent in content with the patient's mood state, examples being delusions of worthlessness or progressive physical decline. Evidence of psychotic symptoms requires careful assessment to rule out other contributing conditions such as bipolar disorder, schizophrenia or schizoaffective disorder, substance abuse, or organic brain syndrome [10,22].
Poor memory or concentration is a frequent complaint of patients with MDD, but actual cognitive deficits are infrequent and when present may represent pseudodementia. A fluctuating or depressed sensorium suggests delirium, and the patient should be evaluated for organic contributors [21,22].
| A) | They provide a definitive diagnosis of depression. | ||
| B) | They help determine the origin of depressive symptoms. | ||
| C) | They are used to identify patients in need of a full psychologic evaluation. | ||
| D) | They can be used with family members to provide an accurate diagnosis of the patient. |
Depression screening instruments are used to identify patients who should undergo a fuller assessment for depressive disorders [64]. The Patient Health Questionnaire-2 (PHQ-2) is a two-question screen widely recommended for use in primary care [65]:
''In the past two weeks, have you been bothered by little interest or pleasure in doing things?''
''In the past two weeks, have you been feeling down, depressed, or hopeless?''
| A) | Insomnia or hypersomnia | ||
| B) | Reckless, impulsive behavior | ||
| C) | Feeling of worthlessness or inappropriate guilt | ||
| D) | Loss of interest or pleasure in all or almost all activities |
To meet the diagnosis of MDD, a person must have at least five of the following symptoms for at least two weeks' duration and represent a change from previous functioning. At least one of the symptoms must be either depressed mood or loss of interest or pleasure [10]:
Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in all or almost all activities most of the day or nearly every day
Significant weight loss or gain (>5% body weight) or increase or decrease in appetite
Insomnia/hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue/loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt nearly every day
Diminished concentration or indecisiveness nearly every day
Recurrent thoughts of death or suicide, suicide attempt, or a specific plan for attempting suicide
| A) | Mood reactivity | ||
| B) | Interpersonal rejection sensitivity | ||
| C) | Peculiarities of voluntary movement | ||
| D) | Depression regularly worse in the morning |
For a patient with MDD to be classified as meeting the DSM-5-TR criteria for melancholic features he or she must have either a loss of pleasure in all, or almost all, activities or a lack of reactivity to usually pleasurable stimuli (i.e., does not feel much better, even temporarily, when something good happens). In addition, three (or more) of the following symptoms must be present [10]:
Distinct quality of depressed mood (e.g., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)
Depression regularly worse in the morning
Early morning awakening (at least two hours before usual time of awakening)
Marked psychomotor retardation or agitation
Significant anorexia or weight loss
Excessive or inappropriate guilt
| A) | panic attacks. | ||
| B) | somatic symptoms. | ||
| C) | psychotic symptoms. | ||
| D) | delusions of persecution. |
Healthcare providers can create a more comfortable environment for a patient of another culture by acknowledging the impact of culture and cultural differences on physical and mental health [76,77]. Symptom presentation is influenced by cultural factors, and in some cultures, depression and anxiety may be expressed through somatic symptoms, such as musculoskeletal pain and fatigue. Providers may consider starting the conversation with the patient by focusing on physical symptoms. The concept of depression also varies across cultures, and patients may not seek medical treatment unless symptoms manifest as psychosis, conversion disorders, or significant physical ailments [78].
| A) | Black/African American women tend to prefer individual or group therapy over medication. | ||
| B) | Black/African Americans are more likely to seek services earlier and therefore experience better outcomes. | ||
| C) | Black/African Americans are less likely to seek help for psychological distress from primary care settings. | ||
| D) | All of the above |
In general, Black/African Americans are more likely than White Americans to seek help for psychologic distress in the primary care settings and are more likely to believe that mental health professionals can be helpful, but also are more likely to believe mental illness will improve on its own [80]. They tend to seek services later and, therefore, face worse outcomes [81]. When they perceive they need help for an emotional problem, African American women tend to prefer individual or group therapy over medication [79].
| A) | sadness. | ||
| B) | irritability. | ||
| C) | unhappiness. | ||
| D) | vegetative signs. |
Major depression or persistent depressive disorder (dysthymia) with an age of onset after 60 years is referred to as late-onset depression. It is characterized by a greater presence of apathy and less lifetime presence of personality pathology than depression of earlier onset. Older patients tend to exhibit more vegetative signs and cognitive disturbance and complain less of dysphoria. In this population, major depression may be misattributed to physical illness, dementia, or the aging process itself [86]. Depression in the elderly is widespread, often undiagnosed, and usually untreated. Several factors contribute to missed diagnoses of depression in the elderly, including differences in presenting symptoms, stereotyping, provider and organizational barriers, and polypharmacy [21].
| A) | Reluctance to stigmatize | ||
| B) | Doubts over treatment effectiveness | ||
| C) | Uncertainty over diagnosis and proper treatment | ||
| D) | Abundant continuing physician training and education on depression |
Provider-specific factors contributing to under-detection and under-treatment of depression include reluctance to inform older patients of a depression diagnosis due to uncertainty over the diagnosis and proper treatment, reluctance to stigmatize, concern regarding medication interactions, lack of access to psychiatric care, and doubts regarding treatment effectiveness and cost-effectiveness [89]. Additional factors are physician overconfidence in their ability to diagnose, treat, and manage depression in the absence of sufficient training and education and a presumption (based on their familiarity with the patient) that they have nothing new to learn about the patient [89,90,91].
| A) | Amphetamines | ||
| B) | Steroids | ||
| C) | Antihypertensive medications | ||
| D) | Cytotoxic chemotherapy agents |
Medications that can induce mood changes include antihypertensive medications, steroids, medications that affect sex hormones, H2 histamine blockers, sedatives, muscle relaxants, appetite suppressants, and cytotoxic chemotherapy agents. Patients taking several medications are at increased risk.
| A) | social phobia. | ||
| B) | generalized anxiety disorder. | ||
| C) | post-traumatic stress disorder. | ||
| D) | borderline personality disorder. |
Additional psychiatric disorders are present in many patients with MDD. Comorbidity rates differ between studies conducted with community compared with clinical populations. However, the most commonly occurring psychiatric comorbidities and their rates of occurrence in persons with MDD are [22,105,106,107,108]:
Generalized anxiety disorder (62%)
Social phobia (52%)
Post-traumatic stress disorder (PTSD) (50%)
Panic disorder (48%)
Specific phobia (43%)
Obsessive-compulsive disorder (42%)
Any personality disorder (30%)
Impulse control disorders (30%)
Substance use disorders (24%)
Borderline personality disorder (10% to 15%)
| A) | an antipsychotic alone. | ||
| B) | an antidepressant alone. | ||
| C) | electroconvulsive therapy alone. | ||
| D) | an antipsychotic and an antidepressant medication or electroconvulsive therapy. |
Combining pharmacotherapy and psychotherapy treatments should be considered for patients with MDD when practical, feasible, available, and affordable. Both approaches combined show better outcomes than either as monotherapy. When unable to combine therapy because of patient preference or problems with availability or affordability, consider psychotherapy when the presentation is mild-to-moderate, and antidepressants when depression is severe or chronic [21]. Patients with MDD with psychotic features should receive an antipsychotic and an antidepressant medication or electroconvulsive therapy (ECT). Lithium can be added in patients unresponsive to antipsychotic/antidepressant therapy [22]. Other specific factors should be considered in treatment planning, including the presence of substance abuse, specific features, and other comorbid disorders. If a patient displays signs of potential suicide, increasing the treatment intensity, including hospitalization if needed, should be considered, and pharmacotherapy and psychotherapy should both be provided [22].
| A) | HIV infection | ||
| B) | Chronic asthma | ||
| C) | Seizure disorders | ||
| D) | Parkinson disease |
As with psychiatric conditions, comorbid medical conditions can impact the treatment plan for patients with depression. Pharmacologic agents should be chosen carefully in these patients due to the increased risk for adverse events and drug-drug interactions, and the following considerations are suggested [22]:
Hypertension or cardiac conditions: Monitor vital signs and cardiac rhythm when treating with TCAs, SNRIs, or antidepressants with anticholinergic effects.
Seizure disorders: Use with caution antidepressants that lower the seizure threshold, such as bupropion, clomipramine, and maprotiline.
Parkinson disease: Serotonergic agents may worsen symptoms, and bupropion may benefit the illness but worsen psychosis if present. Selegiline may interact with L-DOPA, an agent used in the treatment of Parkinson disease.
Obesity: Monitor for weight gain with most antidepressants.
Sleep apnea: Choose an antidepressant with little daytime sedation.
HIV infection: Carefully consider the potential drug-drug interactions between psychotropics and antiretrovirals.
Chronic pain: SNRIs and TCAs are preferred over SSRIs and MAOIs.
| A) | Ease of dosing | ||
| B) | Low toxicity in overdose | ||
| C) | Less prominent side effect profile | ||
| D) | Efficacy in initially addressing anxiety or panic symptoms |
SSRIs are thought to act by inhibiting serotonin transporters (SERT) that reuptake serotonin (5-HT) into the presynaptic cell, increasing 5-HT in the synaptic cleft. SSRIs have advantages of low overdose lethality and better tolerability than first-generation antidepressants, which can improve adherence. SSRIs are particularly effective in patients with obsessive-compulsive symptoms but may initially worsen anxiety or panic symptoms [21,22,122]. This class includes the agents fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox) (off-label for MDD), citalopram (Celexa), escitalopram (Lexapro), and vortioxetine (Brintellix). Escitalopram may have fewer drug-drug interactions than other SSRIs, and fluoxetine may be a better choice in patients with poorer adherence due to its long half-life [21,22,122].
| A) | Muscarinic receptor blockade | ||
| B) | Inhibition of dietary amine catabolism | ||
| C) | Antagonism of intestinal opioid receptors | ||
| D) | Activation of gastrointestinal serotonin receptors |
With oral ingestion, MAOIs inhibit the catabolism of dietary amines. When foods containing tyramine are consumed, the individual may suffer from hypertensive crisis (Table 2) [166]. If foods containing tryptophan are consumed, hyperserotonemia may result. The amount required to cause a reaction varies greatly from individual to individual and depends on the degree of inhibition, which in turn depends on dosage and selectivity.
| A) | Paroxetine | ||
| B) | Fluoxetine | ||
| C) | Venlafaxine | ||
| D) | Amitriptyline |
Antidepressant discontinuation (more appropriately termed withdrawal) symptoms are described by the FINISH mnemonic (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal), may be experienced by up to 40% of patients when antidepressants are stopped abruptly, and may occur with any antidepressant [158,189,190,191]. SSRI withdrawal symptoms are far more frequent with paroxetine. Common symptoms include dizziness, nausea, headache, confusion, low energy, weakness, sleep disturbance, flu-like symptoms, restlessness, agitation, anxiety, panic, anger, and irritability. Less common and more severe symptoms include electric-shock sensations, vertigo, paresthesia, intensified suicidal ideation, aggression, derealization, depersonalization, and visual/auditory hallucinations. Gradual tapering is a reasonable strategy but does not prevent the onset of SSRI withdrawal [192]. SSRI withdrawal syndrome is least likely with fluoxetine and vortioxetine [158].
| A) | Stopping treatment completely | ||
| B) | Adjusting the treatment plan | ||
| C) | Re-evaluating the initial diagnosis | ||
| D) | Optimizing the prescribed therapy |
If a patient fails to adequately respond to an initial antidepressant and/or psychotherapy trial, the clinician should consider adjusting the treatment plan, re-evaluating the initial diagnosis, and/or optimizing the prescribed therapy. If the patient remains unresponsive to treatment, referral to a psychiatrist may be indicated.
| A) | Illness severity | ||
| B) | Medical and psychiatric comorbidity | ||
| C) | Limitations of FDA-approved drug options | ||
| D) | All of the above |
Treatment-resistant depression is a problem increasingly encountered by primary care and mental health providers. Contributors to treatment-resistant depression include illness severity, medical and psychiatric comorbidity, and the limitations of FDA-approved drug options. The definition of treatment resistance lacks consensus, but the most common definition is inadequate response to two or more antidepressants. This does not consider adjunctive strategies or distinguish patients with partial versus non-response [158,180].
| A) | Bupropion | ||
| B) | Paroxetine | ||
| C) | Venlafaxine | ||
| D) | Maprotiline |
FDA RATINGS OF ANTIDEPRESSANT PREGNANCY RISK
| Rating | Definition and Examples |
|---|---|
| A | No currently available antidepressant medications are rated A, which would indicate a failure to demonstrate risk to the fetus in well-controlled studies of pregnant women. |
| B | Maprotiline—no evidence of risk in humans, and either animal findings show risk but human findings do not, or animal findings are negative if no adequate human studies have been performed. |
| C | Amitriptyline, amoxapine, bupropion, protriptyline, sertraline, trazodone, trimipramine, and venlafaxine—risk cannot be ruled out, and although human studies are lacking and animal studies are either positive for fetal risk or are lacking, potential benefits may justify the potential risks. |
| D | Imipramine, nortriptyline, and paroxetine—positive evidence of risk. Investigational or postmarketing data show risk to the fetus. The potential benefits may outweigh the potential risks, and if needed in a life-threatening situation or a serious disease, the drug may be acceptable if safer drugs cannot be used or are ineffective. |
| X | No currently used antidepressant medications are rated X, which would indicate that use is contraindicated in pregnancy due to animal or human studies that conclude that fetal risk clearly outweighs potential benefits. |
| A) | Black boys and men | ||
| B) | White boys and men | ||
| C) | Hispanic girls and women | ||
| D) | Asian/Pacific Islander girls and women |
White boys and men accounted for 70% of all suicides in the United States in 2021; the suicide rate in this population is two times greater than that for non-White boys/men. White men 45 to 64 years of age had the highest suicide rate and number of any demographic in 2021 [374]. White girls and women also have markedly higher suicide rates than their non-White counterparts [374].
| A) | attempt suicide. | ||
| B) | die by suicide. | ||
| C) | experience depression. | ||
| D) | seek help for mental health problems. |
Aside from measures of suicide-related deaths, various levels of suicidality among adults have been studied, with suicidal thoughts, plans, and attempts quantified (Table 6). Among adults with past-year suicidal ideation, around 1 in 4 plan suicide and 1 in 7 attempt suicide. There are 25 attempts for every suicide, increasing to 100 to 200 attempts per suicide in individuals 15 to 24 years of age and decreasing to 4 attempts per suicide among the elderly. For each male attempt are three female attempts, and there are 3.9 male suicides for each female suicide [374].
| A) | are racial/ethnic minorities. | ||
| B) | do not experience unique challenges. | ||
| C) | did not seek campus counseling services. | ||
| D) | All of the above |
Suicide is the second most common cause of death among college students, with an estimated 1,000 students taking their lives on college campuses each year. More than 50% of college students report having had suicidal thoughts, and another 10% report a serious suicide attempt. An estimated 80% to 90% of college students who died by suicide were not receiving help from college counseling centers [387]. A study published in 2019 from the American College Health Association/National College Health Assessment survey assessed mental health diagnoses and suicidality from more than 67,000 undergraduate students across 108 institutions [388]. According to the results, one in five students have had thoughts of suicide, with 9% making a suicide attempt and 20% reporting self-injury [388]. Students leaving home for college face unique challenges that may increase suicide risk in vulnerable students, including separation from support systems and social networks, academic stress, pressure to succeed, feelings of isolation, poor coping skills, and mental health stigma.
| A) | Social involvement | ||
| B) | Greater family support | ||
| C) | Stigma and discrimination | ||
| D) | Higher perceived safety at school |
Sexual orientation or gender identity harassment and being threatened or injured with a weapon at school are the most damaging forms of school-based victimization for sexual minority adolescents, and these factors have the greatest association with suicidality [390]. For sexual minority youth, risk factors for bullying and violence include social isolation, lack of parental support, lack of safety or support at school, and harmful norms about masculinity and femininity associated with violence against those seen as not masculine or feminine enough [389].
| A) | Most who die by suicide accessed care in the week before their death. | ||
| B) | Multiple deployments are associated with greater suicide risk among deployed veterans. | ||
| C) | The estimated lifetime prevalence of suicide ideation was 12.7% for men and 20.1% for women. | ||
| D) | All of the above |
In one study, veterans during the Iraq and Afghanistan war era (317,581 deployed to war zones, 964,493 nondeployed) were followed from the time of discharge to 2010. With 1,868 suicide deaths, both veteran cohorts had 41% to 61% higher risk of suicide relative to the general population, but suicide risk was not associated with a history of war zone deployment and multiple deployments were not associated with greater suicide risk among deployed veterans [407].
Among U.S. Armed Forces veterans, the estimated lifetime prevalence of suicide ideation was 12.7% for men and 20.1% for women, and the prevalence of lifetime suicide attempts was 2.5% and 5.1%, respectively [408]. Among active Armed Forces suicide decedents, roughly 50% accessed health care in the month before their death and more than 25% accessed care in the week before their death. Male, never married, and non-Hispanic Black individuals were less likely to access care prior to death. The number of mental health encounters was the only predictor of suicide risk documentation among decedents at 4 weeks and 52 weeks prior to death [409].
| A) | psychologic pain (psychache) is one of three essential dimensions in suicide risk. | ||
| B) | no actions can be taken to lessen the risk of suicide in at-risk populations. | ||
| C) | high belongingness and low burdensomeness contribute to suicide risk. | ||
| D) | persons will not make lethal suicide attempts unless they have developed the desire and ability to do so. |
The Interpersonal-Psychological Theory of Suicide posits that persons will not make lethal suicide attempts unless they have developed the desire (i.e., low belongingness, high burdensomeness) and ability to do so [377]. Thwarted belongingness is defined as the experience of having little or no social connectedness, a result of living alone, death of a spouse, or disabling physical or psychiatric illness. The need to belong is a core aspect of human nature; when unfulfilled, suicide risk increases [428]. Perceived burdensomeness is evident when persons feel their family members and the world in general would be better off if they were no longer living, and this can initiate suicidal ideation [428]. Acquired capability for suicide refers to reaching the point at which a patient overcomes his or her innate fears of pain, injury, and death with suicide. Opponent process theory suggests with repeated exposure, the effects of previously noxious, aversive, or provocative stimuli may recede, and the opposite effect of the stimuli becomes strengthened and amplified [429]. Persons can habituate to pain, injury, or death through previous suicide attempts, exposure to trauma, armed combat, violence, or death and diverse experiences related to psychologic and physical pain [350,351].
| A) | a means to escape positive cognitive states. | ||
| B) | rare among adolescent psychiatric patients. | ||
| C) | unintentional damage to the bodily surface. | ||
| D) | more common in girls and women than boys and men. |
Non-suicidal self-injury (NSSI) is intentional, non-socially accepted damage to the bodily surface, without suicidal intent, by cutting, scratching, hitting/banging, carving, or scraping. Roughly 17% to 18% of teens have one or more NSSI event; up to 60% of adolescent psychiatric patients have one NSSI event and 50% have repetitive NSSI [431,432]. NSSI prevalence is higher in girls and women. It rises from late childhood to early adolescence, peaks in mid- to late-adolescence, and generally declines by young adulthood [383]. NSSI can occur without a psychiatric diagnosis [433].
NSSI serves as a means to escape aversive emotional (e.g., sadness, anxiety) or cognitive (e.g., negative thoughts or memories) states, relieve tension or anger, or regain perception of control [383,434]. Adolescents with repetitive NSSI remain at high risk of dysfunctional emotion regulation strategies after ceasing the behaviors and show increased substance abuse as the behaviors decrease [435]. Those who cut themselves on body areas other than arms or wrists have the greatest risk of subsequent suicide [436]. Identifying with "goth" or "emo" youth subculture, sexual minority status, social media exposure to self-injury behaviors, bullying, and childhood emotional abuse are risk factors for NSSI [437].
| A) | schizophrenia. | ||
| B) | panic disorder. | ||
| C) | bipolar disorder. | ||
| D) | major depression. |
Traditional suicide risk factors include mood (e.g., bipolar disorder, MDD), anxiety, impulse control, personality, psychotic, and alcohol/substance use disorders [368]. There is little evidence that trait impulsivity increases risk of attempts in ideators, although suicidal behavior can occur during transient impulsive states [456]. In patients with MDD, the condition most associated with suicide, the lifetime suicide prevalence is 4% for hospitalized individuals, 2.2% in mixed inpatient/outpatient populations, and 8.6% if hospitalized for suicidality [66]. However, it is important to remember that MDD alone does predict acute risk of suicide, and depression and most psychiatric disorders alone do not predict transition from ideation to suicidal plans or attempts.
| A) | Less than 1% | ||
| B) | 19% | ||
| C) | 39% | ||
| D) | 79% |
While symptomatic panic disorder, PTSD, and generalized anxiety disorder influence suicide behavior more than any other psychiatric disorders, it is the acute state of anxious agitated distress (not an anxiety disorder diagnosis) that greatly increases risk of ideators moving to suicide attempts [368,457]. Among inpatient suicides, 79% met diagnostic criteria for severe or extreme anxiety and/or agitation.
| A) | More than 33% of suicides occur during alcohol use. | ||
| B) | Alcohol intoxication significantly increases suicide risk. | ||
| C) | Substance use disorder and suicidality can be temporarily linked. | ||
| D) | All of the above |
More than 33% of suicides occur during alcohol use, typically at high levels of ingestion, and controlled trials confirm that acute alcohol use is a potent suicidal risk factor [461,462,463,464]. Alcohol intoxication significantly increases suicide risk and may heighten psychologic distress and aggression, encourage suicide attempts, and inhibit adaptive coping strategies [465]. During intoxication, disinhibition facilitates movement from ideation to impulsive action, and alcohol intoxication predicts use of lethal means in suicide [465,466]. However, substance use disorder and suicidality can be temporarily linked, as patients are likely to deny suicidality after intoxication has resolved [467,468].
| A) | firearms. | ||
| B) | poisoning. | ||
| C) | suicide by cop. | ||
| D) | suffocation/hanging. |
In 2021, firearms were the most common means used in suicide deaths (54.6%), followed by suffocation/hanging (25.8%) and poisoning (11.6%) [374]. In the United States, the rate of suicide by firearm is eight times greater than the rates in other economically developed countries [472]. Household gun ownership strongly correlates with firearm suicide, and storage practices impact suicide rates, which are higher in geographic areas with greater household prevalence of loaded guns. The presence of loaded, unlocked firearms within reach is a risk factor for fatal outcomes from suicidal behavior [473].
| A) | revenge and shame. | ||
| B) | command hallucinations. | ||
| C) | gaining attention or reaction from others. | ||
| D) | the motivation to escape unbearable pain. |
Most suicides and attempts are driven by the motivation to escape unbearable pain. Other motives include revenge, shame, humiliation, delusional guilt, command hallucinations, gaining attention or reaction from others, loneliness, self-hatred, or a sense of being a burden, not belonging, feeling trapped, or having no purpose [364]. Individuals have a unique balance between their personal motivations for suicide and their reasons for living. Reasons for living can include religious beliefs, a sense of responsibility to children or others, plans for the future, or a sense of purpose in life. A strong social support network is also protective against suicide [364]. Importantly, "reasons for living" become irrelevant when suicidal intent is moderate or greater.
| A) | cognitive therapy. | ||
| B) | dialectical behavioral therapy. | ||
| C) | interpersonal psychotherapy. | ||
| D) | collaborative assessment and management of suicidality. |
Dialectical behavioral therapy is the most thoroughly studied and effective psychotherapy for suicidal behavior. It has been shown in multiple studies to decrease suicide attempts, self-harm, and other suicide-relevant markers such as suicidal ideation and hopelessness. This psychotherapy emphasizes skills training and mindfulness-based emotion regulation [482].
| A) | Inability to sleep | ||
| B) | Command hallucinations | ||
| C) | Verbalizations of hopelessness | ||
| D) | Seeking access, or recent use, of lethal means |
Suicide warning signs are recent, unusual changes in the patient, often an acute response to precipitants, and proximally associated with imminent suicide risk. Intent may be signaled through emotions, thoughts, or behaviors. Danger is elevated with previous suicide attempts, family history of suicide, or possession of a lethal method. Presence of any of the following warning signs requires immediate attention, mental health evaluation, and possibly hospitalization to ensure patient safety, stability, and security:
Suicide communication—threatening to harm or kill self
Preparations for suicide
Seeking access, or recent use, of lethal means