Case study: Follow-up for suicide attempt in primary care

by Heena Desai, MD

Heena Desai, MD, is a pediatric psychiatrist at Children's Hospital of Wisconsin. She also is an assistant professor of Pediatrics (Child and Adolescent Psychiatry) at The Medical College of Wisconsin and a member of Children's Specialty Group. 

Anne is a 16-year-old girl who lives in a rural area. Two weeks ago she attempted suicide via overdose and was admitted to a pediatric intensive care unit. After a brief stay in the PICU, she was admitted to her local adolescent psychiatric inpatient unit for seven days before being discharged to outpatient care.

She has a three-year history of periods of depressed mood, anhedonia, decreased appetite, increased sleep and suicidal ideation. This was her first attempt. Her grades in school have been progressively declining, as has her attendance. Over time she gradually has lost regular contact with her peer group as well.

She presents with her parents for follow-up care. The next available appointment for the local child psychiatrist is in three months. The psychiatric hospital asked the family to follow up with the primary care physician for outpatient care until then, and to return to inpatient care for any acute issues. Anne does have a new therapist who is conducting manualized cognitive behavioral therapy with her, and the therapist recently sent the primary care physician a treatment plan.

Anne has been on fluoxetine 5 mg for four weeks. She reports no side effects. She denies any current suicidal ideation. There is no drug or alcohol use.*

Management and next steps: Some considerations

Step 1: Avoiding common pitfalls
In general, suicidal patients should be assumed to have multiple problems rather than a single problem driving their suicidality. The chronic suicidal ideation, in turn, can become a driving force for additional problems. It can be tempting to oversimplify the issue as a Òchemical imbalanceÓ in the brain triggering depression of which the suicidal ideation is a symptom. This oversimplification can result in missed opportunities for intervention. Depression treatment is critical, but psychopharmacology should not be the sole intervention in a suicidal patient.

In addition, a ÒnoÓ answer to the question of whether Anne has current suicidal ideation should not be taken as a signal that there is no need for risk factor modification. Suicidal ideation can recur and should be monitored and planned for. Concurrently, interventions to decrease risk for completed suicide should be implemented, placing the patient, provider and family in good stead should the suicide crisis recur.

Step 2: Interventions to assess and decrease risk
Patients with suicidal ideation present on a continuum of risk. Where they are on this continuum depends on a number of different risk factors, many of which can be modified. The two proven interventions to decrease risk of suicide on a population level are physician education regarding depression treatment and removal of access to lethal means.

*This case is fictional and developed to illustrate specific teaching points. Any resemblance to actual persons is purely coincidental. This information is not a substitute for professional medical or mental health advice or services, particularly in acutely suicidal individuals who warrant immediate evaluation in an emergency setting.

It is important to have a discussion with the family regarding risk when firearms are in the home. Firearms should be removed from the home. In addition, all medication in the home should be locked up, including those that are over-the-counter. The argument put forth by some is that the adolescent simply will obtain more over-the-counter medications. However, I would argue that removal of access to means has its most significant impact on impulsive suicide attempts and the delay caused by a lack of access to immediate means can provide the suicidal individual time to Òcome to their senses.Ó Finally, suicidal adolescents should not keep and manage their own depression medications. Parents should take responsibility for dispensing medication to improve adherence and decrease intentional overdose risk.

An important question to ask the patient as part of the suicide screen is her reasons for living. The answer to this question prompts the patient to think of her own reasons for living and offers the provider critical information. A patient who cannot list reasons for living is at much higher risk than one who can easily and quickly state multiple reasons for living. The patient who cannot state reasons for living should be assessed for hospitalization for acute safety and stabilization.

A crisis plan should be developed with the patient and the family. At minimum, the crisis plan should identify emergency contact numbers (such as the local crisis line, parents, primary care physician, therapist). The patient should be encouraged to program these numbers into her cell phone, if she has one, or to memorize the numbers if she doesn't. At least one number should be available 24 hours a day, 7 days a week (such as the crisis line). Beyond this, the crisis plan can identify distress tolerance behaviors. These are any behaviors patients can engage in to distract themselves from current emotional distress or decrease it, and not act on it. Activities can include playing with a pet, listening to mood-incongruent music, watching a movie, engaging in high-intensity exercise, prayer, etc. The patient should have ready access to her crisis plan at all times.

Step 3: Medication risk
Research indicates a small but significant increase in risk of suicidal ideation in children and adolescents on antidepressant medication. FDA guidelines recommend face-to-face evaluation once a week for four weeks, once every two weeks for four weeks, then once a month, and then as clinically indicated with every medication initiation or dose change. Primary care physicians can enlist the assistance of the therapist in such monitoring. Medications should not be avoided in suicidal patients because of this reason.

Step 4: Ensuring adequate treatment
Primary care physicians should ensure not only adequate pharmacological treatment but also psychological treatment. For chronically suicidal patients, patients with multiple problems or patients who have otherwise failed usual outpatient management, consider an intensive outpatient treatment called dialectical behavioral therapy. Unfortunately, this treatment is not available in many communities.

Ensuring adequate treatment includes adequate psychopharmacology. In general, two antidepressants, escitalopram and fluoxetine, are approved for adolescent depression. Ideally, Anne would have been started on 5 mg of fluoxetine with an increase to 10 mg at one week. The general recommendation is to wait 6-8 weeks between dose adjustments. However, a minimal effective dose is generally 10 mg rather than 5 mg for adolescents. Further dose changes can be made at a 6-8 week interval.

Ensuring adequate psychotherapy is a larger challenge. Anne clearly is receiving appropriate therapy. While cognitive behavioral therapy and interpersonal psychotherapy (another evidence-based psychotherapy for depression) are more widely available than dialectical behavioral therapy, they can be difficult to find. In cases such as Anne's, symptom resolution in a timely fashion is critical. It is important to ensure that Anne is receiving manualized, evidence-based treatment.

Some of the interventions that Anne should receive in therapy, and that can be reinforced at her primary care visits, include developing a list of activities of mastery and pleasure and to participate in at least one each day: exercising daily, ensuring adequate nutritional intake, maintaining a regular sleep schedule with good sleep hygiene and regular school attendance. The parents should monitor their child closely.

Finally, there always is room for generating hope. Frequent reminders that the depression will resolve are helpful for both the patient and the family, particularly when it has been ongoing for some time.

Heena Desai, MD, is part of the Psychiatry and Behavioral Medicine Center at Children's Hospital of Wisconsin. She manages the Second Opinion Clinic, which helps primary care physicians manage children's mental health needs. Typical diagnoses include attention-deficit/hyperactivity disorder, depression and anxiety. The primary care physician receives a comprehensive report with the diagnostic evaluation and treatment recommendations, including next steps.

References
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Jouko L, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahasi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide prevention strategies: A systematic review. JAMA. 2005, 294(16), 2064-2074.

Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Archives of General Psychiatry. 2006, 63, 332-339.

Stone M, Laughren T, Jones ML, Levenson M, Holland CP, Hughes A, Hammad TA, Temple R, Rochester G. Risk of suicidality in clinical trials of antidepressants in adults: Analysis of proprietary data submitted to US Food and Drug Administration. BMJ. 2009, 339(b2880), 1-10.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association. 2000.

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 46:11, 1503-1526.

Mosholder AD, Willy, M. Suicidal adverse events in pediatric randomized, controlled clinical trials of antidepressant drugs are associated with active drug treatment: A meta-analysis. Journal of Child and Adolescent Psychopharmacology. 2006, 16(1/2), 25-32.

Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for staying alive when you are thinking of killing yourself: The reasons for living inventory. Journal of Consulting and Clinical Psychology. 1983, 51(2), 276-286.

Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press. 1993.