Current Psychiatry

I’ve found that, as a resident in psychia­try, it’s rare to experience a moment of truly unbridled achievement while on call. Manning the revolving door of acute psychiatric admissions can be frustrating, not to mention unfulfilling. Maybe that’s why accomplishing a small miracle, you might say, while on call recently felt so satisfying.

Broken window = workplace woes
When working a 12-hour shift, especially overnight, it’s important to have an envi­ronment that is conducive to work. As fatigue and stress build, physical comfort means a lot.

Our problem finding physical comfort in the psychiatry resident call room at Saint Louis University was that a fixture on one of the windows had been broken for several years. You could push the win­dow open, but you could not close it. If you called the janitor, he would come and close the window, but there was no guar­antee when he’d show up. You might end up typing your notes all evening in the path of a chilly stream of air.

The residents had made a formal request to have the window repaired in a more permanent manner, but this resulted in it being bolted shut. That was a solution, but an imperfect one: Now we had no way to cool the call room in the winter, and it was beginning to smell of body odor.

The psychiatry resident call room is one of the nicer ones I’ve seen, but the build­ing it occupies is a few decades old, and no replacement parts were available for the fixtures. We were stuck with a closed window—so I thought.

That miraculous morning
I was supervising an intern one Saturday, and she had not been paged yet to see patients. The call room was a mess; I tele­phoned housekeeping to have the beds changed, and maintenance to unclog the sink. When the maintenance man (I’ll call him “Tom”) arrived and fixed the sink, I praised him and asked him to take a look at the window.

“It’s my dream,” I said to no one in par­ticular, “to have a window we can open and shut.”

I didn’t get angry or exert pressure. Tom explained to me that there were no replace­ment parts.

“Hmm… I see…,” I said.

To my delight, Tom seemed excited to be given a problem to solve. He left to pil­fer parts from other windows on the floor.

No luck. The parts were all gone. Tom apologized and suggested we purchase a suction cup, with a cord attached, to pull the window closed.

“Good idea!” I said, thanking him as he went on his way.

But 2 hours later, our maintenance hero, Tom reappeared in the doorway.

“I’ve been thinking about your window all morning,” he announced.

Tom approached the window, unbolted it, and screwed one end of a chain into the frame, creating a makeshift handle. He dem­onstrated how to pull the window shut.

Voilà! A window we could open and close. The intern’s jaw dropped in amazement. I turned to dance a little jig.

Satisfaction
It’s important to be able to control the temperature in the call room; even more important to have a comfortable, healthy work environment. But knowing I can influence my surroundings to get what I need at work? That’s more important than anything else at all.


Disclosure
Dr. Jennings reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

I’ve found that, as a resident in psychia­try, it’s rare to experience a moment of truly unbridled achievement while on call. Manning the revolving door of acute psychiatric admissions can be frustrating, not to mention unfulfilling. Maybe that’s why accomplishing a small miracle, you might say, while on call recently felt so satisfying.

Broken window = workplace woes
When working a 12-hour shift, especially overnight, it’s important to have an envi­ronment that is conducive to work. As fatigue and stress build, physical comfort means a lot.

Our problem finding physical comfort in the psychiatry resident call room at Saint Louis University was that a fixture on one of the windows had been broken for several years. You could push the win­dow open, but you could not close it. If you called the janitor, he would come and close the window, but there was no guar­antee when he’d show up. You might end up typing your notes all evening in the path of a chilly stream of air.

The residents had made a formal request to have the window repaired in a more permanent manner, but this resulted in it being bolted shut. That was a solution, but an imperfect one: Now we had no way to cool the call room in the winter, and it was beginning to smell of body odor.

The psychiatry resident call room is one of the nicer ones I’ve seen, but the build­ing it occupies is a few decades old, and no replacement parts were available for the fixtures. We were stuck with a closed window—so I thought.

That miraculous morning
I was supervising an intern one Saturday, and she had not been paged yet to see patients. The call room was a mess; I tele­phoned housekeeping to have the beds changed, and maintenance to unclog the sink. When the maintenance man (I’ll call him “Tom”) arrived and fixed the sink, I praised him and asked him to take a look at the window.

“It’s my dream,” I said to no one in par­ticular, “to have a window we can open and shut.”

I didn’t get angry or exert pressure. Tom explained to me that there were no replace­ment parts.

“Hmm… I see…,” I said.

To my delight, Tom seemed excited to be given a problem to solve. He left to pil­fer parts from other windows on the floor.

No luck. The parts were all gone. Tom apologized and suggested we purchase a suction cup, with a cord attached, to pull the window closed.

“Good idea!” I said, thanking him as he went on his way.

But 2 hours later, our maintenance hero, Tom reappeared in the doorway.

“I’ve been thinking about your window all morning,” he announced.

Tom approached the window, unbolted it, and screwed one end of a chain into the frame, creating a makeshift handle. He dem­onstrated how to pull the window shut.

Voilà! A window we could open and close. The intern’s jaw dropped in amazement. I turned to dance a little jig.

Satisfaction
It’s important to be able to control the temperature in the call room; even more important to have a comfortable, healthy work environment. But knowing I can influence my surroundings to get what I need at work? That’s more important than anything else at all.


Disclosure
Dr. Jennings reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

I’ve found that, as a resident in psychia­try, it’s rare to experience a moment of truly unbridled achievement while on call. Manning the revolving door of acute psychiatric admissions can be frustrating, not to mention unfulfilling. Maybe that’s why accomplishing a small miracle, you might say, while on call recently felt so satisfying.

Broken window = workplace woes
When working a 12-hour shift, especially overnight, it’s important to have an envi­ronment that is conducive to work. As fatigue and stress build, physical comfort means a lot.

Our problem finding physical comfort in the psychiatry resident call room at Saint Louis University was that a fixture on one of the windows had been broken for several years. You could push the win­dow open, but you could not close it. If you called the janitor, he would come and close the window, but there was no guar­antee when he’d show up. You might end up typing your notes all evening in the path of a chilly stream of air.

The residents had made a formal request to have the window repaired in a more permanent manner, but this resulted in it being bolted shut. That was a solution, but an imperfect one: Now we had no way to cool the call room in the winter, and it was beginning to smell of body odor.

The psychiatry resident call room is one of the nicer ones I’ve seen, but the build­ing it occupies is a few decades old, and no replacement parts were available for the fixtures. We were stuck with a closed window—so I thought.

That miraculous morning
I was supervising an intern one Saturday, and she had not been paged yet to see patients. The call room was a mess; I tele­phoned housekeeping to have the beds changed, and maintenance to unclog the sink. When the maintenance man (I’ll call him “Tom”) arrived and fixed the sink, I praised him and asked him to take a look at the window.

“It’s my dream,” I said to no one in par­ticular, “to have a window we can open and shut.”

I didn’t get angry or exert pressure. Tom explained to me that there were no replace­ment parts.

“Hmm… I see…,” I said.

To my delight, Tom seemed excited to be given a problem to solve. He left to pil­fer parts from other windows on the floor.

No luck. The parts were all gone. Tom apologized and suggested we purchase a suction cup, with a cord attached, to pull the window closed.

“Good idea!” I said, thanking him as he went on his way.

But 2 hours later, our maintenance hero, Tom reappeared in the doorway.

“I’ve been thinking about your window all morning,” he announced.

Tom approached the window, unbolted it, and screwed one end of a chain into the frame, creating a makeshift handle. He dem­onstrated how to pull the window shut.

Voilà! A window we could open and close. The intern’s jaw dropped in amazement. I turned to dance a little jig.

Satisfaction
It’s important to be able to control the temperature in the call room; even more important to have a comfortable, healthy work environment. But knowing I can influence my surroundings to get what I need at work? That’s more important than anything else at all.


Disclosure
Dr. Jennings reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Approximately 113,000 bariatric sur­geries were performed in the United States in 2010; as many as 80% of persons seeking weight loss surgery have a history of a psychiatric disorder.^1,2

Bariatric surgery can be “restrictive” (limiting food intake) or “malabsorptive” (limiting food absorption). Both types of procedures can cause significant changes in pharmacokinetics. Bariatric surgery patients who take a psychotropic are at risk of tox­icity or relapse of their psychiatric illness because of inappropriate formulations— immediate-release vs sustained-release—or incomplete absorption of medications. You need to anticipate potential pharmacokinetic alterations after bariatric surgery and make appropriate changes to the patient’s medica­tion regimen.

Pharmacokinetic concerns
Roux-en-Y surgery is a malabsorptive procedure that causes food to bypass the stomach, duodenum, and a variable length of jejunum. Secondary to bypass, iron defi­ciency anemia is a common nutritional complication.

Other changes that affect the pharma­cokinetics of psychotropics after bariatric surgery include:
   • an increase in percentage of lean body mass as weight loss occurs
   • a decrease in glomerular filtration rate as kidney size decreases with postsur­gical weight reduction
   • reversal of obesity-associated fatty liver and cirrhotic changes.

With time, intestinal adaptation occurs to compensate for the reduced length of the intestinal tract; this adaptation pro­duces mucosal hypertrophy and increases absorptive capacity.³

Medications to taper or avoid
The absorption and bioavailability of a medication depend on its dissolv­ability; the pH of the medium; surface area for absorption; and GI blood flow.⁴ Medications that have a long absorp­tive phase—namely, sustained-release, extended-release, long-acting, and enteric-coated formulations—show compromised dissolvability and absorption and reduced efficacy after bariatric surgery.

Avoid slow-release formulations, includ­ing ion-exchange resins with a semiper­meable membrane and those with slowly dissolving characteristics; substitute an immediate-release formulation.

Medications that require acidic pH are incompletely absorbed because gastric exposure is reduced.

Lipophilic medications depend on bile availability; impaired enterohepatic circulation because of reduced intestinal absorptive surface causes loss of bile and, therefore, impaired absorption of lipo­philic medications.

Medications that are poorly intrinsi­cally absorbed and undergo entero­hepatic circulation are likely to be underabsorbed after a malabsorptive bar­iatric procedure.

Lamotrigine, olanzapine, and quetiap­ine may show decreased efficacy because of possible reduced absorption.

The lithium level, which is influenced by volume of distribution, can become toxic postoperatively; consider measuring the serum lithium level.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Approximately 113,000 bariatric sur­geries were performed in the United States in 2010; as many as 80% of persons seeking weight loss surgery have a history of a psychiatric disorder.^1,2

Bariatric surgery can be “restrictive” (limiting food intake) or “malabsorptive” (limiting food absorption). Both types of procedures can cause significant changes in pharmacokinetics. Bariatric surgery patients who take a psychotropic are at risk of tox­icity or relapse of their psychiatric illness because of inappropriate formulations— immediate-release vs sustained-release—or incomplete absorption of medications. You need to anticipate potential pharmacokinetic alterations after bariatric surgery and make appropriate changes to the patient’s medica­tion regimen.

Pharmacokinetic concerns
Roux-en-Y surgery is a malabsorptive procedure that causes food to bypass the stomach, duodenum, and a variable length of jejunum. Secondary to bypass, iron defi­ciency anemia is a common nutritional complication.

Other changes that affect the pharma­cokinetics of psychotropics after bariatric surgery include:
   • an increase in percentage of lean body mass as weight loss occurs
   • a decrease in glomerular filtration rate as kidney size decreases with postsur­gical weight reduction
   • reversal of obesity-associated fatty liver and cirrhotic changes.

With time, intestinal adaptation occurs to compensate for the reduced length of the intestinal tract; this adaptation pro­duces mucosal hypertrophy and increases absorptive capacity.³

Medications to taper or avoid
The absorption and bioavailability of a medication depend on its dissolv­ability; the pH of the medium; surface area for absorption; and GI blood flow.⁴ Medications that have a long absorp­tive phase—namely, sustained-release, extended-release, long-acting, and enteric-coated formulations—show compromised dissolvability and absorption and reduced efficacy after bariatric surgery.

Avoid slow-release formulations, includ­ing ion-exchange resins with a semiper­meable membrane and those with slowly dissolving characteristics; substitute an immediate-release formulation.

Medications that require acidic pH are incompletely absorbed because gastric exposure is reduced.

Lipophilic medications depend on bile availability; impaired enterohepatic circulation because of reduced intestinal absorptive surface causes loss of bile and, therefore, impaired absorption of lipo­philic medications.

Medications that are poorly intrinsi­cally absorbed and undergo entero­hepatic circulation are likely to be underabsorbed after a malabsorptive bar­iatric procedure.

Lamotrigine, olanzapine, and quetiap­ine may show decreased efficacy because of possible reduced absorption.

The lithium level, which is influenced by volume of distribution, can become toxic postoperatively; consider measuring the serum lithium level.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Approximately 113,000 bariatric sur­geries were performed in the United States in 2010; as many as 80% of persons seeking weight loss surgery have a history of a psychiatric disorder.^1,2

Bariatric surgery can be “restrictive” (limiting food intake) or “malabsorptive” (limiting food absorption). Both types of procedures can cause significant changes in pharmacokinetics. Bariatric surgery patients who take a psychotropic are at risk of tox­icity or relapse of their psychiatric illness because of inappropriate formulations— immediate-release vs sustained-release—or incomplete absorption of medications. You need to anticipate potential pharmacokinetic alterations after bariatric surgery and make appropriate changes to the patient’s medica­tion regimen.

Pharmacokinetic concerns
Roux-en-Y surgery is a malabsorptive procedure that causes food to bypass the stomach, duodenum, and a variable length of jejunum. Secondary to bypass, iron defi­ciency anemia is a common nutritional complication.

Other changes that affect the pharma­cokinetics of psychotropics after bariatric surgery include:
   • an increase in percentage of lean body mass as weight loss occurs
   • a decrease in glomerular filtration rate as kidney size decreases with postsur­gical weight reduction
   • reversal of obesity-associated fatty liver and cirrhotic changes.

With time, intestinal adaptation occurs to compensate for the reduced length of the intestinal tract; this adaptation pro­duces mucosal hypertrophy and increases absorptive capacity.³

Medications to taper or avoid
The absorption and bioavailability of a medication depend on its dissolv­ability; the pH of the medium; surface area for absorption; and GI blood flow.⁴ Medications that have a long absorp­tive phase—namely, sustained-release, extended-release, long-acting, and enteric-coated formulations—show compromised dissolvability and absorption and reduced efficacy after bariatric surgery.

Avoid slow-release formulations, includ­ing ion-exchange resins with a semiper­meable membrane and those with slowly dissolving characteristics; substitute an immediate-release formulation.

Medications that require acidic pH are incompletely absorbed because gastric exposure is reduced.

Lipophilic medications depend on bile availability; impaired enterohepatic circulation because of reduced intestinal absorptive surface causes loss of bile and, therefore, impaired absorption of lipo­philic medications.

Medications that are poorly intrinsi­cally absorbed and undergo entero­hepatic circulation are likely to be underabsorbed after a malabsorptive bar­iatric procedure.

Lamotrigine, olanzapine, and quetiap­ine may show decreased efficacy because of possible reduced absorption.

The lithium level, which is influenced by volume of distribution, can become toxic postoperatively; consider measuring the serum lithium level.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

There is an association between inflam­mation and depression: Patients with a major depressive disor­der (MDD) have elevated levels of pro-inflammatory cytokines interleukin (IL)-1, IL-6, tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). Abnormal cell-mediated immunity and lymphocyte proliferation also have been reported in patients with MDD^1-2 (Box).^1,3-7

Production of cytokines in serum and cerebrospinal fluid can be triggered by psychosocial stress, administration of interferon-α or IL-2, and acute stimula­tion of the immune system after vacci­nation; this production of cytokines is associated with development of MDD.^1-3 Inflammatory disorders raise a person’s vulnerability to MDD; affective illness is the most common psychiatric condition seen in association with multiple sclerosis, for example.² 

Principal receptor targets
Glucocorticoid receptors. Synchrony between the hypothalamic-pituitary-adrenal axis and adrenal function occurs during stressful circumstances.² Down-regulation, or reduced activity, of glucocorticoid recep­tors in depression leads to glucocorticoid resistance, resulting in hyperactivity of this axis. TNF-α is associated with glucocorti­coid resistance by its action in opposing the influx of the cortisol-glucocorticoid recep­tor complex into the nucleus and inhibiting its linkage with DNA. Cytokines increase levels of corticotropin-releasing hormone and adrenocorticotrophic hormone, leading to a higher-than-normal cortisol concentra­tion in depressed patients.⁸

N-methyl-d-aspartate (NMDA) receptors are involved in the monoamine and glu­tamatergic pathways that are associated with depression.² NMDA-receptor acti­vation raises the intracellular calcium con­centration, causing neuronal cell death. Inflammatory mediators, including TNF-α, induce activation of the kyneurin pathway. Thus, instead of serotonin production, tryp­tophan is diverted to the synthesis of the NMDA-receptor agonists kynurenine and quinolinic acid, which leads to apoptosis.

The glutamatergic pathway involves binding of IL-1β and IL-1R complexes to hippocampal NMDA receptors.² Persistent activation of these receptors results in calcium toxicity and neuronal death. Reuptake inhibition of neurotransmit­ters is explained by the action of IL-1β on reuptake of glutamate, which enhances its availability to stimulate NMDA-receptor activation.

Any prospects for therapeutics?
As described, an association exists between inflammation and depression. Psychosocial stresses initiate inflammatory responses that might result in affective illness. In treat­ing depression and preventing its relapse, the question is whether psychotherapy provides clinical efficacy through stress reduction, thereby leading to potential anti-inflammatory action.¹

Inflammation has a detrimental influence in a subset of MDD cases.⁹ Identification of those patients through genetic research is ongoing, with the goal of establishing spe­cific anti-inflammatory or antidepressant therapies.

Anti-inflammatory drugs such as aspi­rin, celecoxib, and etanercept do induce antidepressant effects and augment the antidepressant response to other thera­pies.^1,3 In the future, anti-inflammatory treatments might become an option for select MDD patients.


Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

There is an association between inflam­mation and depression: Patients with a major depressive disor­der (MDD) have elevated levels of pro-inflammatory cytokines interleukin (IL)-1, IL-6, tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). Abnormal cell-mediated immunity and lymphocyte proliferation also have been reported in patients with MDD^1-2 (Box).^1,3-7

Production of cytokines in serum and cerebrospinal fluid can be triggered by psychosocial stress, administration of interferon-α or IL-2, and acute stimula­tion of the immune system after vacci­nation; this production of cytokines is associated with development of MDD.^1-3 Inflammatory disorders raise a person’s vulnerability to MDD; affective illness is the most common psychiatric condition seen in association with multiple sclerosis, for example.² 

Principal receptor targets
Glucocorticoid receptors. Synchrony between the hypothalamic-pituitary-adrenal axis and adrenal function occurs during stressful circumstances.² Down-regulation, or reduced activity, of glucocorticoid recep­tors in depression leads to glucocorticoid resistance, resulting in hyperactivity of this axis. TNF-α is associated with glucocorti­coid resistance by its action in opposing the influx of the cortisol-glucocorticoid recep­tor complex into the nucleus and inhibiting its linkage with DNA. Cytokines increase levels of corticotropin-releasing hormone and adrenocorticotrophic hormone, leading to a higher-than-normal cortisol concentra­tion in depressed patients.⁸

N-methyl-d-aspartate (NMDA) receptors are involved in the monoamine and glu­tamatergic pathways that are associated with depression.² NMDA-receptor acti­vation raises the intracellular calcium con­centration, causing neuronal cell death. Inflammatory mediators, including TNF-α, induce activation of the kyneurin pathway. Thus, instead of serotonin production, tryp­tophan is diverted to the synthesis of the NMDA-receptor agonists kynurenine and quinolinic acid, which leads to apoptosis.

The glutamatergic pathway involves binding of IL-1β and IL-1R complexes to hippocampal NMDA receptors.² Persistent activation of these receptors results in calcium toxicity and neuronal death. Reuptake inhibition of neurotransmit­ters is explained by the action of IL-1β on reuptake of glutamate, which enhances its availability to stimulate NMDA-receptor activation.

Any prospects for therapeutics?
As described, an association exists between inflammation and depression. Psychosocial stresses initiate inflammatory responses that might result in affective illness. In treat­ing depression and preventing its relapse, the question is whether psychotherapy provides clinical efficacy through stress reduction, thereby leading to potential anti-inflammatory action.¹

Inflammation has a detrimental influence in a subset of MDD cases.⁹ Identification of those patients through genetic research is ongoing, with the goal of establishing spe­cific anti-inflammatory or antidepressant therapies.

Anti-inflammatory drugs such as aspi­rin, celecoxib, and etanercept do induce antidepressant effects and augment the antidepressant response to other thera­pies.^1,3 In the future, anti-inflammatory treatments might become an option for select MDD patients.


Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

There is an association between inflam­mation and depression: Patients with a major depressive disor­der (MDD) have elevated levels of pro-inflammatory cytokines interleukin (IL)-1, IL-6, tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). Abnormal cell-mediated immunity and lymphocyte proliferation also have been reported in patients with MDD^1-2 (Box).^1,3-7

Production of cytokines in serum and cerebrospinal fluid can be triggered by psychosocial stress, administration of interferon-α or IL-2, and acute stimula­tion of the immune system after vacci­nation; this production of cytokines is associated with development of MDD.^1-3 Inflammatory disorders raise a person’s vulnerability to MDD; affective illness is the most common psychiatric condition seen in association with multiple sclerosis, for example.² 

Principal receptor targets
Glucocorticoid receptors. Synchrony between the hypothalamic-pituitary-adrenal axis and adrenal function occurs during stressful circumstances.² Down-regulation, or reduced activity, of glucocorticoid recep­tors in depression leads to glucocorticoid resistance, resulting in hyperactivity of this axis. TNF-α is associated with glucocorti­coid resistance by its action in opposing the influx of the cortisol-glucocorticoid recep­tor complex into the nucleus and inhibiting its linkage with DNA. Cytokines increase levels of corticotropin-releasing hormone and adrenocorticotrophic hormone, leading to a higher-than-normal cortisol concentra­tion in depressed patients.⁸

N-methyl-d-aspartate (NMDA) receptors are involved in the monoamine and glu­tamatergic pathways that are associated with depression.² NMDA-receptor acti­vation raises the intracellular calcium con­centration, causing neuronal cell death. Inflammatory mediators, including TNF-α, induce activation of the kyneurin pathway. Thus, instead of serotonin production, tryp­tophan is diverted to the synthesis of the NMDA-receptor agonists kynurenine and quinolinic acid, which leads to apoptosis.

The glutamatergic pathway involves binding of IL-1β and IL-1R complexes to hippocampal NMDA receptors.² Persistent activation of these receptors results in calcium toxicity and neuronal death. Reuptake inhibition of neurotransmit­ters is explained by the action of IL-1β on reuptake of glutamate, which enhances its availability to stimulate NMDA-receptor activation.

Any prospects for therapeutics?
As described, an association exists between inflammation and depression. Psychosocial stresses initiate inflammatory responses that might result in affective illness. In treat­ing depression and preventing its relapse, the question is whether psychotherapy provides clinical efficacy through stress reduction, thereby leading to potential anti-inflammatory action.¹

Inflammation has a detrimental influence in a subset of MDD cases.⁹ Identification of those patients through genetic research is ongoing, with the goal of establishing spe­cific anti-inflammatory or antidepressant therapies.

Anti-inflammatory drugs such as aspi­rin, celecoxib, and etanercept do induce antidepressant effects and augment the antidepressant response to other thera­pies.^1,3 In the future, anti-inflammatory treatments might become an option for select MDD patients.


Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Despite the high prevalence of suicide and its impact on society,¹ psychiat­ric practitioners achieve only mod­est success at predicting and preventing suicide. With this in mind, evaluating sui­cide risk when designing a safe treatment plan for a patient admitted with acute sui­cidal ideation or after a suicide attempt can be daunting. The mnemonic SUICIDE can remind you of the key elements to include in these patients’ charts.

Suicide assessment. Evaluate the patient for suicide risk factors and protec­tive factors.² Key risk factors include pre­vious suicide attempts, family history of suicide, access to lethal means, history of a psychiatric disorder, history of alcohol and substance abuse, recent loss of a loved one, and severe hopelessness. Protective factors can be family and community sup­port, problem-solving skills, and religious beliefs that discourage suicide.

Unpredictable and unpreventable. You are responsible for performing a com­prehensive risk assessment, responding appropriately to those risks, and institut­ing a safe discharge plan. Despite your best effort, you might not be able to avert a suicide, and you must provide the patient and family members with this information and document it.

Interventions. Proceed with biological, psychological, and social treatment options. Review the patient’s medications and, when appropriate, consider suicide protec­tive drugs, such as clozapine or lithium.³ Advocate for substance abuse rehabilitation. Encourage psychotherapy and work with your patient to improve social stressors.

Clear and comprehensive documentation. Detailed, accurate, and thorough daily notes are key. Go beyond reporting “no SI/ HI” (suicidal ideation/homicidal ideation). Report what the patient said and how she (he) said it. If the patient denies current sui­cidal ideation, ask when her (his) last sui­cidal thought occurred. How did the patient respond to that thought? Why? Avoid using a suicide contract—it is not a substitute for a thorough suicide assessment; it isn’t a legal document; it does not protect against legal liability; and it is ineffective.⁴

Intent. Evaluate the lethality of the suicidal attempt or plan. Ask about the means of sui­cide that were used or considered, whether the patient made provisions to ensure or avoid discovery, and how long she (he) has been planning the attempt.

Discuss the treatment plan with a collateral informant (family, friend, community support, outpatient providers). Facilitate safe discharge by including social support in planning. Request that all methods of self-harm, including guns and old prescrip­tions, be removed from the patient’s home. Help family members and friends identify signs of suicidal ideation.

Educate, engage, and empathize with the patent. Use the Collaborative Assessment and Management of Suicidality (CAMS), which is a structured, evidence-based method of risk assessment and treatment planning. CAMS provides a framework to involve the patient in the assessment of her suicidality and to design a suicide-specific treatment plan.⁵


A mnemonic can’t prevent all suicides
But using SUICIDE can ensure that the key elements of the evaluation, treatment, and discharge of a patient admitted for acute suicidal ideation or after a suicide attempt are addressed to the best of your ability during an inpatient hospitalization. In doing so, you’ll better identify modifiable risk and protective factors that will inform this plan.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Despite the high prevalence of suicide and its impact on society,¹ psychiat­ric practitioners achieve only mod­est success at predicting and preventing suicide. With this in mind, evaluating sui­cide risk when designing a safe treatment plan for a patient admitted with acute sui­cidal ideation or after a suicide attempt can be daunting. The mnemonic SUICIDE can remind you of the key elements to include in these patients’ charts.

Suicide assessment. Evaluate the patient for suicide risk factors and protec­tive factors.² Key risk factors include pre­vious suicide attempts, family history of suicide, access to lethal means, history of a psychiatric disorder, history of alcohol and substance abuse, recent loss of a loved one, and severe hopelessness. Protective factors can be family and community sup­port, problem-solving skills, and religious beliefs that discourage suicide.

Unpredictable and unpreventable. You are responsible for performing a com­prehensive risk assessment, responding appropriately to those risks, and institut­ing a safe discharge plan. Despite your best effort, you might not be able to avert a suicide, and you must provide the patient and family members with this information and document it.

Interventions. Proceed with biological, psychological, and social treatment options. Review the patient’s medications and, when appropriate, consider suicide protec­tive drugs, such as clozapine or lithium.³ Advocate for substance abuse rehabilitation. Encourage psychotherapy and work with your patient to improve social stressors.

Clear and comprehensive documentation. Detailed, accurate, and thorough daily notes are key. Go beyond reporting “no SI/ HI” (suicidal ideation/homicidal ideation). Report what the patient said and how she (he) said it. If the patient denies current sui­cidal ideation, ask when her (his) last sui­cidal thought occurred. How did the patient respond to that thought? Why? Avoid using a suicide contract—it is not a substitute for a thorough suicide assessment; it isn’t a legal document; it does not protect against legal liability; and it is ineffective.⁴

Intent. Evaluate the lethality of the suicidal attempt or plan. Ask about the means of sui­cide that were used or considered, whether the patient made provisions to ensure or avoid discovery, and how long she (he) has been planning the attempt.

Discuss the treatment plan with a collateral informant (family, friend, community support, outpatient providers). Facilitate safe discharge by including social support in planning. Request that all methods of self-harm, including guns and old prescrip­tions, be removed from the patient’s home. Help family members and friends identify signs of suicidal ideation.

Educate, engage, and empathize with the patent. Use the Collaborative Assessment and Management of Suicidality (CAMS), which is a structured, evidence-based method of risk assessment and treatment planning. CAMS provides a framework to involve the patient in the assessment of her suicidality and to design a suicide-specific treatment plan.⁵


A mnemonic can’t prevent all suicides
But using SUICIDE can ensure that the key elements of the evaluation, treatment, and discharge of a patient admitted for acute suicidal ideation or after a suicide attempt are addressed to the best of your ability during an inpatient hospitalization. In doing so, you’ll better identify modifiable risk and protective factors that will inform this plan.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Despite the high prevalence of suicide and its impact on society,¹ psychiat­ric practitioners achieve only mod­est success at predicting and preventing suicide. With this in mind, evaluating sui­cide risk when designing a safe treatment plan for a patient admitted with acute sui­cidal ideation or after a suicide attempt can be daunting. The mnemonic SUICIDE can remind you of the key elements to include in these patients’ charts.

Suicide assessment. Evaluate the patient for suicide risk factors and protec­tive factors.² Key risk factors include pre­vious suicide attempts, family history of suicide, access to lethal means, history of a psychiatric disorder, history of alcohol and substance abuse, recent loss of a loved one, and severe hopelessness. Protective factors can be family and community sup­port, problem-solving skills, and religious beliefs that discourage suicide.

Unpredictable and unpreventable. You are responsible for performing a com­prehensive risk assessment, responding appropriately to those risks, and institut­ing a safe discharge plan. Despite your best effort, you might not be able to avert a suicide, and you must provide the patient and family members with this information and document it.

Interventions. Proceed with biological, psychological, and social treatment options. Review the patient’s medications and, when appropriate, consider suicide protec­tive drugs, such as clozapine or lithium.³ Advocate for substance abuse rehabilitation. Encourage psychotherapy and work with your patient to improve social stressors.

Clear and comprehensive documentation. Detailed, accurate, and thorough daily notes are key. Go beyond reporting “no SI/ HI” (suicidal ideation/homicidal ideation). Report what the patient said and how she (he) said it. If the patient denies current sui­cidal ideation, ask when her (his) last sui­cidal thought occurred. How did the patient respond to that thought? Why? Avoid using a suicide contract—it is not a substitute for a thorough suicide assessment; it isn’t a legal document; it does not protect against legal liability; and it is ineffective.⁴

Intent. Evaluate the lethality of the suicidal attempt or plan. Ask about the means of sui­cide that were used or considered, whether the patient made provisions to ensure or avoid discovery, and how long she (he) has been planning the attempt.

Discuss the treatment plan with a collateral informant (family, friend, community support, outpatient providers). Facilitate safe discharge by including social support in planning. Request that all methods of self-harm, including guns and old prescrip­tions, be removed from the patient’s home. Help family members and friends identify signs of suicidal ideation.

Educate, engage, and empathize with the patent. Use the Collaborative Assessment and Management of Suicidality (CAMS), which is a structured, evidence-based method of risk assessment and treatment planning. CAMS provides a framework to involve the patient in the assessment of her suicidality and to design a suicide-specific treatment plan.⁵


A mnemonic can’t prevent all suicides
But using SUICIDE can ensure that the key elements of the evaluation, treatment, and discharge of a patient admitted for acute suicidal ideation or after a suicide attempt are addressed to the best of your ability during an inpatient hospitalization. In doing so, you’ll better identify modifiable risk and protective factors that will inform this plan.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?


Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
   a) obtain a suicide prevention contract
   b) assess suicide risk and protective factors
   c) determine the cause of Mr. J’s depression
   d) have Mr. J complete a suicide risk self-assessment form
   e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.


In assessing religious affiliation as a protective factor against suicide, you should consider:
   a) the nature of the patient’s religious conviction
   b) the religion’s stated position on suicide
   c) severity of the patient’s illness
   d) presence of delusional religious beliefs
   e) all of the above


The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.


Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
   a) schizophrenia
   b) eating disorders
   c) bipolar disorder
   d) major depressive disorder
   e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands imme­diate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.

The clinician should:
   a) contact Mr. Z’s family, as an emergency exception to confidentiality
   b) e-mail his family members with questions
   c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   d) try to develop a therapeutic alliance with Mr. Z
   e) none of the above

The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.⁸ However, mental health professionals can­not share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clin­ical information. E-mail merely changes the mode of unauthorized communication with significant others.

Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather infor­mation about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.⁹ The definition of emergency var­ies among jurisdictions. Consulting with a knowledgeable attorney may be neces­sary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.¹⁰

Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves sud­denly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?

The treatment team should consider all of the following options except:
   a) obtain records of earlier hospitalizations
   b) check collateral sources of information
   c) assess Mr. G’s compliance with treatment
   d) obtain psychological testing to evaluate Mr. G’s honesty
   e) determine whether behavioral signs of depression are present

The best response option is D
Short length of hospital stay makes it diffi­cult to assess sudden patient improvement.¹¹ Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collat­eral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimula­tive patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.

Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depres­sion and auditory hallucinations command­ing her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.

The psychiatrist conducts a compre­hensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psy­chiatrist weighs and synthesizes risk and pro­tective factors into an overall assessment of Ms. M’s suicide risk.

The main purpose of suicide risk assessment is to:  
   a) predict the likelihood of suicide  
   b) determine imminence of suicide  
   c) inform patient treatment and safety management  
   d) identify malingered suicidal ideation  
   e) provide a legal defense against a mal­practice claim

The best response option is C
Suicide cannot be predicted.¹² The term imminent suicide is a veiled attempt to pre­dict when a patient will attempt suicide.¹³ The process of a comprehensive or system­atic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.³ The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in deter­mining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment meth­odology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.

Although not the main purpose, system­atic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.¹⁴

Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psycho­therapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic rela­tionship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.

The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospi­talization. The psychiatrist performs a sys­tematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to par­ticipate in civil causes. The overall suicide risk  is determined by the assessment of individ­ual and evidence-based protective factors.

All of the following options are evidence-based protective factors except:
   a) therapeutic alliance
   b) survival and coping beliefs
   c) responsibility to family
   d) fear of suicide
   e) moral objections to suicide

The best response option is A
Clinical consensus holds that the thera­peutic alliance is an important protec­tive factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.

Linehan et al¹⁵ developed the Reasons for Living Inventory, a self-report instru­ment that identifies 6 subscales:
   • survival and coping beliefs
   • responsibility to family
   • child-related concerns
   • fear of suicide
   • fear of social disapproval
   • moral objections to suicide.

Survival and coping beliefs, responsi­bility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al¹⁶ administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted sui­cide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.

Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depres­sion; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.

The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.

Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
   a) clozapine
   b) clonazepam
   c) lorazepam
   d) lithium
   e) quetiapine

The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.¹⁷

Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.

Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emer­gency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.

Drug Brand Names
Clonazepam • Klonopin              Lorazepam • Ativan
Clozapine • Clozaril                    Quetiapine • Seroquel
Lithium • Eskalith, Lithobid

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.

Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.

Since clozapine was launched in 1989, miraculous improvements and “awak­enings” have been reported in many patients afflicted with severe schizo­phrenia and considered hopelessly refractory to antipsychotic pharmaco­therapy. Not only do severely disabled patients regain their sanity and return to normal functioning, but the joy that their family and treating psychiatrist experi­ence is priceless.

That’s why I am perplexed by how infrequently clozapine is used in the United States (in about 5% of patients)—even though approximately 25% of patients who have schizophrenia are either treatment-resistant or have refrac­tory hallucinations or delusions.

Consider Bethany’s case. She was one of my young patients, who, after taking clozapine, recovered fully and resumed a productive life, after years of homeless­ness during which she was controlled by auditory hallucinations.

Bethany’s story began well…
Bethany grew up in a loving home, smart and talented, an “A” student in high school and talented violin­ist. She received a scholarship to a prestigious private university at 16 and left her parent’s home in Ohio to major in molecular biol­ogy. Her goal was to attend medical school. She excelled during her first 3 years of college, and even published 2 papers in top-tier science journals.

In her senior year, after returning from a trip to Africa, Bethany began to change. She neglected her studies and focused on raising money for HIV clinics in Africa. She began getting F’s instead of A’s, lost her scholarship and her residence hall room, and had to drop out of college. Soon, she began hearing voices commanding her every action.

..but took a really bad turn
Bethany became homeless for the next 4.5 years. She ate discarded food from garbage cans, had no change of clothes, and slept on a concrete slab behind a downtown church in a major city in California. Her parents lost track of her, although her mother, a retired nurse, frantically and relentlessly tried to find out what happened to her only daughter during that time.

Eventually, Bethany was arrested when she was found screaming back at the voices, at midnight in a residential area of the city. She was hospitalized on a psychiatric ward and given antipsychot­ics, but with only modest improvement.

Her parents were contacted; immedi­ately, they flew to California to see her. The treating psychiatrist told them that their daughter had schizophrenia, and that they should lower their expectations because she would be totally disabled for the rest of her life. They brought Bethany back to Ohio where, after a tumultuous year of failed trials of several antipsy­chotics to suppress the auditory halluci­nations, we gave her clozapine.

Gradually, Bethany improved, but she still could not read a book or maga­zine (which I urged her to do) without the voices intensifying and preventing her from reading.


Bethany recovers
After 6 to 8 months on clozapine, however, Bethany’s auditory hal­lucinations faded away. With my encouragement, she enrolled at the University of Cincinnati and took 1 course at a time. She began to get A’s again—in advanced courses, such as genetics, physics, and molecular biol­ogy. She completed her degree require­ments and graduated with honors, with a Bachelor of Science degree in molecular biology. She also served as a marshal in the commencement ceremony procession.

Over the next year, with strong encouragement, Bethany wrote a book about her remark­able recovery from refractory psychosis.¹ In addition, her mother wrote a deeply emo­tional book that described the gut-wrenching ordeal that she and her husband went through during the years that Bethany disappeared.² I urge you to read these inspiring books (Figure) about the remarkable recovery from refractory psychosis and the heavy family burden of schizophrenia.

No doubt, clozapine is associated with serious side effects¹⁵—but so is chemotherapy for cancer, and oncolo­gists do not hesitate to use it to save their patients from physical death. Severe schizophrenia is like a can­cer of the mind, and clozapine is its chemotherapy.

Fortunately for Bethany, she had almost no physical adverse effects from clozapine except for intense sedation, which was mitigated with modafinil.

We should use clozapine more than we do
Clozapine has the potential to have a healing effect for many patients whose schizophrenia is resistant to treatment. Most such patients, however, never receive a trial of the drug. Furthermore, few practitioners use clozapine for schizophrenia patients with suicidal ten­dencies, despite the high rate of suicide completion in schizophrenia.¹⁶

Clozapine remains, regrettably, an underutilized agent in psychiatry. Until other breakthrough drugs are discovered, its use ought to be double or triple what it is now because there are many people like Bethany who are not being given a chance to recover from their illness.

Since clozapine was launched in 1989, miraculous improvements and “awak­enings” have been reported in many patients afflicted with severe schizo­phrenia and considered hopelessly refractory to antipsychotic pharmaco­therapy. Not only do severely disabled patients regain their sanity and return to normal functioning, but the joy that their family and treating psychiatrist experi­ence is priceless.

That’s why I am perplexed by how infrequently clozapine is used in the United States (in about 5% of patients)—even though approximately 25% of patients who have schizophrenia are either treatment-resistant or have refrac­tory hallucinations or delusions.

Consider Bethany’s case. She was one of my young patients, who, after taking clozapine, recovered fully and resumed a productive life, after years of homeless­ness during which she was controlled by auditory hallucinations.

Bethany’s story began well…
Bethany grew up in a loving home, smart and talented, an “A” student in high school and talented violin­ist. She received a scholarship to a prestigious private university at 16 and left her parent’s home in Ohio to major in molecular biol­ogy. Her goal was to attend medical school. She excelled during her first 3 years of college, and even published 2 papers in top-tier science journals.

In her senior year, after returning from a trip to Africa, Bethany began to change. She neglected her studies and focused on raising money for HIV clinics in Africa. She began getting F’s instead of A’s, lost her scholarship and her residence hall room, and had to drop out of college. Soon, she began hearing voices commanding her every action.

..but took a really bad turn
Bethany became homeless for the next 4.5 years. She ate discarded food from garbage cans, had no change of clothes, and slept on a concrete slab behind a downtown church in a major city in California. Her parents lost track of her, although her mother, a retired nurse, frantically and relentlessly tried to find out what happened to her only daughter during that time.

Eventually, Bethany was arrested when she was found screaming back at the voices, at midnight in a residential area of the city. She was hospitalized on a psychiatric ward and given antipsychot­ics, but with only modest improvement.

Her parents were contacted; immedi­ately, they flew to California to see her. The treating psychiatrist told them that their daughter had schizophrenia, and that they should lower their expectations because she would be totally disabled for the rest of her life. They brought Bethany back to Ohio where, after a tumultuous year of failed trials of several antipsy­chotics to suppress the auditory halluci­nations, we gave her clozapine.

Gradually, Bethany improved, but she still could not read a book or maga­zine (which I urged her to do) without the voices intensifying and preventing her from reading.


Bethany recovers
After 6 to 8 months on clozapine, however, Bethany’s auditory hal­lucinations faded away. With my encouragement, she enrolled at the University of Cincinnati and took 1 course at a time. She began to get A’s again—in advanced courses, such as genetics, physics, and molecular biol­ogy. She completed her degree require­ments and graduated with honors, with a Bachelor of Science degree in molecular biology. She also served as a marshal in the commencement ceremony procession.

Over the next year, with strong encouragement, Bethany wrote a book about her remark­able recovery from refractory psychosis.¹ In addition, her mother wrote a deeply emo­tional book that described the gut-wrenching ordeal that she and her husband went through during the years that Bethany disappeared.² I urge you to read these inspiring books (Figure) about the remarkable recovery from refractory psychosis and the heavy family burden of schizophrenia.

No doubt, clozapine is associated with serious side effects¹⁵—but so is chemotherapy for cancer, and oncolo­gists do not hesitate to use it to save their patients from physical death. Severe schizophrenia is like a can­cer of the mind, and clozapine is its chemotherapy.

Fortunately for Bethany, she had almost no physical adverse effects from clozapine except for intense sedation, which was mitigated with modafinil.

We should use clozapine more than we do
Clozapine has the potential to have a healing effect for many patients whose schizophrenia is resistant to treatment. Most such patients, however, never receive a trial of the drug. Furthermore, few practitioners use clozapine for schizophrenia patients with suicidal ten­dencies, despite the high rate of suicide completion in schizophrenia.¹⁶

Clozapine remains, regrettably, an underutilized agent in psychiatry. Until other breakthrough drugs are discovered, its use ought to be double or triple what it is now because there are many people like Bethany who are not being given a chance to recover from their illness.

Since clozapine was launched in 1989, miraculous improvements and “awak­enings” have been reported in many patients afflicted with severe schizo­phrenia and considered hopelessly refractory to antipsychotic pharmaco­therapy. Not only do severely disabled patients regain their sanity and return to normal functioning, but the joy that their family and treating psychiatrist experi­ence is priceless.

That’s why I am perplexed by how infrequently clozapine is used in the United States (in about 5% of patients)—even though approximately 25% of patients who have schizophrenia are either treatment-resistant or have refrac­tory hallucinations or delusions.

Consider Bethany’s case. She was one of my young patients, who, after taking clozapine, recovered fully and resumed a productive life, after years of homeless­ness during which she was controlled by auditory hallucinations.

Bethany’s story began well…
Bethany grew up in a loving home, smart and talented, an “A” student in high school and talented violin­ist. She received a scholarship to a prestigious private university at 16 and left her parent’s home in Ohio to major in molecular biol­ogy. Her goal was to attend medical school. She excelled during her first 3 years of college, and even published 2 papers in top-tier science journals.

In her senior year, after returning from a trip to Africa, Bethany began to change. She neglected her studies and focused on raising money for HIV clinics in Africa. She began getting F’s instead of A’s, lost her scholarship and her residence hall room, and had to drop out of college. Soon, she began hearing voices commanding her every action.

..but took a really bad turn
Bethany became homeless for the next 4.5 years. She ate discarded food from garbage cans, had no change of clothes, and slept on a concrete slab behind a downtown church in a major city in California. Her parents lost track of her, although her mother, a retired nurse, frantically and relentlessly tried to find out what happened to her only daughter during that time.

Eventually, Bethany was arrested when she was found screaming back at the voices, at midnight in a residential area of the city. She was hospitalized on a psychiatric ward and given antipsychot­ics, but with only modest improvement.

Her parents were contacted; immedi­ately, they flew to California to see her. The treating psychiatrist told them that their daughter had schizophrenia, and that they should lower their expectations because she would be totally disabled for the rest of her life. They brought Bethany back to Ohio where, after a tumultuous year of failed trials of several antipsy­chotics to suppress the auditory halluci­nations, we gave her clozapine.

Gradually, Bethany improved, but she still could not read a book or maga­zine (which I urged her to do) without the voices intensifying and preventing her from reading.


Bethany recovers
After 6 to 8 months on clozapine, however, Bethany’s auditory hal­lucinations faded away. With my encouragement, she enrolled at the University of Cincinnati and took 1 course at a time. She began to get A’s again—in advanced courses, such as genetics, physics, and molecular biol­ogy. She completed her degree require­ments and graduated with honors, with a Bachelor of Science degree in molecular biology. She also served as a marshal in the commencement ceremony procession.

Over the next year, with strong encouragement, Bethany wrote a book about her remark­able recovery from refractory psychosis.¹ In addition, her mother wrote a deeply emo­tional book that described the gut-wrenching ordeal that she and her husband went through during the years that Bethany disappeared.² I urge you to read these inspiring books (Figure) about the remarkable recovery from refractory psychosis and the heavy family burden of schizophrenia.

No doubt, clozapine is associated with serious side effects¹⁵—but so is chemotherapy for cancer, and oncolo­gists do not hesitate to use it to save their patients from physical death. Severe schizophrenia is like a can­cer of the mind, and clozapine is its chemotherapy.

Fortunately for Bethany, she had almost no physical adverse effects from clozapine except for intense sedation, which was mitigated with modafinil.

We should use clozapine more than we do
Clozapine has the potential to have a healing effect for many patients whose schizophrenia is resistant to treatment. Most such patients, however, never receive a trial of the drug. Furthermore, few practitioners use clozapine for schizophrenia patients with suicidal ten­dencies, despite the high rate of suicide completion in schizophrenia.¹⁶

Clozapine remains, regrettably, an underutilized agent in psychiatry. Until other breakthrough drugs are discovered, its use ought to be double or triple what it is now because there are many people like Bethany who are not being given a chance to recover from their illness.