Overview of Psychiatric Disorders

1
Overview of Psychiatric Disorders

• Douglas Jacobs, MDAssociate Clinical Professor
  of Psychiatry
• Harvard Medical School

2
Overview of Clinical Context of Spontaneous
Reports

• Suicide
• clinical and demographic correlates
• clinical features
• Suicidal Behavior
• definitional issues as they relate to spontaneous
  reports
• Depression
• definitions - illness vs symptoms
• relationship to medications
• relationship to suicide
• Depression and Suicide in Ages 15-24
• diagnostic issues
• epidemiology and risk factors

3
Suicide A Multi-Factorial Event - Adult
No apparentpsychopathology
Psychiatric IllnessCo-morbidity
Neurobiology
Substance Use/Abuse
Impulsiveness
Severe Medical Illness
Suicidal Behavior
SUICIDE
Personality Disorder/Traits
Life Stressors
Family History
Access To Weapons
Hopelessness
4
Incidence of Suicide

• 30,000 suicides per year in the US
• 0.01 annual incidence rate (11.4/100,000)
• 80 suicides are in males (41 m/f ratio)
• Third leading cause of death in the 15-24 age
  group representing 20 of suicides (approximately
  6,000)

5
Suicide Clinical Features

• Associated with severe depression
• Majority not in mental health treatment
• 75 have seen a physician in previous six months
• No one factor predictive of suicide
• 60 suicide on first attempt
• No medication has ever been proven to cause
  suicide

6
Profile of the Suicides in the Accutane Medwatch
Reports

• 30,000 suicides per year in the US
• 0.01 annual incidence rate (11.4/100,000)
• 80 suicides are in males (41 m/f ratio)
• Third leading cause of death in the 15-24 age
  group representing 20 of suicides

• Associated with severe depression
• Majority not in mental health treatment
• 75 have seen a physician in previous six months
• No one factor predictive of suicide
• 60 suicide on first attempt
• No medication has ever been proven to cause
  suicide

7
Definitional Issues - Suicidal Behavior

• Suicidal Ideation
• A) nonspecific -- thoughts of death
• B) specific -- the thought of death includes an
  intent to die with a plan of action
• Prevalence of suicidal ideation 2.6
• Thoughts of death 28.2
• Suicidal ideation (definition B) is associated
  with a psychiatric disorder, primarily depression

• Suicide Attempts
• A) (U.S.) Potential or actual self-injurious
  behavior accompanied by intent to die
• B) (Europe) Parasuicide -- a self-harmful act
  with nonfatal outcome -- intent not included in
  definition
• (U.S.) Current prevalence estimates 0.3 to
  0.8
• Male/Female ratio 13 (inverse of suicides)
• Attempts/completion 18/1
• Higher incidence of attempts in 15-24 age
  population 100/1 (parasuicide)
• Serious suicide attempts indicative of severe
  psychiatric illness

8
Overview of Suicidal Behavior
Thoughts of death (28)
Suicide Ideators (2.6)
Suicide Attempters
Ideators 5,000,000 Attempters
600,000 Completers 31,284 (1995)
Completers
Self Destructive Behavior
estimate
9
Depression Epidemiology

• Prevalent disorder 12 annually - 20 million
  people
• Undertreated and Underdiagnosed - Only 20 with
  recent episodes in treatment 40 lifetime.
• 20 appear in general medical practices 50
  undiagnosed
• Decreased age of onset since WW II
• Male/Female ratio 12

10
Depression The Illness VersusDepressive
Symptoms - (The Blues)
Depression The Blues

• Essential distinction An illness A normal
  reaction to life situations
• Prevalence 12 25
• Symptoms Multiple mood, Single
  mood thoughts, bodily functions
• Duration Persists, episodic Temporary
• Suicide Potential Can result in Rarely
  produces suicide suicidal thoughts
• Treatment Requires specific Requires a
  good medical/psychiatric listener
  and/or treatment time to heal

11
The Issue of Medications and Depression

• Are medications that are reported to cause
  depression (approximately 100) associated with
  diagnosed depressive disorders or depressive
  symptoms?
• Case reports vs empirical evidence
• Majority of evidence suggests association with
  depressive symptoms and not depressive disorders
• Clinical significance of depressive symptoms is
  minimal

12
Adolescent Depression - Clinical Features

• Increased moodiness, irritability,
  argumentativeness
• Poor concentration
• Sleep and appetite changes
• Increased self-criticism
• Despair, sadness, emptiness
• Loss of energy
• Lack of interest in usual activities and friends
• Increased talk of death and dying
• Threats of suicide

13
Why Adolescent Depression Is Undiagnosed

• Normal adolescents often moody, frequently argue
• Symptoms of depression overlap with traits of
  normal adolescence
• Parents, teachers and other adults label it
  troubled teenage behavior
• Adolescents conceal symptoms from parents and
  care givers

14
Adolescent Depression - Relationship to Stressful
Events

• Depression can occur after a stressful event or
  in teenagers who have not experienced a stressful
  event (50-50)

15
Suicide Rates for All Persons and Persons Aged 15
to 24, U.S., 1900-1995
Ages 15-241950 41980 12.3
13.35
SuicideRate(per 100,000)
11.9
1950
1980
Year
Adapted from Rosenberg et al, 1987. The
Emergence of Youth Suicide An Epidemiologic
Analysis and Public Health Perspective. Annual
Review of Public Health, 8417-44 Updated from
National Center for Health Statistics Center
PSY 110, (1063), 7/18/00
16
Suicide A Multi-Factorial Event - Adolescent
No apparentpsychopathology
Psychiatric IllnessCo-morbidity
Neurobiology
Substance Use/Abuse
Impulsiveness
Exposure to Suicide
Suicidal Behavior
SUICIDE
Conduct Disorder
Severe Acne
Age Specific Stressors
Family History
Access To Weapons

• Self-esteem/image
• Academic Problems
• Disciplinary Crisis/ Humiliation

Hopelessness
17
No Apparent Psychopathology

• Psychological autopsy studies reveal risk
  factors
• subsyndromal psychopathology
• past suicidality
• familial psychiatric disorder
• legal/disciplinary problems
• presence of firearm (or other lethal method)

Note Cases 15, 29, 1, 61, 14, 8 (patient had 2
courses of Accutane,argues against impulsive rx
to Accutane
18
Clinical Analysis of Spontaneous Reports

• Dr. Jacobs

19
Questions Addressed

• Is there any pattern to suicide reports in
  relationship to Accutane?
• e.g., gender distribution and on/off Accutane
• What is the significance of the temporal
  association with depression?
• Does Accutane exacerbate underlying
  psychopathology and lead to suicide?
• Does Accutane cause impulsive suicides?

20
Categories of Suicides in Medwatch Reports

• Relationship to Accutane Use
• Concealment of symptoms
• Confounding factors e.g. pre-existing psychiatric
  history
• No apparent psychopathology
• Miscellaneous

21
Suicide On/Off Accutane

• 30 cases were on Accutane, including 4 that were
  on over 6 months
• 24 cases were off Accutane
• 10 unknown
• No evidence of predominance of on/off factor
• Gender -- total males 53, total females 11
• total suicides consistent with known demographics
  
• on/off ratio the same, regardless of gender

22
Case Example Relationship to Accutane
On Accutane lt 1 Month
Off Accutane 9 Months

• 22 year-old male
• Firearm
• No relevant findings

• 19 year-old male
• Firearm
• History of psychosis
• School stressors
• Duration 6 months

Analysis No consistent relationship to Accutane
23
Depression Occurring While On Accutane

• 17 out of 64 reports
• 10 cases committed suicide on Accutane
• 7 cases committed suicide off Accutane
• Only one case had psychiatric treatment

24
Case Example Concealment of Symptoms
Case Description
Case Analysis

• 14 year-old male
• Committed suicide 2 months on Accutane
• Psychiatric History -- none reported
• No depression or suicidal ideation noted while on
  Accutane

• Pre existing depression and suicidal ideation --
  revealed by diary found after suicide
• Depression with suicidal ideation requires
  psychiatric treatment
• Analysis Depression and suicidal ideation
  concealed from family and physician

25
Prior Psychiatric History Related to On/Off
Accutane

• Question What is the impact of Accutane on this
  at-risk group for exacerbation of underlying
  illness leading to suicide?
• Results 9 cases on Accutane 12
  cases off Accutane

26
Reports With Prior Psychiatric History That
Represent Controls
Time Off
Duration

• None of these reports developed symptoms of
  underlying illness while on Accutane
• Accutane did not precipitate symptoms in
  persons at-risk
• Suicide unrelated to Accutane
• Analysis Suicide related to underlying
  psychiatric disorder

• gt 6 mo
• 9 mo
• 18 mo
• 6 yrs
• 6 yrs
• 8 yrs
• 10 yrs
• 10 yrs

8 mo 6 mo 4 mo 6 mo 3 mo 18 mo 6 mo
1 yr
27
Case Example No Apparent Psychopathology
Case Description
Case Analysis

• Engaged in risky behavior
• Method suggestive of getting high
• Analysis Suicide intent not established,
  possible accidental death

• 18 year-old male
• On Accutane lt 1 month
• No history of depression, mood swings or
  stressors
• Suicide by inhaling pellets placed in a canister,
  attached to tubing and a face mask

28
Case of Murder-Suicide
Case Description
Case Analysis

• Duration 8 months
• Off Accutane 4 months
• Method killed self and child by drowning (child
  not exposed to Accutane)
• Prior history post-partum depression
• Accutane stopped because of delirium
• Hospitalization offered but refused

• Infanticide consistent with psychotic depression
• Post-partum depression occurs in manic-depressive
  illness
• Delirium most likely was psychotic episode
• Analysis Events related to severe underlying
  psychiatric disorder

29
Case Example Substance Abuse/Impulsive Behavior
Case Description
Case Analysis

• 21 year-old male
• Psychiatric history
• Patient had been in and out of substance abuse
  rehabilitation treatment
• On Accutane, 6 months
• No report of depressive symptoms nor of drug
  relapse
• Committed suicide 1 year off Accutane

• Substance abusers are at-risk for mood disorders
  and impulsive behavior
• Accutane did not cause relapse, mood symptoms, or
  impulsive actions
• Analysis Suicide was related to
  pre-existing psychiatric conditions and happened
  a considerable amount of time after
  discontinuation of Accutane

30
Summary of Clinical Analysis

• No alteration of gender distribution
• No impact of on/off Accutane
• No significant relationship to concurrent
  depression
• No exacerbation of underlying psychiatric
  disorders
• Lack of warning signs consistent with youth
  suicide
• No evidence of impulsive factor