Dr. Grossi's Blog
There are psychiatrists who have had a patient commit suicide and there are psychiatrists who will have a patient commit suicide. High-risk patients in clinical practice are not uncommon. Assessment of the risks have been complicated by a variety of factors in the past. Among them were flaws in the precision of definitions and measurements. For example, an overdose of medication might be called a gesture, an accident, a threat, a cry for help, an attempt, or a manipulation. This imprecision hindered a more organized study of this problem.
A number of years ago the FDA convened a task force to study this problem. It was largely driven by development and introduction of a large number of antidepressants in the 1990s and the desire to determine whether these newer agents were implicated in increasing suicidal behavior. This led to the "black box" warnings that are present in the antidepressant entries in the Physician's Desk Reference. It also led to a more precise measurement of suicidal risk. What follows is a description of factors to consider in a more modern risk assessment.
The assessment of suicide is divided into three areas. First is that of suicidal ideation. This includes wishes to be dead, thoughts of wanting to end one's life, thoughts of suicide with some consideration of means, thoughts of suicide with some intent to act, thoughts with a detailed plan that has been developed. The second area is designated intensity of ideation. This includes the number of times a person has suicidal thoughts per day or week, the amount of time engaged with those thoughts, whether the individual can control or stop thinking the thoughts, whether there are deterrents such as children, family, etc. that stop the individual from thinking about suicide. This area also includes the reasons for thinking about suicide such as attention, revenge, pain, etc. The third and final area is suicidal behavior. This includes whether an attempt was made, how many attempts, type of attempts, any non-suicidal self-injurious behavior, any interrupted or aborted attempts and any preparatory acts or behavior.
The weighing of the above factors as well as considering whether the patient has a substance abuse problem, is psychotic, has a history that includes the suicide of significant others as well as the quality and strength of the relationship to the psychiatrist or therapist make the final judgment about suicidality of a particular individual a complex and challenging decision. Taking all these issues into account does help to make a reasonably accurate but not perfectly accurate response to the individual's question, "To be or not to be."
The final three months of the study was designated the re-feeding period. The men received from 1,877 to 4,158 calories. During the first six weeks moodiness, irritability, poor morale, depression and loss of interest in earlier humanitarian concerns for starving people were prominent findings. They were quarrelsome and more aggressive but less introverted and interested in their surroundings. Hunger during the first 12 weeks of re-feeding was immense with many eating to the feeling of bursting with food. Their preoccupation with food continued and their table manners deteriorated. During week 13, all food restrictions were lifted and the men ate an average of 5,218 calories. They ate and slept continuously. By week 15 social behavior at meals was returning to normal. By week 20 all subjects felt normal and were less preoccupied with food. Slowly humor, sociability and interest returned to the subjects who began planning for the future.
Re-feeding had noticeable effects on their bodies. The men gained fat quickly and lean tissue more slowly. Physical discomforts did not disappear quickly. Apathy, lethargy, and dizziness disappeared relatively quickly but it took longer to recover from tiredness, weakness, and reduced libido. Thirst increased and edema continued to be an issue.
Discussions about sleep occupy a prominent place in many discussions in the office. It is surprising that many people do not practice good sleep hygiene especially in light of the fact that the elements of good sleep hygiene are well known. I am setting them out for easy reference.
Good sleep hygiene starts with a quiet, somewhat cool room with a comfortable bed which can be made dark. It should be used only for sleep and sex. The bed should not be used as a work area. It is desirable to go to sleep at the same time every day including weekends and to arise at about the same time every day including weekends. If an alarm is needed then it should be used and the time should be adjusted so that the person is not experiencing daytime sleepiness. It is best to avoid eating within two hours of bedtime and avoid heavy meals within four hours of bedtime. Excessive fluids in the evening should be avoided as should energy drinks or caffeine. Avoid or change the schedule of any medications that interfere with sleep so that they are taken earlier in the day. Many over-the-counter medications interfere with sleep.
In general anything that produces stimulation should be avoided near bedtime. This would include exciting television programs, video games, arguments, fights, disagreements, and strenuous exercise. It is best to exercise in the morning or afternoon. If possible, the bedroom should not have a television, game console, or computer. Generally naps should be avoided and exposure to a lot of natural light all during the day should be encouraged. Most people find it helpful to have a brief routing leading up to going to bed. This could include a warm shower or bath, reading, a small snack, etc.
Following the above simple principles will help to produce sleep reliably.
(Read the related post about circadian rhythms.)