Do Antidepressants Cause SUICIDE?

by Chris Ballas, M.D.

Monday, May 14, 2007

First, and most importantly, the answer is no. No single thing can cause a complex behavior such as suicide (or violence), and to say that a drug, or event, or illness made someone do something is simplistic and, well, wrong.

A more refined question would be whether antidepressants (or anything else) can contribute to the suicide process, move someone further along. Cocaine doesn't cause violence, but if you see a violent guy on cocaine, it's best to get out of the way.

The FDA, in 2002 and 2004, issued warnings about suicidal ideations in children who take antidepressants. Here are a couple of points for us to consider.

1. These were kids
2. The point of discussion is suicidal ideation, not suicide (death) per se.

The FDA reviewed nine, then later 24 pediatric studies and found that the risk of ideation "doubled" from two to four percent.

The authors of a recent review of 29 studies found a similar small increase in risk.

Importantly, however, no actual suicides occurred.

They also analyzed whether or not the antidepressants were actually helpful to people, and weighted that finding against the risk of suicide. Their results determined the risk/reward ratio to be about 11:1, meaning that patients have 11 times better chance of being helped than hurt by antidepressants.

I should point out that, in my opinion, while there is absolutely no compelling evidence that these drugs promote suicidality, there is also a lack of compelling evidence indicating that they reduce suicidality. Nor would I expect there to be. Again, these drugs may change how someone feels, but there are a million steps between a feeling and an action. Which has the greater impact on suicidality: medications or the availability of a gun?

Asking the question simply, "do antidepressants cause suicide?" misses the meat of the argument. Cause? In whom? When, and under what circumstances? The real question is whether someone who is depressed is more likely to commit suicide off of the medicines than on them.

So while we ponder that question, let me offer a sobering statistic.

Only 30% of the people who committed suicide had seen a psychiatrist in the past year. That means 70% hadn't.

Source: JAMA. 2007;297:1683-1696.

Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment, A Meta-analysis of Randomized Controlled Trials,Jeffrey A. Bridge et al,JAMA.2007;297:1683-1696.

Conclusions: Relative to placebo, antidepressants are efficacious for pediatric MDD, OCD, and non-OCD anxiety disorders, although the effects are strongest in non-OCD anxiety disorders, intermediate in OCD, and more modest in MDD. Benefits of antidepressants appear to be much greater than risks from suicidal ideation/suicide attempt across indications, although comparison of benefit to risk varies as a function of indication, age, chronicity, and study conditions.








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Copycat Suicides

October 17, 2006
Werther Effect: Copycat Suicides May Not Exist

Goethe's popular comic book, Sorrows of Young Werther, published in 1774, allegedly inspired two imitations; many young men decided to kill themselves, and many, many young men decided to dress in yellow pants and blue jackets.

Well, that's all great, but I decded to investigate whether suicide rates really do increase after one is popularized-- a propos of the previous post's discussion about whether Lott's roommate's suicide pushed Lott towards it as well. I was pretty sure it existed, but I may have been wrong. Preliminarily, here's what I found, through 4 examples:

A study in Austria found that gun suicides increased in the three weeks following a famous gun suicide (as compared to the three weeks preceding). There are lots of this kind of study, which are correlations based on statistical anomalies.

A better kind of study actually interviewed the suicide attempters to see what had affected them. For example, a U.S. study found that exposure to parental suicide was not associated with suicide; exposure to a friend or acquaintance's suicide was mildly protective, and media accounts were strongly protective. However, this study wasn't about the immediate risk (e.g. in the following month), and the authors did note that this protective effect was only if the friend's suicide or media report was greater than a year in the past. It is easy to speculate that the longer you have to think about what they did, the more likely you are to think it wasn't the best option.

A 1993 study in adolescents found that within one month of the suicide of a friend, depression and suicidal ideation increased; but actual suicide attempts did not.

Most of the studies finding no correlation are done using the general population; how would it be different if we looked only at people with established mental illnesses? A 2005 study found that suicides in mental illness patients were clustered in terms of place, time, and method. Unfortunately, this study looked at the clusters and did not identify whether or not the victims were actually even known-- or whether the patients had even heard about the suicides. (For example, they might happen at the same clinic, but that doesn't mean they knewabout each other.)

Etc, etc. So clustering, at least in terms of lethal attempts, appears not to happen much, (and if it does it is primarily in teens.)

As an observation, most of the articles finding Werther effects were written pre 1980, while most finding no relationship were written post 2000. One explanation is that we are more rigorous now (HA!); the other explanation being that there is considerably less idealization of suicide now. In fact, suicide now is unremarkable. Consider the "medicalization" of depression and suicide, as biological diseases rather than character pathology or expressions of emotion, a communication of sorts. Suicides then "meant" something-- something more than "I'm depressed," while suicides now are simply symptoms. Suicide= more Wellbutrin.

I still think they "mean" something, and I try to interpret it, but the focus nowadays is certainly not to interpret suicide as an expression of anything. Too bad.

April 30, 2007
Does Media Reporting Of Suicides and Homicides Promote Copycats?

I won't give a detailed answer to this question here (it seems to be no), but there is an article making the reddit rounds now that I need to kill before it becomes another meme.

The article is from BMJ 2002, called Influences of the Media On Suicide, and it puts its conclusion right at the top:

Reporting and portrayal of suicidal behaviour in the media may have potentially negative influences and facilitate suicidal acts by people exposed to such stimuli. Recent systematic reviews by others and ourselves (unpublished) have found overwhelming evidence for such effects.1

And it offers about 8 references in support. And so now every nut with a microphone can proclaim it loudly: it's the media's fault.

We may want to take a pause and examine these 8 references: none of them offer anything close to "overwhelming evidence." For example:

Reference 1-- the one directly cited for the above statements-- is indicative of the type of "overwhelming evidence" that exists. The study finds that media reporting of suicide is extensive and detailed, but not that there is a clear link to future suicides.

In the summary, the authors use phrases like, "dearth of literature," "evidence is less reliable," "few studies permitting/demonstrating [the link]," "does not demonstrate consistency," "many studies fail to demonstrate" over 11 times in the 3 pages describing the studies.

Despite this, they are sure the link exists-- but they don't actually show the link, they infer a link. The authors repeat phrases, "it is fair to conclude that the evidence suggests an association [exists]" "tends to suggest," "probably reasonable to regard the association is causal" 13 times in two pages. Under these criteria, it's reasonable to assume the Matrix is real.

Reference 3 (not even linked correctly) is a letter to the editor, describing two cases, where the method of suicide was affected by internet, but not the decision to commit suicide. And the methods were rather weak: one guy took two pills of castor oil, and the other woman tried to drink water. No, I'm not kidding.

Reference 5 is frequently cited in support of media's impact. It supposedly says that a TV show with a Tylenol OD caused more Tylenol ODs: 20% of these suicidal viewers said it influenced their decision to attempt suicide in the first week post broadcast. Maybe-- that 20% is really 6 people. And most had attempted Tylenol OD in the past. Oh, and the authors note that while 17% of the suicidal viewers' choice of Tylenol was influenced by the show, some of them chose not to use it because of the show.

Reference 12 is probably the most cited reference in this field. In 1978 Vienna built a subway, which soon became a popular method of suicide. So the government established guidelines for reporting-- specifically, that the method not be mentioned-- and subways suicides decreased by 80%. Fantastic. Overall suicide rates didn't change, though. Too bad.

So much for the "overwhelming evidence" for a soon to be media soundbite.

The article doesn't make a good case for media influencing the decision to kill yourself, though I'll admit that it may influence the method. And that's where it gets tricky.

It's important to make a distinction between copycat suicides and copycat homicides: more poeple die in the latter, and, let's postulate, they didn't want to die. That has to be part of the calculus in media reporting. Copying suicide by water (instead of pills) is different than copying a 30 person massacre (instead of killing, say, one person.)

But you have to weigh this against the societal costs. The solution offered in these articles is to restrict media reporting. I think we can agree that the media are neither liberal nor conservative, but sensationalists, their bias is titillation. But to allow anyone, especially government, to affect the content of reporting-- literally, the information we are allowed to have-- seems exactly the wrong solution to a problem which may not actually exist. (e.g. I know it seems prurient, but I actually want to know all the details of David Kelly's suicide.)

Not to mention that if you say the media are partly responsible, then you're saying that you're less responsible.

June 4, 2007
"The Copycat Effect:" Does Reporting Violence Lead To Violence?

A reader asked me to read his book before saying that copycat suicides is not a real phenomenon.

To be fair, his book is really good. It is worth the price even as a reference guide/catalog of suicides and homicides that share similar characteristics, which are striking. While the majority of the information is a google search away, the fact is that he actually did the searches. It's also a good read-- it neither bores you nor crams the conclusions into your head.

But, I respectfully disagree. I think.

The main disagreement I have with the book is that he conflates two phenomena. His stated thesis of the book is that media reporting of violence and suicides begats copycats. However, in support of this premise, he uses examples of the media itself (e.g. movies) causing copycats.

A perfect example of this is the Werther Effect, so named for the Sorrows of Young Werther, the 1774 comic book by Goethe in which the protagonist kills himself because he can't get the girl. Subsequently, there were numerous copycat suicides-- staging it (same clothes, same desk) as Werther in the novel. Ok, I get it-- that's a copycat. But that's not an example of media reporting causing copycats.

In contrast, here's an example of a reporting-induced copycat: Coleman relates the Bergenfield Four. For a few months, there were rumors that a bunch of kids who called themselves "The Burnouts" had made a suicide pact. In September of 1986 their leader killed himself; in March of 1987 four others carbon monoxided themselves in a parking garage, leaving a note that clearly linked the deaths. One week after that, a cop found two other kids trying to do the same thing in the same garage. The day after the original four suicides, but in Illinois, two other teens suicided the same way (in a garage, in fact.) Coleman writes that by checking newspapers, he counted 22 teen carbon monoxide suicides in two weeks-- 47 in a month.

But then there's the case of Barry Loukaitis, who in 1996 shot two kids and a math teach, and said he got the idea from Stephen King's Rage, Pearl Jam's Jeremy, Natural Born Killers and The Basketball Diaries. Coleman writes that "the media attention...triggered a series of similar events." So, in these copycats, was it Basketball Diaries or the evening news? It's hard for me to see how the news can be more influential to a suicidal kid than the movie itself-- do kids even watch the news?

In fairness, he does cite numerous examples of media reporting induced copycats (check out the chapter "Planes Into Buildings" for a wild ride) but overall the argument is weakened by using both together. I left the book reasonably convinced that media can inspire copycat violence, but not that they inspire violence itself. In other words, I think those Werther scholars were going to kill themselves somehow, but they decided to shoot themselves (as oppposed to self-immolation) because of the book.

The distinction-- media or media reporting-- is important because the solutions are different. Here's an example: the book opens with the story about how one month after Marilyn Monroe's suicide, 197 (mostly blonde women) "appear to have used the model," to suicide-- an increase in the suicide rate of 12%. Furthermore, the suicide rate never went down after that. "This is the copycat effect working with a vengeance." Maybe. Or maybe the graphic description of the suicide wasn't to blame, but rather that a huge icon had done it at all. Are they copying her, or is society ripe for self-destruction? Either way, should we not report that Monroe killed herself at all? How much do you control information to protect the people? If the government is doing the controlling, then I can't imagine the answer should be anything other than "not at all, get the hell out of my face."

I've always said that the "mainstream media" is neither liberal nor conservative-- they are sensationalist. Of course I think they overreport, and overdramatize unusual violence. But I see that as more of a symptom of our culture than the cause of anything. You could close down all news portals, it won't change the amount of violence. Sure, maybe you wouldn't have thought of playing Russian Roulette. But you were going to come up with something.

Coleman wrote a thorough book, using the type of diligent research the CIA is supposed to be good at: compiling open source information and forming links. I only partly disagree with his conclusion, and I am still open to further arguments. But I am against the solution.

It's worth remembering that, in response to the copycat suicides, Sorrows of Young Werther was banned in Germany. I know I am one of only 8 people who has actually read it, but do we really want it banned? Maybe "dangerous" books need to be delayed by a generation to be published? And you see my problem.

Absent direct power or wealth, the only thing that keeps us free is information. I believe it is worth the risk of copycat suicides, especially since influencing the choice of the method of suicide isn't the same as influencing the choice of commiting suicide.

Writing a Risk Assesssment

From The Last Psychiatist - September 27, 2006

How to Write A Suicide Note

I'll write this for the ER psychiatrist seeing acute cases, but the strategy applies to all types of psychiatry. Always keep in mind what is the purpose of the note, and who will actually be reading it.

1. Write so the reader doesn't have to guess what you were thinking.

The overall biggest mistake in medical note writing is spending too much time/too many words on the "Objective" or narrative portion of the note, and not enough on the "Assessement."

Who is going to read this note? Insurance companies read the objective and bill based on it. But no one else will care about this. The only part that other doctors, lawyers, and juries care about is the assessment and plan (assuming its more than two lines.)

And so you must write your assessment and plan in a way that makes it completely obvious why you did what you did.

For example, a common error is trying to convince the reader that the person was not suicidal by listing occurrences or patient statements. "Patient was denying suicidal ideations...had good affect and was joking with staff... etc etc." You are forcing the reader to make an inference, to have to connect the dots himself. This is bad, because what if they come up with a different conclusion? Make the train of thought obvious. "I was able to conclude that he wasn't suicidal because not only was he denying suicidality, but his good affect and joking with staff indicated to me he felt better."

Did the person shave himself this morning, with attention to detail? If yes, that's a good clue he wants to live. But write it down in the note. Don't write it as, "Appearance: clean" because it's more important than that. Put it in sentence form in the body of the note. Here's an example of a suicidal surgical patient I was saw in consultation. "I noted that he was cleanly shaved with attention to the margins along his goatee; I asked him if he had done it (or a nurse) and he said he did it, he was trying to look good." That's gold. He may be suicidal, but he was hopeful enough to want to look good. Now link it explicitly: "This supported my assessment that he was still interested in life, and that he wanted to live."

2. Prime real estate should be valued.

The maxim "if it wasn't written, it wasn't done" is idiotic, and false. But if it is written, it shows it carried more importance to you relative to other parts of the note. Writing about a patient's future plans in the objective shows it mattered more to you than did, say, checking a box near "Appearance: Clean." Or, the reverse: not writing about his future plans makes it look like it mattered LESS to you than his appearance.

Don't waste space with SIGECAPS and the like; no one cares. I know this contradicts everything you've been taught, but it's true. It's important in making the diagnosis of depression, but the actual readers of the note (other doctors, lawyers, and juries) only care what your diagnosis was, and what you did about it.

3. Your note should be timeless.

Certainly you need to assess suicidality, and explain why you think he isn't right now. But keep in mind that your assessment will last more than 24 hours. If he kills himself next week, lawyers are still going to come looking for you-- and documenting that he wasn't suicidal at that precise instant isn't necessarily going to be enough. You need to evaluate his future and what should be done about it. For example, you have a person who has had multiple suicide attempts (but is not malingering) in the ER. You're convinced he's not suicidal now. But what about next week?

"Currently he is not suicidal, feels fairly hopeful about the future and has made some specific future plans like XXX..." [list them!]

Note that hopelessness/pessimism about future-- not depression, psychosis, etc,-- is the best predictor of suicide. So note it explicitly.

Okay, in the near term he is not likely to be suicidal. Or is he? He's had nine attempts before, after all. What about that?

"...However, given his history of [impulsiveness/poor judgment/poor frustration tolerance/drugs], it is probable that he will attempt suicide again at some point in his life. Unfortunately, this is a function of his future acute stressors-- over which I have no current control-- not how he feels right now. He feels fine now, but on the drive home something bad could happen (e.g. girlfriend leaves him, loses his job, etc) which will activate his suicidal impulses..."

That's key, because it sets up the problem: he is going to attempt it again-- let's just get that out into the open-- but that has nothing to do with how he feels today. And it explains how you can't be held responsible now for it then. So now you explain why you didn't do the "obvious" thing, which is hospitalize:

Hospitalization and/or medication now is not going to alter that future eventuality, and thus are not indicated today. In fact, hospitalization may be detrimental because it sets up a pattern of dependency. Rather than finding better ways to deal with distress, he learns to run to the hospital whenever he is faced with frustration. He does not learn how to cope with stress. The main risk is thus that if he can't get to an ER, or the distress is particularly severe, he will not be able to cope and will have an even greater risk of suicide. In essence, hospitalizing him now puts him at greater risk for suicide later..."

But what makes you a good doctor (and saves you from the charge of negligence) is the next two sentences:

"Given the chronicity of his suicidality, I have to do something that will actually help him long-term. I believe he is not suicidal now, so my responsibility is to help decrease his suicide risk, as best I can, forever. The best way to help him is to refer him for [intensive therapy/day program/psychiatric visit, etc] for long term follow-up, so that he can have somewhere to go and someone to manage him as symptoms and stressors develop. This is the best way to keep him alive. So, we discussed a crisis plan for future suicidality: at the first sign of distress he will call X; if this is not sufficient he will Y, then Z; ultimately he will come to ER..."

That's what the note should say, in your own style and with the contents of your interview. So that when the lawyer asks, "why the hell didn't you hospitalize him?" he and the jury already know the answer.

4. The note is a not a newspaper article, it is an op-ed.

Also note the way I wrote my sentences. They are personal and informal. "Best way to keep him alive." "...over which I have no control." Etc. The note is your educated opinion, not a scientific article. You have to explain-- pretend it is to a jury, if that will help-- not just what you did, but why you did it-- and why not something else. "His affect changed when I left the room and he was noted to be joking" does not powerfully (enough) convey what you saw and what it meant to you. "With me, he was crying, but when I left the room and he thought the evaluation was over, I watched him joking and laughing with one of the nursing assistants." See how that changes things?

5. You can be wrong, but you cannot be negligent.

It should be obvious from the note exactly what you were thinking-- and, importantly, that you were thinking. That you took time to ask questions, observe, assess, draw conclusions that were reasonable. You might have been wrong, but you did a thorough job. That's why the assessment matters. Simply having volume to the Assessment shows that you gave due consideration to the case.

In other words: the note isn't written to help you win a lawsuit, it's to prevent one from being filed. You want a potential plaintiff's attorney to look at your notes and say, "forget it, it's not worth it-- it's obvious he isn't negligent."

6. Call someone.

Very important: get someone else's opinion, and document it. It's one thing for you to say he is not suicidal; but it's tremendously helpful to have a family member tell you he isn't, or that this situation is common, or that this happens whenever he gets upset, etc. If his girlfriend, etc, seems to think it is ok for him to come home, write that down!

"Spoke with his wife, who expressed no reluctance in taking him home despite everything he had been saying."

or, better:

"Spoke with his wife who was happy to take him home, and did not think he needed to be hospitalized."

See how telling that sentence is? Sure, by itself it is meaningless, and the wife is no psychiatrist, etc. But in combination with the other things you (will) write, it details what's going on and why you did what you did.

(In the converse, you should be hesitant to go against a family member, because they know them better than you. If the mom says he needs inpatient, you have to have a really good set of reasons why he doesn't. If you can't convince mom, you'll never be able to convince a jury after they die.)

If family and friends are not available (document that you tried-- that also shows effort and is above standard of care!) then get a second doctor, or nurse. I don't mean atttending phone back-up, which is useless. I mean another resident, or an ER doc, anyone, so that you can write this next sentence:

"Discussed the situation with X who also evaluated the patient, and X agreed with me that..."

Apart from giving you a valuable second opinion, it also helps establish "standard of care," loosely defined as how a "respectable minority" of docs in your situation would have proceeded. Two docs is pretty much a respectable minority, as far as I'm concerned (and have testified to such.)

7. If you discharge a suicidal patient, you must show that this is a better treatment than admssion.

You read all this and say, "well what if they say they're still suicidal?" Let's assume they are not malingering. (I'll get to that later.) And let us assume you don't actually think they need hospitalization and should be better served somehow else.

What's the key? To explain to the reader why you kicked them out of the ER despite actually believing their suicidality. (I say "kicked out" because that's how the lawyers are going to phrase it.)

First thing is to explain why you felt he would be alive next week despite his suicidality now. What's keeping him alive for later until Thursday, when is he has his outpatient appointment? Explicitly list all the reasons for hope for the future and his future plans.

Second thing is to explain why hospitalizing him isn't going to help him. Essentially, it's the same note as in #3.

"Given his history of multiple suicide attempts, what needs to be done is to get him through this acute situation, and then prepare him for the future. Hospitalizing him will have no impact on his future suicidaliity as it is stressor dependent. Obviously, his history of other hospitalizations, medications, and ER visits have done little to prevent him from being at this point again and in this ER now. Thus, hospitalizing him will only "ensure" his safety for the few days he is inpatient, and do nothing to keep him alive long term. It delays, not treats his suicidality, and when another stressor comes this hospitalization will have done nothing to help keep him alive.

Given this, the best way to help him is to refer him for... [as above].

As for his suicidality now, the plan is to let him decompress and reorganize for an hour or two here in the ER. We will give him some Ativan (etc) to help him. I'll give him supportive therapy as well as try to give him some better coping techniques for the future, and have RN do the same, to reinforce it. I was upfront with my opinion that hospitalization was not helpful here, and I explained my reasons, and while he was not happy with this and did not agree--he wanted to be inpatient-- he at least understood my perspective and was satisfied I was trying to help him. Of course [note word choice "of course"], I called his family/friend/etc who agreed to come pick him up and stay with him continuously, and would not let him out of their sight, and would bring him back if things worsened, etc. I told them how and when to give ativan. etc.

This is tricky, so let me be clear: this note isn't to convince you he's not going to die. You have to already be convinced, for yourself, that despite his suicidality he will be alive tomorrow. Then, and only then, should you be writing a note supporting your decision.

8. Plan should match Assessment; You can be wrong, but not negligent.

This again? Here I refer specifically to diagnosis and plan. If the diagnosis is malingering, and you kick him out of the ER, don't write "Psychosis NOS; Plan: discharge." Because the plan is not obvious for the diagnosis. The diagnosis should be, "Malingering; Plan: discharge." Because that fits. To the reader, it's obvious.

You may be wrong. You need to work on not being wrong. But for the purposes of negligence, an incorrect diagnosis with a reasonable plan for that diagnosis is better than the correct diagnosis with an unreasonable plan.

The note should convey an obvious train of thought. Obvious means that the person could guess what your plan will be based on the diagnosis, and vise versa. A person comes in suicidal because they broke up with their boyfriend yesterday should not have a note that says, "Depression: discharge." It should say, "Adjustment disorder: discharge." Because that plan seems more obvious for that diagnosis to a reader.

If you diagnose "depression" you are implying a longstanding problem that may exist in the absence of actual stressors. You might not want to be implying this, but it does. All you meant was that the guy was sad, but now you have to write a more detailed note explaining the future course or treatment.

This applies to personality disorder. If a borderline has another self-cutting event, the diagnosis is not depression; it's borderline. Writing, "Axis I: Depression; Axis II: Borderline" means, "oh my God, she was acutely depressed on top of an underlying borderline personality disorder!" Which is worse.

9. Write the note as if the patient died, but you have a chance to change your note.

First, an amusing anecdote about why doctors are idiots. I did a malpractice case where the doctor received a subpoena for records, and sent them in. Great. Except the plaintiff's attorney already had a copy of the records, which he used to show that doctor had altered his copy after receiving the subpoena. Game over. You lose. I am told this is a common maneuver.

So don't change your note. But imagine the patient kills himself-- and you have the ability to change your note. What would you change? If the guy shot himself, maybe you'll have wanted to write he had denied having a gun, or that you discussed removing the gun with the family. Or if he was on drugs, you'll have wanted to document discussing abstinence, protecting against withdrawal, or at least noted there were no signs of intoxication. Etc. Well, write this all in the note now. Pretend they're dead, and write the note from that perspective, in other words justifying how you could not have predicted this-- any reasonable person would have concluded they would live, not die-- and how extensively you attempted to prevent it.

And this is purusant to #2. If the patient suicided, your magnificent documentation of SIGECAPS and his Family Psychiatric History isn't going to be worth squat. It may even hurt you without a rigorous Assessment (#3). This is a real quote: "Doc, you've documented pretty clearly the guy was depressed: low energy, poor appetite, poor sleep, lack of pleasure, lack of interest in sex, chronic lower back pain-- how the hell could you let this guy out of the ER? Did it not occur to you he was going to hang himself? Or did you think he was just going to catch a movie to cheer himself up?"

Obviously, you're not supposed to lie in the note. I'm trying to get you to think proactively, to start asking the right questions (SIGECAPS is the wrong question) and assessing the right things. And then documenting them.

Write what you will someday desperately wish you would have written. Make the Assessment and Plan strong.

November 9, 2006

Suicide Note Revisited: Formulation

Previously, I had written an (what I thought to be outstanding) article about suicide documentation. The main point was a refocusing of the note away from Objective and towards Assessment. It now occurs to me that what I was really trying to get at is the lost art of writing a psychiatric formualtion of a patient.

The reason we don't do formulations anymore-- they're not even taught in most residencies, certainly not in mine or now to the residents I supervise-- is because it's not clear what the formulation is supposed to do. Doctors get overwhelmed by the psychodynamics of it and can't seethe practical utility. Someone brought them twenty ingredients but didn't tell them what they were cooking.

A formulation is different than a diagnosis or description of the patient. The formulation seeks to convey the relevant parts of a patient so that you can predict how a patient might behave in future circumstances. By way of example, a formulation is similar to a "profile" in crime movies. When they say things like, "he's going to want to tie the women with piano wires, because he's a schizophrenic who was forced to sleep in a tuba..." that's a formulation (sort of-- you get the idea.)

The formulation helps prediction by linking the various aspects-- seemingly unrelated, perhaps-- of a patient's existence. It's the stuff you know is relevant, but DSM and standard psychiatry have no room for. What does it mean if I tell you an inpatient brought with her fuzzy bunny slippers? That's goes in the formulation. A statement such as, "the strong family history of bipolar disorder, along with his chronic alcohol abuse and prior suicide attempts, and the pending divorce and custody battle, and his recent apostasis from Catholicism put him at higher risk for suicide" is the type of sentence I want in the Assessment-- and it is precisely a short example of a "biopsychosocial" formulation.

Note the importance of having all factors together, as opposed to individually. It sets up the logic; it lets the reader know, immediately and obviously, what you were thinking. This is very different than writing in one part of the note, "Fam Hx: strong bipolar;" and in another part of the note, "Chronic alcohol abuse; history of multiple suicide attempts;" and in another place, "patient divorcing, and custody trial is next month." Putting it that way, in the classic H&P format, forces the reader to have to infer. Put in a biopsychosocial formulation, and the reader gets it instantly without even reading the rest of the H&P. That's what you want.

Interestingly, the term "biopsychosocial" was coined by George Engel, psychoanalyst(?), who in 1977 made the startling observation, "The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness."

[It] would seem that psychiatry would do well to emulate its sister medical disciplines by finally embracing once and for all the medical model of disease. But I do not accept such a premise. Rather, I contend that all medicine is in crisis, and, further, that medicine's crisis derives from the same basic fault as psychiatry's, namely, adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.

Plus ca change...

Engel, like others, had understood that somatic symptoms such as pain, weakness, etc, and autonomic symptoms such as reflux, tachycardia, etc could be symbolic expressions of emotion or conflict. How could the Objective portion of a note ever explain why you discharged a person with acute bilateral leg paralysis? It can't-- but a biopsychosocial formualtion can.

As per Engel, the main question such a biopsychosocial model seeks to answer is why some patients experience an "illness" while others experience a "problem of living." Importantly, the patient himself doesn't often know: the patient defines it as an illness recursively by whether or not he "needs" a doctor, and not by an actual understanding of what's wrong with him. It's the doctor's job to decide whether it is actually an illness or a life problem, and then properly re-educate and re-train the patient.

Note that in my post about suicide documentation, the hypothetical patient was not malingering. He believed he needed to be hospitalized because he was suicidal. But when you discharge such a patient from the ER, you are thinking that the person will not die-- the suicidality is an expression of something else. This is Engel's dichotomy. The patient thinks one thing, you think another-- it's your job to explain to the patient what's really going on, AND explain to the reader why you did what you did.

Typically, formulations are taught, in my opinion, backwards, so students "don't get it." You're taught to start with what's going on now, then describe what historical factors that made the patient who he is (including genetics, upbringing, social stressors, meds, etc),; then psychodynamic explanations, and then your proposed treatment and how you predict the patient will respond. I think it is easier to go backwards. First, decide what you think is going to happen in the future (will commit suicide, won't relapse, is a mania risk, etc) and then explain what it is about his past and present that makes you think this. In this way, you're writing the formulation with a purpose.

"Joe came to the ER for suicidality after he got drunk after getting divorce papers.

Joe takes rejection very hard, and characteristically when the rejection is new, he doesn't spend time to think things through. He exhibits poor judgment (give examples here or in Objective), is impulsive (examples), and also does things which further reduce his judgment and raise his impulsivity (like get drunk.)

Joe has several narcisissitic features . For example, importantly, his suicidality is directed at his ex-wife. The point of the attempt is that she find out, that she know he is feeling hurt. If it was guaranteed that she would never find out, he would not attempt suicide because it would have lost its meaning. He needs her, or at least someone, to acknowledge his pain, and see him as the person he is trying to portray. As we talked, I made it clear that I did see he was hurt, and I understood the rejection--how it not only was a loss of a wife, but also a hint that he himself was unworthy of her. We discussed that she was entitled to leave him, but that she could not deterine his value."

etc, etc. You see how even without an Objective portion, the narrative in the Assessment is quite clear. The reader understands what you were seeing and thinking.

Suicide and Antidepressants

From The Last Psychiatrist - December 19, 2007

Deus Ex Homonymia

Answer the following questions, and don't look at the next until you answer the previous:

1. Does depression in kids raise their risk of violence?
2. If a kid is violent, is it more or less likely they are depressed?
3. If someone is depressed and violent, is it likely they are a kid?
4. Can you define any of the nouns in the preceding questions?

In a study called Perceived Dangerousness of Children With Mental Health Problems and Support for Coerced Treatment the perceptions of 1100 members of the public were evaluated, finding:

Children... with major depression were perceived (by 81% of the sample) as somewhat likely or very likely to be dangerous to themselves or others, compared with children with asthma (15%) or those with "daily troubles" (13%).

and, later:

...compared with the child with "daily troubles," the vignette child with depression was more than twice as likely to be assessed as dangerous toward others and ten times as likely to be assessed as dangerous toward himself or herself.

Now, you lose no money assuming the public at large merely guess at probabilities. So what they think may be right, wrong, both-- who knows. But whatever they think, it's probably important to quote them correctly:

"The issue that was highlighted by this study that was really concerning to us was that Americans have linked depression in youth and violence, particularly violence towards others," said Dr. Pescosolido ["distinguished professor of sociology, Indiana University."] [emphasis mine, but, face it, really theirs.]

Well, no, that's not what the public thinks, at least according to your study. They think that depression leads to violence against themselves, and maybe towards others. Only 9% thought violence towards others was very likely. The majority thought violence towards others was not likely. Right?

Also, please note the subtle cut against "Americans," those barbarous, judgmental, yellow ribbon tying NRA members, i.e. "Texans." (I know, sociology professor...)

"It's really, really horrible. Many people who are not in the field perceive these youths as dangerous-- and yet we have no evidence that these kids are any more dangerous than youth randomly picked..." said Dr. Kelleher, professor of pediatrics at Ohio State.

Wow. I had thought the entire infrastructure of psychiatry rested on the very foundational idea that psychiatric disorders, especially depression, are responsible for increased risk of violence to the self. And these quotes are even more weird given that they come from Ohio and Indiana-- the two states responsible for over half the increase in female youth suicides in the whole country. You know, the increase that everyone is blaming on antidepressants.

But words are lies, and you can use loose language like "violence" and "dangerous" and "youth" and "kids"-- bending its meaning to whatever you need it to mean at that moment-- to make any point you want. The actual arguments for this position can be be flipped when necessary (e.g. Nasrallah saying a school shooting isn't "evil" but "medical illness.") You can do this if you manipulate words, e.g. conflating school shooting and suicide to "violence," and then making "violence" mean what you need it to mean at that moment.

So what is her point? I'm sure she doesn't want to be saying that depressed kids aren't prone to self harm. So?

So nothing. She, they, don't have a point, they want to convey a feeling, a political position, something like, "no one is bad just because they are sick; but if they were bad, then it was because they were sick."

It's a good position, given that it is entirely empty, and can be made into whatever you want. Right or wrong is precisely besides the point.

So what do these authors tackle next? Forced psychiatric treatment, of course.

Next...