Pearls

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The possibility that a patient being treated for alcohol or drug abuse may begin abusing substances again is an ever-present, but not insurmountable, challenge. I’ve found that the following advice can help counter a relapse, get the patient back on track and, hopefully, avert future setbacks.

Address the “abstinence violation effect.” When substance abusers lapse into drug or alcohol use after a period of sobriety, they can easily fall into the “abstinence violation effect.” This is what happens when patients tell themselves, “Well, I’ve blown my sobriety; there’s no use trying to be abstinent now.” Instead of identifying their relapse as a single setback, they are overwhelmed by it and continue to abuse.

Begin steering the patient from this way of thinking before he or she relapses—preferably as soon as you begin to treat the patient. If a relapse does occur, remind the patient that he or she has not blown the prospect of abstinence, and encourage the patient not to give in to discouragement.

“Understand” the relapse. Find out what the patient was thinking when he or she decided to use drugs or alcohol again. Was the patient in denial about the seriousness of what he or she was doing? Did the patient know what he or she was getting into? What were the circumstances surrounding the event? Asking such questions will help you understand the relapse and identify issues that may not yet have been addressed.

Assess the patient’s treatment program. It is possible that the type of treatment the patient is receiving (e.g., group therapy, medication) is inappropriate or inadequate. Find out whether the treatment program makes sense to the patient and whether he or she has been complying with it. If necessary, modify it.

Identify coexisting psychiatric conditions. Reassess the patient’s psychiatric health. It could be that an unidentified coexisting condition, such as depression or hypomania, may have contributed to the relapse. Make sure the patient receives treatment for any comorbidity.

Focus on what the patient is feeling now. Talk with the patient about what he or she feels after the relapse, This goes hand-in-hand with “understanding” the relapse. Ask the patient, “What were you thinking before you picked up that drink. What was different about this time as opposed to the other times that you felt like taking a drink, but didn’t?”

Ascertain the patient’s present difficulties—is substance abuse the only problem, or is the patient also suicidal? Then, make sure he or she receives appropriate care. Determine whether the patient would benefit from increased support group or family involvement, or if detoxification is needed.

Offer the patient hope. This comes back to combating the abstinence violation effect. Help the patient recognize that a relapse does not mean the end of sobriety. In fact, once the issues leading to the relapse are identified and confronted, the patient can be even more hopeful about achieving a sustained recovery.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Diagnosing depression in cancer patients is difficult. In response to the rigors of chemotherapy and other treatments, such patients suffer physical difficulties that may also be associated with depression, including sleep disorders, loss of appetite, and decreased libido.

If you see a cancer patient in whom you suspect depression, you can help rule out cancer treatment-related symptoms if you ask the oncologist the following five questions:

1. Has the patient been depressed for most of the past 2 weeks? Most patients who are depressed for 2 or more weeks will usually meet the other DSM-IV criteria for depression.
2. What is the stage and location of the cancer? Research shows that the incidence of depression increases proportionately with the cancer’s progression.² Some studies suggest that patients with pancreatic cancer, more advanced cancer, or numerous cancerous tumors are more likely than other cancer patients to become depressed because of the increased level of cytokines (proteins that help fight cancer) in their systems. Patients with brain metastases are also susceptible to depression.
3. Which anti-cancer treatments are being administered? This is critical, since anti-cancer drugs may trigger depression. Higher rates of depression have been reported in patients taking interferon and interleukin for kidney cancer and melanoma, and dexamethasone for brain metastasis, because these drugs increase cytokine levels.³ Use of steroids to treat cancer has also been associated with depression.
4. Is the patient experiencing medical complications? For example, if a patient is about to undergo surgery or is vomiting because of chemotherapy, antidepressants with a long half-life have an advantage. Conversely, shorter-term antidepressants prevent toxicity and do not interact adversely with other drugs.
5. What is the patient’s life expectancy? A clinically depressed patient who is expected to die soon may benefit from psychostimulants, which quickly counterattack depression and the negative effects of chemotherapy. Though psychostimulants are not often used to treat depression in physically healthy patients, they can help depressed cancer patients who feel sluggish and fatigued or who are taking an opioid.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Preventing suicide in the severely depressed patient is tricky. Usually a suicidal patient won’t tell you of his or her intent before completing the suicide, making prevention all the more challenging.

Psychiatrists too often assume that their patients see them as allies in treating their depression, even suicidal depression. However, once a patient decides to die by suicide, he or she is likely to see the psychiatrist as an adversary. Indeed, the psychiatrist and suicidal patient are working toward conflicting goals: preserving and improving quality of life versus ending it altogether.

Psychiatrists need to recognize this fundamental change in the patient-psychiatrist relationship once the patient decides to die by suicide. Failure to do so can have fatal results. Busch et al found that two thirds of psychiatric inpatients who died by suicide denied any suicidal intent or ideation shortly before their deaths.¹

For that reason, look for objective evidence of mood improvement or deterioration, rather than relying on the patient’s word. Sleep patterns, eating habits, and changes in affect should be scrutinized.

Before accepting that the depressed patient is improved to any extent, ascertain what has objectively changed in the patient’s situation. For example, has a spouse who planned a divorce relented or has a financial crisis been resolved?

Consult the patient’s family

Since the suicidal patient is your “adversary,” establishing a relationship with his or her family becomes critical. That’s because, based on my experience, patients who are considering suicide are much more likely to communicate their intent to spouses than to clinicians.

Family members are a particularly vital source of information in inpatient management. When the patient is hospitalized for depression, close relatives should be instructed to immediately notify the nursing staff of any suicidal communications that occur during visits. Nurses then have a duty to notify the psychiatrist. Even an isolated, seemingly off-handed remark from the patient (e.g., “If I don’t feel better soon I’ll kill myself”) should be reported.

In treating a potentially suicidal outpatient, consider seeking permission from the patient to contact a close relative as a means of follow-up. The relative should be requested to notify you if the patient talks of suicide or new feelings of hopelessness.

Beware of no-suicide contracts

About 1/3 to 1/2 of psychiatrists and other psychotherapists employ no-suicide contracts,² which are agreements by patients to let therapists know if they become suicidal rather than killing themselves.

Such contracts are dangerous because they can create a false sense of security in therapists. What’s more, nothing in the research literature shows that no-suicide contracts work. Half of the completed inpatient suicides had a no-suicide contract in place.¹

Suicidal patients make great sacrifices to take their lives. They lose their future, stigmatize their children, and accept the possibility of eternal damnation. It is foolhardy to think that a patient determined to commit suicide would keep a promise to notify you of his or her intent, particularly if that patient does not have a longstanding relationship with you. Once the patient views you as an adversary rather than an ally, the contract has little value.

Finally, in malpractice cases resulting from suicide, juries are quick to brand a psychiatrist as unwise for relying on a no-suicide contract.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.

Most psychiatrists might not realize that suicide is a major problem among children, but the evidence shows that it is extremely serious. One study lists suicide as the third leading cause of death among children ages 10 through 14.¹

What are some clues to hidden suicidal tendencies in children? The following behaviors often overlap depressive symptoms:

• Social withdrawal, which typically manifests in the child’s not wanting to participate in activities he or she once enjoyed;
• Lapse in personal hygiene;
• Sudden, unexpected change in personality;
• Oppositional behavior (e.g., running away from home, declining grades at school);
• Sleep disturbances.

A child might be suicidal even if he or she doesn’t meet the criteria for depression. So it is important to recognize other risk factors:

• Family history of suicide or suicide attempts;
• Exposure to past violence, such as physical or sexual abuse;
• Alcohol and/or drug use;
• Aggressive, disruptive behavior;
• Extreme impulsivity;
• Non-aggressive conduct disorder, such as truancy, stealing, or disregard for authority.

Among younger children, a conflict either between them and their parents, or between the parents, as frequently happens in a separation or divorce, can lead the child to believe that he or she let the parents down. Offhand comments such as “I don’t care anymore” or “I’d be better off dead,” also should raise a red flag for both parents and physicians.

Death is a taboo subject in our society—we don’t like to talk about it until it happens. If a child is at risk, it makes sense to confront the subject directly. Just ask the child, “Have you ever thought about hurting yourself?” or “Have you ever thought that life is no longer worth it?”

Finally, psychiatrists can pursue suicide prevention among children by helping to educate referring family physicians and pediatricians. Since depression is by far the number one risk factor for suicide among the young, primary care physicians would be well advised to screen all younger patients for depression as part of their routine wellness checks. This step may prevent a child’s disorder from reaching life-threatening proportions.