Consultation and referral to a psychiatrist is appropriate in selected cases if the primary care physician is concerned about the complexity of the case. The treating physician needs to evaluate the complexity of the symptom picture (eg, RO4929097 purchase delusions,
mixed manic and depressive symptoms) and dangerousness with respect to suicide or homicide at each visit. He or she should Inhibitors,research,lifescience,medical seek consultation in difficult-to-treat cases. Several forms of brief depression-specific psychotherapy, including cognitive therapy12 and interpersonal psychotherapy,13,14 have been shown to have efficacy equal to that of antidepressant medication and should be considered as treatment options or adjuncts. However, a review of these treatment strategies is beyond the scope of this review. Assessment of suicidality Probably half of patients with major depressive episodes report death wishes, feeling that they have no reason to live, thinking they would be better off dead, thoughts
of harming Inhibitors,research,lifescience,medical or killing themselves, or actual plans to do so. Suicidal risk should be assessed not only at the initiation of treatment, but repeatedly throughout treatment. Some patients will not report suicidal Inhibitors,research,lifescience,medical ideation until they feel comfortable with the clinician, often several weeks into treatment. It is essential to ask if patients have thoughts or plans Inhibitors,research,lifescience,medical to harm themselves, whether they have a history of suicide attempts (and, if so, to determine the medical seriousness of prior attempts), and whether they have access to means. This includes specific questions about access to firearms, since half of all suicides in the USA involve hand-guns.15 If a patient acknowledges a plan or intent Inhibitors,research,lifescience,medical to harm
him/herself, then emergency psychiatric evaluation is indicated. Up to 75% of patients who complete suicide15 have seen a primary care physician within the month prior to death, meaning that the physician Histone demethylase has a unique opportunity to prevent suicide through appropriate intervention. Depressed patients with suicidal ideation often take longer to respond to treatment, thus necessitating a longer period of vigilance on the clinician’s part.16 Due diligence includes both frequent assessments of suicidal ideation and hope- lessness, aggressive treatment of the depression, and creation of a safety net involving other members of the health care team and family members or caregivers. In the USA and UK over the past 18 months, considerable furor has raged about the risk that the use of one class of antidepressants, selective serotonin reuptake inhibitors (SSRIs) may actually raise the likelihood of suicidal ideation and suicidal acts, rather than reducing the likelihood.