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Delirium, Dementia, Amnestic and Other Cognitive Disorders

Links:

Delirium 

Dementia

Dementia- Alzheimer's disease:

The following medical conditions can lead to dementia:

Creutzfeldt-Jakob disease

HIV disease

Huntington's disease

Multiple sclerosis

Parkinson's disease

Progressive supranuclear palsy: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001772/

Research articles:

Delirium

Levenson, J. L., & Bostwick, J. (2005). Suicidality in the medically ill. Primary Psychiatry, 12(3), 16-18. Retrieved from EBSCOhost.

Presents updates in psychosomatic medicine and consultation. A common question facing psychiatrists and other clinicians caring for depressed medically ill patients is whether a patient is suicidal. Suicidal ideation among the medically ill is not uncommon, although completed suicide attempts are rare. In medical settings, three general patient categories show elevated suicide risk: patients admitted to medical-surgical units after suicide attempts; patients with delirium, dementia, substance abuse, or withdrawal from substance abuse with resultant agitation and impulsivity; and patients overwhelmed by chronic medical illness. Constant observation by a sitter is indicated for patients judged at high risk. The physician should also be vigilant for reversible contributors to impulsivity, including delirium, unrecognized substance withdrawal, and medical illness or medications that may be contributing to mood, anxiety, or psychotic disorders. Conceptually, physician-assisted suicide (PAS) follows a rational request from a competent, hopelessly ill patient whose decision is not excessively or inappropriately affected by psychiatric illness. Providing a comprehensive evaluation for the presence of a treatable psychiatric disorder can result in a patient's decision to withdraw the PAS request and live longer. Access to appropriate palliative care also reduces PAS requests. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Younger, S. C., Clark, D. C., Oehmig-Lindroth, R., & Stein, R. J. (1990). Availability of knowledgeable informants for a psychological autopsy study of suicides committed by elderly people. Journal of the American Geriatrics Society, 38(11), 1169-1175. Retrieved from EBSCOhost.

Examined the number and availability of knowledgeable informants for 145 people (aged at least 60 yrs) who committed suicide. The stereotype of the "average expectable" elderly suicide victim as socially isolated and living alone or in an institutional setting was not supported. A high percentage of Ss were married at the time of death. There was at least 1 knowledgeable informant in 90% of the cases and 2 or more in almost 50%. In 46%, the S had expressed despondency over illness. In a prospective study involving interviews with informants for 8 additional elderly suicide victims, all 8 had at least 2 knowledgeable and willing informants. Case vignettes of 2 Ss from the preliminary study illustrate the role of delirium and an ominous diagnosis (cancer) as causes of suicide. Data support the feasibility of using the psychological autopsy method. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Dementia

Draper, B., Peisah, C., Snowdon, J., & Brodaty, H. (2010). Early dementia diagnosis and the risk of suicide and euthanasia. Alzheimer's & Dementia, 6(1), 75-82. doi:10.1016/j.jalz.2009.04.1229

Background: Diagnosis of dementia is occurring earlier, and much research concerns the identification of predementia states and the hunt for biomarkers of Alzheimer's disease. Reports of suicidal behavior and requests for euthanasia in persons with dementia may be increasing. Methods: We performed a selective literature review of suicide risk in persons with dementia and the ethical issues associated with euthanasia in this population. Results: In the absence of any effective treatments for Alzheimer's disease or other types of dementia, there is already evidence that persons with mild cognitive change and early dementia are at risk of suicidal behavior, often in the context of comorbid depression. The ensuing clinical, ethical, and legal dilemmas associated with physician-assisted suicide and euthanasia in the context of dementia are a subject of intense debate. By analogy, the preclinical and early diagnoses of Huntington's disease are associated with an increased risk of suicidal behavior. Thus there is the potential for a preclinical and early diagnosis of Alzheimer's disease (through biomarkers, neuroimaging, and clinical assessment) to result in increased suicide risk and requests for physician-assisted suicide. Conclusions: Although dementia specialists have long recognized the importance of a sensitive approach to conveying bad news to patients and families and the possibility of depressive reactions, suicidal behavior has not been regarded as a likely outcome. Such preconceptions will need to change, and protocols to monitor and manage suicide risk will need to be developed for this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Erlangsen, A., Zarit, S., & Conwell, Y. (2008). Hospital-diagnosed dementia and suicide: A longitudinal study using prospective, nationwide register data. American Journal of Geriatric Psychiatry, 16(3), 220-228. Retrieved from EBSCOhost.

OBJECTIVE: The current study aims to examine the risk of suicide in persons diagnosed with dementia during a hospitalization and its relationship to mood disorders. DESIGN: Event-history analysis using time-varying covariates. SETTING: Population-based record linkage. PARTICIPANTS: All individuals aged 50+ living in Denmark (N=2,474,767) during January 1, 1990 through December 31, 2000. MEASUREMENTS: Outcome of interest is suicide. Relative risks are calculated based on person-days spent in each stratum. RESULTS: A total of 18,648,875 person-years were observed during the 11-year study period. During this period, 136 persons who previously had been diagnosed with dementia died by suicide. Men and women aged 50-69 years with hospital presentations of dementia have a relative suicide risk of 8.5 (95% confidence interval: 6.3-11.3) and 10.8 (95% confidence interval: 7.4-15.7), respectively. Those who are aged 70 or older with dementia have a threefold higher risk than persons with no dementia. The time shortly after diagnosis is associated with an elevated suicide risk. The risk among persons with dementia remains significant when controlling for mood disorders. As many as 26% of the men and 14% of the women who died by suicide died within the first 3 months after being diagnosed whereas 38% of the men and 41% of the women died more than 3 years after initial dementia diagnosis. CONCLUSIONS: Dementia, determined during hospitalization, was associated with an elevated risk of suicide for older adults. Preventive measures should focus on suicidal ideation after initial diagnosis but also acknowledge that suicides can occur well after a dementia diagnosis has been established.

Haw, C., Harwood, D., & Hawton, K. (2009). Dementia and suicidal behavior: A review of the literature. International Psychogeriatrics, 21(3), 440-453. doi:10.1017/S1041610209009065

Hierholzer, R. (2001). Suicide in dementia: Case studies of failure as a risk factor. Clinical Gerontologist, 24(1/2), 159. Retrieved from EBSCOhost.

Presents a case study on the incidence of suicide among patients with dementia in the U.S. Risk factors for suicide; History of psychiatric disorders and substance abuse; Detection of cognitive impairments.

Osvath, P., Kovacs, A., Voros, V., & Fekete, S. (2005). Risk factors of attempted suicide in the elderly: The role of cognitive impairment. International Journal of Psychiatry in Clinical Practice, 9(3), 221-225. doi:10.1080/13651500510029020

The authors’ aim was to assess the prevalence and importance of dementia and cognitive impairment in relation to suicidal behaviour in elderly psychiatric inpatients. The level of cognitive functioning (according to the Mini Mental State Examination – MMSE) of the elderly suicidal inpatients ( N =62) were compared to the general elderly inpatients ( N =152). There were significant differences in cognitive functioning between the two groups, in the non-suicidal group the level of cognitive function was significantly lower. However, mild cognitive deficit or mild dementia were registered in 60% of the suicide attempters. The results indicate that not only mood disorders, but other risk factors (especially mild cognitive impairment), have a key role in developing suicidal behaviour in the elderly. Thus, in the treatment and prevention of suicidal behaviour in the elderly, it is important to apply the complex bio-psycho-social model, in which (besides adequate pharmacotherapy) psychotherapeutic approaches and procedures to enhance cognitive functioning are of outstanding significance. [ABSTRACT FROM AUTHOR]

Purandare, N., Voshaar, R., Rodway, C., Bickliey, H., Burns, A., & Kapur, N. (2009). Suicide in dementia: 9-year national clinical survey in England and Wales. British Journal of Psychiatry, 194(2), 175-180. doi:10.1192/bjp.bp.108.050500

Background: Knowledge of suicide in people with dementia is limited to small case series Aims: To describe behavioural, clinical and care characteristics of people with dementia who died by suicide Method: All dementia cases (n = 118) from a 9-year national clinical survey of suicides in England and Wales (n = 11512) were compared with age- and gender-matched non-dementia cases (control group) (n = 492) by conditional logistic regression. Results: The most common method of suicide in patients with dementia was self-poisoning, followed by drowning and hanging, the latter being less frequent than in controls In contrast to controls, significantly fewer suicides occurred within 1 year of diagnosis in patients with dementia Patients with dementia were also less likely to have a history of self-harm, psychiatric symptoms and previous psychiatric admissions. Conclusions: Known indicators of suicide risk are found less frequently in dementia suicide cases than non-dementia suicide cases. Further research should clarify whether suicide in dementia is a response to worsening dementia or an underappreciation of psychiatric symptoms by clinicians. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Creutzfeldt-Jakob disease

Lendvai, I., Saravay, S. M., & Steinberg, M. D. (1999). Creutzfeldt-Jakob disease presenting as secondary mania. Psychosomatics: Journal of Consultation Liaison Psychiatry, 40(6), 524-525. Retrieved from EBSCOhost.

This article reports on a patient with Creutzfeldt-Jakob disease who presented with mania and was initially diagnosed and treated for Bipolar I Disorder, manic type. The S was a 45 yr old female. Creutzfeldt-Jakob disease is a type of subacute spongiform encephalopathy caused by transmissible agent termed a prion. In the case of Creutzfeldt-Jakob disease the article describes, prominent symptoms of mania, including pressured speech, thought racing, abrupt shift of thought, insomnia, and spending sprees building up considerable credit card debt, were the presenting symptoms. The S was admitted to hospital and she died 2 mos after admission. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Frontotemporal dementia

Fonseca, L. L., & Machado, Á. Á. (2011). P01-483 - Suicide in frontotemporal dementia. European Psychiatry, 26, 487. doi:10.1016/S0924-9338(11)72194-0

Introduction: Behavioral and personality changes are the core symptoms of frontotemporal dementia. Suicide and suicide attempts have been reported in demented patients. Clinical case: We present a case of an 80 years-old-male patient, with a suicide attempt at the age of 76 as the presentation symptom of FTD. Clincal study: There are few studies of suicide or selfharm in frontotemporal dementia where such behavior might be expected to be more common. We are conducting a clinical study in FTD patients about the relation between FTD and suicide. The results of such study will be presented and discussed. Discussion: To our knowledge, there are no reliable data or reports about suicide in FTD patients. Also, we didn’t find any case report of a suicide attempt as the first presentation symptom of FTD. We discuss the known data about this issue considering our clinical study and report. [Copyright &y& Elsevier]

Multi-infarct dementia

Rao, R., Dening, T., Brayne, C., & Huppert, F. A. (1997). Suicidal thinking in community residents over eighty. International Journal of Geriatric Psychiatry, 12(3), 337-343. Retrieved from EBSCOhost.

Objective. Main objective: to study the relationship between suicidal thinking and both cognitive impairment and depression. Design. Random sample selected for interview, all of whom were a cohort in a pre-existing epidemiological study of dementia. Setting. Community residents. Patients and other participants. Participants aged over 81. Study excluded the following: moved out of area/died/too frail/severe communication difficulties/refused interview, refusal by GP/family/carers. 300 names selected at random from database. 170 eligible participants approached; 31 refused, 125 interviewed. 125 informants approached for interview; 118 interviewed. Main outcome measures. CAMDEX, 15-item Geriatric Depression Scale (GDS), and Scale for Suicidal Ideation (SSI) (including informant versions of latter 2 scales). Results. 9 people showed suicidal thinking, all women; 6 had clinical evidence of cardiovascular/cerebrovascular disease. Those with suicidal thinking showed higher CAMDEX depression scores, weaker strength of the wish to go on living, higher rates of expressing wish to die and higher rates of depressive illness and mixed DAT/multi-infarct dementia as primary psychiatric diagnoses. No significant associations between suicidal thinking and GDS scores, Alzheimer-type dementia alone, awareness of memory difficulties or severity of dementia. Conclusions. Results show association between suicidal thinking and both depression and mixed DAT/multi-infarct dementia, but do not support an association between suicidal thinking and awareness of memory problems/severity of dementia. Given the methodological limitations, the significance of the results should be viewed with caution. Further exploration of the role of cerebrovascular disease in depressive disorder is suggested. © 1997 by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Dementia- Alzheimer's disease

Barak, Y., & Aizenberg, D. (2002). Suicide amongst Alzheimer's disease patients: A 10-year survey. Dementia and Geriatric Cognitive Disorders, 14(2), 101-103. doi:10.1159/000064931

Suicide is a major public health problem with advancing age being one of the factors associated with increased risk. It has been suggested that most DSM axis-I disorders contribute to increased suicidal risk while dementia is one of the few exceptions. The authors conducted a 10-yr retrospective analysis of all elderly patients suffering from dementia admitted to a large urban mental health center. Between 1991 and 2000 there were 1,551 admissions to the center who were 65 yrs or older. Of these, 341 were diagnosed (DSM-IV criteria) as suffering from dementia and 215/341 as suffering from Alzheimer's disease (AD). Sixteen AD patients (7.4% of all AD patients) were admitted immediately following a suicide attempt. The control group consisted of the next admission of an elderly AD patient matched for age and gender. The index group (suicidal patients) differed from controls in Clinical Dementia Rating scores and higher frequency of previous suicide attempts. Lifetime psychopathology was not associated with higher rates of suicide attempts. Physicians should be aware that suicide attempts are not rare in elderly AD patients. Higher level of daily functioning and previous suicide attempts are associated with increased suicidal risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Kishikawa, Y., Friedland, R. P., Ueda, H., Kitabayashi, Y., & Fukui, K. (2007). Socio-psychological factors in suicide with Alzheimer’s disease: Comparative case studies of two patients in the USA and Japan. Psychogeriatrics, 7(1), 37-39. doi:10.1111/j.1479-8301.2006.00174.x

The objective of this case report is to illustrate the influence of socio-psychological background on behavior in patients with Alzheimer’s disease (AD). A comparative analysis was undertaken of two suicide cases with AD in the USA and Japan. Both cases were in the early stages of AD. They succeeded in suicide even with their disturbed executive functions, because they felt deprived of their dignity for different reasons according to their socio-cultural background. Early stage AD patients may retain the behavior and intellectual functions associated with their dignity and desire. Since dignity and desire are very cultural concerns, socio-psychological background should be cautiously considered when dealing with the emotional problems of AD patients. [ABSTRACT FROM AUTHOR]

Lim, W., Rubin, E. H., Coats, M., & Morris, J. C. (2005). Early-stage Alzheimer disease represents increased suicidal risk in relation to later stages. Alzheimer Disease and Associated Disorders, 19(4), 214-219. doi:10.1097/01.wad.0000189051.48688.ed

The level of risk for suicide in individuals with Alzheimer disease (AD) generally is considered to be low. It is important to recognize, however, that suicide can occur in early-stage Alzheimer disease on the background of a distinct high-risk profile. The objective of this report is to describe the clinical profiles of individuals with very mild Alzheimer disease who either attempted or completed suicide. We describe two participants in a longitudinal study of early-stage Alzheimer disease who were in the ninth decade of life and had very mild Alzheimer disease. Consistent with earlier cases reported in the literature, both displayed the following high-risk phenotype predisposing to suicidal risk: male gender, highly educated professional, preserved insight, dysthymic symptoms that did not meet criteria for major depression and postdated the onset of cognitive decline, and suicidal ideation. Neuropathological examination confirmed histologic Alzheimer disease in both cases. These cases, taken together, emphasize the need for awareness that early-stage Alzheimer disease may present a unique suicidal risk compared with later stages. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Rubio, A., Vestner, A., Stewart, J. M., Forbes, N. T., Conwell, Y., & Cox, C. (2001). Suicide and Alzheimer's pathology in the elderly: A case-control study. Biological Psychiatry, 49(2), 137-145. doi:10.1016/S0006-3223(00)00952-5

Elderly individuals are also at increased risk for suicide, but comprehensive studies of the association between Alzheimer's pathology and suicide are lacking. This case-control study determined if Alzheimer's disease changes are overrepresented in elderly people committing suicide. Cases were 28 63–92 yr olds who completed suicide. For each case, 2 age- and gender-matched individuals who died naturally were selected as controls. Neuropathologic examination of hippocampal sections was performed blindly and included a modified Braak scoring system and assessment of neurofibrillary tangles, amyloid deposition, Lewy bodies, and Lewy-associated neurites. Data were analyzed by conditional logistic regression. The brains of Ss who committed suicide had higher modified Braak scores than controls. The number of neurofibrillary tangles in hippocampal CA1 was not an independent predictor of suicide status in the statistical analysis, although the distribution was more highly skewed among the cases (75th percentile of 10.5 for cases, vs. 2 for controls). Severe Alzheimer's disease pathology is overrepresented in elderly patients who complete suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Vascular dementia

Ito, T., Yamadera, H., Ito, R., Endo, S., & Satoh, T. (2002). A study of suicidal cases of vascular dementia. Seishin Igaku (Clinical Psychiatry), 44(12), 1295-1303. Retrieved from EBSCOhost.

Investigated clinical manifestation in cases of suicide attempt in vascular dementia (VD) patients. Among 80 male and 161 female elderlies ranged 65–101-yrs-old with VD who stayed at Koutokukai Sato Hospital in Japan between April, 1982 and May, 1998, 5 of attempted suicide and 4 of them were successful. The results of their clinical study show that: (1) all the cases of suicide attempts fell in the early stage of dementia; (2) among all dementia cases, VD patients had the shorter morbidity period, lower mean age, and milder cognitive disorder than other types of dementia; (3) all cases of suicidal actions had physical problems and most cases manifested particular psychiatric symptoms such as depression, anxiety and hypochondria before suicide attempts while some manifested paranoia; and (4) CT scan views detected multiple cerebral infarctions in the basal nuclear area. These results suggest that cardiovascular disorders need long-term treatment and complications of motor and/or sensory function disturbance increase the risk of demented patients committing suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

HIV disease

Alfonso, C. A., & Cohen, M. (1994). HIV-dementia and suicide. General Hospital Psychiatry, 16(1), 45-46. doi:10.1016/0163-8343(94)90087-6

Presents 2 case studies of suicidal individuals with HIV-dementia. Evaluation of a 32-yr-old man and a 37-yr-old woman illustrates that suicidal ideation and behavior can be dangerous concomitants of HIV-dementia. Both had psychomotor retardation, global memory impairment, concrete thinking, affective lability, irritability, and word-finding difficulty. Substance abuse intensified the risk of suicide in these Ss. Both Ss had evidence of HIV-dementia before they developed suicidality. Caregivers must be alerted to the dangerous concomitant of suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Bennett, W., Joesch, J. M., Mazur, M., & Roy-Byrne, P. (2009). Characteristics of HIV-positive patients treated in a psychiatric emergency department. Psychiatric Services, 60(3), 398-401. doi:10.1176/appi.ps.60.3.398

Objective: Knowledge about the characteristics of patients using psychiatric emergency services is expanding. However, the prevalence of HIV infection among patients treated at psychiatric emergency departments is not known, and neither are the characteristics of HIV-positive patients seen in this setting. Methods: To estimate the prevalence and demographic and clinical correlates of HIV infection among patients utilizing psychiatric emergency services in a level 1 trauma center, the authors analyzed data from a series of 58,301 consecutive visits (28,817 unique patients). Results: Of the total psychiatric emergency visits, 2.0% were by HIV-positive patients, who were more likely to be male, homeless, or African American. These patients were also more likely to show dementia or to be suicidal, abusing substances, or coping with borderline personality disorder. Conclusions: More precise description of HIV-positive patients visiting psychiatric emergency departments may help elucidate the needs of this population and help plan for improvements in care in this setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Huntington's disease

Wider, C. C., & Lüthi-Carter, R. R. (2006). Huntington's disease: Clinical and aetiologic aspects. Schweizer Archiv für Neurologie und Psychiatrie, 157(8), 378-383. Retrieved from EBSCOhost.

Huntington's disease is the most prevalent inherited human neurodegenerative disorder worldwide, affecting between 2 to 8 per 100000 inhabitants of Western countries, with an average age of onset close to 40 (range 2-80) and a usually slow progression over 10 to 30 years. Tremendous progress has been made in the understanding of the mechanisms implicated in this disease since the original description by George Huntington in 1872, marked by the identification of the locus in 1983 and the responsible gene in 1993. Clinical features include impaired motor control, manifesting as motor impersistence and inability to perform tasks that require motor sequences, along with abnormal movements such as chorea, athetosis, impaired ocular saccades and characteristic gait disturbances. Psychiatric and cognitive symptoms are also prominent, including depression and psychosis, with a high incidence of suicide, personality changes, aggressive or uncontrolled behaviour, impaired problem-solving abilities and ultimately more diffuse neuropsychological deficits leading to dementia. Genetically, the disease demonstrates fully penetrant autosomal dominant inheritance through a CAG trinucleotide repeat expansion in the protein-coding region of the huntingtin gene. There is an inverse correlation between the number of repeats and the patient's age at onset of the disease. Due to a phenomenon referred to as anticipation, the number of CAG trinucleotide repeats tends to increase when the disease is inherited from the father (paternal transmission), with disease onset at a younger age in the affected children. Despite 10 years of intensive study, the exact route between mutant protein and neurodegenerative illness remains elusive. Protein aggregation, mitochondrial dysfunction, transcriptional dysregulation, calcium homoeostasis and signalling anormalities, and organellar transport defects are leading candidate disease mechanisms. Huntington's disease pathology is characterised by marked atrophy of the caudate and putamen, with involvement of cerebral cortex, thalamus, subthalamus, nucleus accumbens, globus pallidus and substantia nigra pars reticulata. Within the caudate and putamen, the medium spiny GABA-ergic projection neurons are selectively vulnerable. Huntington's disease progresses slowly but irremediably to a state where patients are bedridden and demented, followed by death from secondary complications such as pneumonia. Current disease treatment is limited to pharmacologic management of symptoms, mostly antipsychotics, both for the abnormal movements and some psychiatric symptoms, and antidepressants. Future therapies targeting underlying disease mechanisms are currently under evaluation, raising tremendous hope for the development of curative treatments. They include metabolic support, neurotrophic intervention, cell replacement, transcriptional regulation and reducing the expression of the causative gene using small interfering RNA. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Multiple sclerosis

Turner, A., Williams, R., Bowen, J., Kivlahan, D., & Haselkorn, J. (2006). Suicidal ideation in multiple sclerosis. Archives of Physical Medicine & Rehabilitation, 87(8), 1073-1078. Retrieved from EBSCOhost

OBJECTIVE: To examine risk factors for suicidal ideation among people with multiple sclerosis (MS). DESIGN: Cohort study linking computerized medical records with a mailed self-report survey. SETTING: Veteran's Health Administration (VHA) region covering the northwestern United States. PARTICIPANTS: VHA patients with MS (N=445) who returned mailed surveys. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Suicidal ideation is assessed by the Patient Health Questionnaire (PHQ) suicide item with suicidal ideation more than half the days considered persistent. RESULTS: One hundred thirty-one (29.4%) of 445 respondents (95% confidence interval [CI], 25.4%-33.9%) endorsed suicidal ideation, and 35 (7.9%; 95% CI, 5.7%-10.8%) endorsed persistent suicidal ideation over the last 2 weeks. In bivariate analyses, suicidal ideation was associated with younger age, earlier disease course, progressive disease subtype, lower income, not being married, lower social support, not driving, higher levels of physical disability (mobility, bowel, bladder), and depression. Analyses on persistent suicidal ideation yielded similar results. In fully adjusted multivariate logistic regression, only depression severity and bowel disability were independently associated with suicidal ideation. Only depression severity was independently associated with persistent suicidal ideation. By using the 2-question depression screen (U.S. Preventive Services Task Force) consisting of the depression and anhedonia items from the PHQ-9, sensitivity and specificity were marginal for suicidal ideation (65.6% and 79.9%) but acceptable for persistent suicidal ideation (88.6% and 71.2%). CONCLUSIONS: Suicidal ideation is common among VHA patients with MS, and depression severity is the best risk marker. Brief screening for depression in MS should include the assessment of suicidal ideation. Copyright CO 2006 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Comments

06/11/2017 at 10:22 PM
Tom
My wife was humiliated by bowel dysfunction. The whole idea of losing your bowels without knowing bothered her tremendously. She believed I would lose interest in her sexually which was not the case. I loved her as she was. We were 18 days from our 31st anniversary when she chose to leave. I can't express how much I miss her.
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