It is imperative that ob/gyns are able to recognize four very common conditions that are highly associated with suicidal thoughts, suicide attempts and suicide completion.
Kimberly Yonkers, MD
Major depressive disorder, bipolar disorder, post-traumatic stress disorder (PTSD) and substance use disorder are four clinical conditions that pose a high risk of suicide among US women.
“About 20% of women will experience an episode of major depressive disorder at some point in their lives,” said Kimberly Yonkers, MD, a professor of psychiatry, ob/gyn and reproductive sciences at Yale School of Medicine. “And the 12-month prevalence of major depressive disorder is roughly 8% in women.”
Similarly, substance use disorders occur in slightly less than 20% of women during their lifetime, followed by PTSD in about 6% of women and bipolar disorder in 2% to 3% of women.
“These are four very common conditions that are highly associated with suicidal thoughts, suicide attempts and suicide completion,” said Dr. Yonkers in a presentation on when clinical conditions collide at the 2019 ACOG annual clinical and scientific meeting in Nashville.
The cardinal feature of a major depressive disorder is low, blue mood and/or loss of pleasure. “These symptoms are pervasive and endure for at least 2 weeks,” Dr. Yonkers told Contemporary OB/GYN. “The disorder is also extremely debilitating and causes a lot of distress, so that people may no longer be able to perform their usual activities.”
Cognitive symptoms like concentration difficulties and poor self-esteem are also linked to major depressive disorder. Physical symptoms include sleep disturbances, fatigue, and changes in appetite.
“However, particularly in pregnant women and in women with gynecologic cancer or recovering from gynecologic surgical interventions, we need to rely on the cognitive symptoms because these people tend to be very fatigued and have sleep and appetite disturbances,” Dr. Yonkers said.
The major symptom of bipolar disorder is mania, often manifesting immediately postpartum with feeling highly revved up and too much energy at the expense of sleep and appetite. “About 80% of women with bipolar disorder will have an episode of mania during the immediate postpartum time,” Dr. Yonkers said. “In addition, individuals with bipolar disorder are the highest risk group for suicide. Hence, this is a condition that as clinicians we do not want to miss.”
PTSD occurs in people who have experienced or witnessed a trauma, or who have had strong indirect exposure to trauma by hearing aversive details, for instance. These women are haunted by intrusive memories, nightmares and flashbacks that keep them constantly on alert, constantly vigilant and constantly anxious.
“It is very hard for women with PTSD to turn off the memory,” Dr. Yonkers said.
Substance use disorder is a new category for anyone who misuses any substance like alcohol, cigarettes, opioids, cocaine or other stimulant. “This disorder has a permissive impact on an individual who is vulnerable to self-harm,” Dr. Yonkers said. “The person ends up with a kind of toxic brain cocktail that can lead to a suicide attempt or a successful suicide.”
For a person diagnosed with a major depressive episode or major depressive order, or with bipolar disorder, the likelihood of a suicide attempt is three times greater than for an individual without one of these diagnoses.
A full 50% of all suicides (either sex) are with firearms, followed by suffocation and poisoning.
In March, the US Food and Drug Administration approved brexanolone (Zulresso, Sage Therapeutics) injection via intravenous infusion for treating depressive and suicidal symptoms. The drug is administered for 60 hours in a medical setting for monitoring.
Preliminary data indicate that an oral version of brexanolonemay also be effective, according to Dr. Yonkers
Dr. Yonkers reports no relevant financial disclosures.