Monday, August 27, 2007

Articles on Suicide

Psychiatry Drug Alerts reviewed three studies, with a combined total of 109,000 patients. Attempts increased prior to treatment, peaking in the month prior to treatment, dropping steeply after the start of treatment, and continuing to decrease as treatment continued. This conclusion contradicts the FDA Psychopharmacology Committee black box warning, and makes it garbage science. The same conclusion resulted from a separate VA study of adults, that SSRI anti-depressants do not increase the risk of suicide. (Psychiatry Drug Alerts 21: 57-58)

Decision making in suicidal patients was tested with a standardized gambling test. Subjects learn to defer immediate rewards to get long-term rewards. Their score correlated with interpersonal difficulties in the affective domain. (J Affect Disord 99:59-62, 2007)

Patients over 50 with major depression had more impulsive suicide attempts with cognition problems, disability, and impaired self-care. They prepared for a suicide more often when older, isolated or living alone. (J Affect Disord 97:123-128, 2007)

Blacks do not have lower rates of suicidality. The lifetime prevalence of attempts was 4.1%, for suicidal ideas, 11.7%. In the first year of ideas, 77% progressed to an attempt. Increased risk associated with a younger cohort, lower educational attainment, living in the Midwest. These rates are those of the general population, and not lower. (JAMA 26:2112-2123, 2006)

Compared to depressed controls, adult patients with depression and a history of child abuse more often attempted suicide, got rated as impulsive and aggressive. Those who attempted suicide (71% v. 43% in the control group), had higher scores for impulsivity and aggression. (Am J Pscyhiat 158:1871-1877, 2001)

Of over 3000 female twins, ages 13 to 19, 4% reported attempting suicide before age 17. About half the attempters and a twelfth of the non-attempters had depression. Other risk factors included childhood physical abuse, social phobia, alcohol dependence, being black, and having conduct disorder. Risk increased 4 to 10 fold if a relative had died of suicide. The identical twin concordance rate was 25%, and 13% for dizygotic twins. Aside from psychopathology association with suicide, a familial link exists. (J Am Acad Child Adol Psychiat 40:1300-1207, 2001)

The highest levels of suicidal ideas take place in bipolar patients during the mixed phase. Age and depth of depression predicted suicide attempts. Anxiety did not. Patients did not make suicide attempts during mania. (J Affect Disord 2007; 97:101-107)

Among depressed patients, 16% reported prior suicide attempts. These were less educated, less likely married, more likely unemployed, with more substance abuse, co-morbidities, and PTSD. They had earlier onsets, increased severity, more episodes, and greater risk of suicidal behavior than the other depressed patients. (J Affect Disord 97:77-84, 2007)

A quarter of elderly depressed patients had suicidality. In half the suicidal patients, suicidality resolved after a month. In a quarter, it emerged late in treatment. About a quarter never experienced suicidality at any time. Suicidal and non-suicidal patients had equal severity of depression. The suicidal group has more anxiety, earlier onsets, more low self-eateem, and partial or no response to treatment. (J Affect Disord 2007; 98:153-161)

Anxiety symptoms associated with suicidal ideation in bipolar patients. It was ruminations, especially, that best linked to suicidal ideation. (J Affect Disord 97: 91-99, 2007)

At risk youth endorsed maladaptive coping strategies, increasingly more often with increasing risk factors. They avoided help seeking behavior. Such thinking requires persuasion during psychotherapy to change coping reactions. (J Am Acad Child Adol Psychiat 43:1124-1133, 2004)

Suicide rates peak in May, are lowest in February. Season represents a risk factor for suicide. Sunspot activity and geomagnetic field change did not. (J Affect Disord 81:133-139, 2004).

Among very depressed patients, these features predicted a higher risk of suicide attempt: a history of suicide attempt, subjective ratings of depression severity, cigarette smoking, aggression or impulsivity. (Am J Psychiat 161:1433-1441, 2004).

Dating Violence Increases the Risk of Suicidal Behavior by Girls by 60%

Girls suffer dating violence at a rate of 11%, and boys at 10%. Such female victims had a rate of suicidality 60% higher. Boys subject to dating violence did not have an increase in rates of suicidal behavior.

Defendants in a suicide malpractice lawsuit might consider a cross-claim against any dating abuser for increasing the risk of suicide of the victim.

Dr. Andrew Leon and the Rest of the Irresponsible FDA Advisory Committee, Resign Now, Take the FDA Commissioner With You.

Dr. Andrew Leon tries to justify the ineffable repetition of the mistake his FDA Advisory Committee made. In this Perspective Article, he describes the low rate of suicidal ideas or behaviors, not any suicide, just ideas and gestures.

He fails to adequately address the catastrophic deterrence of family doctors and general practitioners from prescribing SSRI's. With the sole measure that reduces suicide being long term treatment of the underlying condition, fewer people will get treated, and more will commit suicide. He dismisses the excess of 100's of children and adolescents who committed suicide since the irresponsible warning issued in 2003. "The public health experiment has just begun," he retorts. Nice to know the families that needlessly lost a loved one thanks to his irresponsible vote were participating in an experiment.

Thursday, August 23, 2007

Gastric Bypass Surgery Tripled the Suicide Rate

In this article, the bariatric surgery markedly decreased overall mortality, especially from cardiac and cancer causes. Suicide increased in the surgery group by three fold (0.9/10,000 person-year in the control group of 7925 people, vs 2.6 in the matched surgery group of 7925). The rate of the control group would be average for the general population, with 1% of people dying, and 1% of the mortality being by suicide. The implication is that weight loss tripled the suicide rate.

In the prior article on the mortality results in a Swedish sample, suicide was not addressed specifically. There were fewer non-cardiac, non-cancer deaths in the surgery group.

The finding of excess suicide should be confirmed in other studies.

Friday, August 17, 2007

Why Patients Sue

Findings without comment here. These motivations represent a checklist of questions to be posed during depositions of the plaintiff.

As reviewed in Physician Protect Thyself, by Alan G. Williams, JD, Margol, Denver, CO, 2007. Pp. 23-30. They felt deserted. They felt their concerns were not taken seriously enough. Providers failed to convey information well enough. They felt the provider did not understand them. They cited poor communication after an adverse event and an attempt to cover it up. They filed a lawsuit to find out more.

Arch Phys Med Rehabil. 2007 May;88(5):589-96. What patient attributes are associated with thoughts of suing a physician? Fishbain DA, Bruns D, Disorbio JM, Lewis JE.

RESULTS: The highest percentage (11.5%) of patients affirming the S-MD statement were those involved in workers' compensation and personal injury litigation, compared with only 1.9% of community-living subjects. Stepwise regression of BHI 2 variables produced a 13-variable model explaining 38.04% of the variance. A logistic regression of demographic variables (eg, education, ethnicity, litigiousness) explained 20% of the variance. CONCLUSIONS: Anger (P<.001), mistrust (P<.001), a focus on compensation (P<.001), addiction (P<.001), severe childhood punishments (P<.001), having attended college (P<.001), and other patient variables were associated with thoughts of suing a physician.

N Engl J Med. 2006 May 11;354(19):2024-33. Claims, errors, and compensation payments in medical malpractice litigation. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan TA.

RESULTS: For 3 percent of the claims, there were no verifiable medical injuries, and 37 percent did not involve errors. Most of the claims that were not associated with errors (370 of 515 [72 percent]) or injuries (31 of 37 [84 percent]) did not result in compensation; most that involved injuries due to error did (653 of 889 [73 percent]). Payment of claims not involving errors occurred less frequently than did the converse form of inaccuracy--nonpayment of claims associated with errors. When claims not involving errors were compensated, payments were significantly lower on average than were payments for claims involving errors (313,205 dollars vs. 521,560 dollars, P=0.004). Overall, claims not involving errors accounted for 13 to 16 percent of the system's total monetary costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78 percent of total administrative costs. CONCLUSIONS: Claims that lack evidence of error are not uncommon, but most are denied compensation. The vast majority of expenditures go toward litigation over errors and payment of them. The overhead costs of malpractice litigation are exorbitant.

N Engl J Med. 1996 Dec 26;335(26): Relation between negligent adverse events and the outcomes of medical-malpractice litigation. Brennan TA, Sox CM, Burstin HR.

RESULTS: Of the 51 malpractice cases, 46 had been closed as of December 31, 1995. Among these cases, 10 of 24 that we originally identified as involving no adverse event were settled for the plaintiffs (mean payment, $28,760), as were 6 of 13 cases classified as involving adverse events but no negligence (mean payment, $98,192) and 5 of 9 cases in which adverse events due to negligence were found in our assessment (mean payment, $66,944). Seven of eight claims involving permanent disability were settled for the plaintiffs (mean payment, $201,250). In a multivariate analysis, disability (permanent vs. temporary or none) was the only significant predictor of payment (P=0.03). There was no association between the occurrence of an adverse event due to negligence (P = 0.32) or an adverse event of any type (P=0.79) and payment. CONCLUSIONS: Among the malpractice claims we studied, the severity of the patient's disability, not the occurrence of an adverse event or an adverse event due to negligence, was predictive of payment to the plaintiff.

Med Care. 2000 Mar;38(3):250-60. Negligent care and malpractice claiming behavior in Utah and Colorado. Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA.

RESULTS: Eighteen patients from our study sample filed claims: 14 were made in the absence of discernible negligence and 10 were made in the absence of any adverse event. Of the patients who suffered negligent injury in our study sample, 97% did not sue. Compared with patients who did sue for negligence occurring in 1992, these nonclaimants were more likely to be Medicare recipients (odds ratio [OR], 3.5; 95% CI [CI], 1.3 to 9.6), Medicaid recipients (OR, 3.6; 95% CI, 1.4 to 9.0), > or =75 years of age (OR, 7.0; 95% CI, 1.7 to 29.6), and low income earners (OR, 1.9; 95% CI, 0.9 to 4.2) and to have suffered minor disability as a result of their injury (OR, 6.3; 95% CI, 2.7 to 14.9). CONCLUSIONS: The poor correlation between medical negligence and malpractice claims that was present in New York in 1984 is also present in Utah and Colorado in 1992. Paradoxically, the incidence of negligent adverse events exceeds the incidence of malpractice claims but when a physician is sued, there is a high probability that it will be for rendering nonnegligent care. The elderly and the poor are particularly likely to be among those who suffer negligence and do not sue, perhaps because their socioeconomic status inhibits opportunities to secure legal representation.

Wednesday, August 15, 2007

Suicide Assessment Garbage Guidelines

It has been weeks since I requested data showing that following suicide assessment guidelines reduces the risk of suicide, short term or long term. I have not yet received any studies, nor even anecdotal reports. I contacted several authors of article putting forth these garbage guidelines. No reply. I have patience.

If any defendant finds himself facing these guidelines in a complaint or in discovery, I would appreciate an email from the defense attorney.

Monday, August 13, 2007

Authentication of E-Mail in E-Discovery

Authenticate emails before admission into evidence. On the other, seek to exclude adverse email by arguing against their authenticity, or about their being hearsay, so says the review.

Friday, August 10, 2007

Suicide in Bipolar Patients Tied to Being Male and Anxious

This retrospective study found a rate of suicide among bipolar patients of 1 in a 1000 person-years, and a rate of suicide attempts of 5 in a 1000. In terms of legal foreseeability, those chances are in the lottery ticket correct number selection range. Suicide attempts rates increased with substance abuse, decreased with age. Suicide increased with male sex, and anxiety co-morbidity.

Wednesday, August 8, 2007

Las Vegas Has the Highest Suicide Rate; Seniors Lead the Way

This article reviews the excess number of suicides in Nevada, and especially in Clark County.