Associate Clinical Professor of Orthopaedics and Rehabilitation
Yale University School of Medicine
Co-Director of Foot and Ankle Clinics
Yale New Haven Hospital
Section Chief of Orthopaedics
St Raphael Hospital
New Haven, Connecticut
Finally androgen hormone katy order pilex 60 caps line, the condition may remit before or just after the medical condition remits prostate cancer vaccine news order pilex uk, particularly wh^n treatment of the manic/hypomanie symptoms is effective prostate weight order pilex online. Gender-Related Diagnostic Issues Gender differences pertain to those associated with the medical condition man health blog buy discount pilex 60caps online. Diagnostic Markers Diagnostic markers pertain to those associated with the medical condition man health org health id order genuine pilex on-line. In these cases prostate cancer x ray images generic pilex 60caps without prescription, clinical judgment using all of the evidence in hand is the best way to try to separate the most likely and/or the most important of two etiological factors prostate exam procedure video discount pilex 60 caps fast delivery. Comorbidity Conditions comorbid with bipolar and related disorder due to another medical condition are those associated with the medical conditions of etiological relevance man health over 50 purchase 60 caps pilex otc. The episodes of hypomanie symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features. If this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanie episode are met. Unspecified Bipolar and Related Disorder V 296. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. Full criteria are met for a manic episode or hypomanie episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania: 1. Prominent dysphoria or depressed mood as indicated by either subjective report. Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others). Psychomotor retardation nearly every day (observable by others; not merely subjective feelings of being slowed down). Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick). For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment. Note: Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity. Note: the essential feature of a rapid-cycling bipolar disorder is the occurrence of at least four mood episodes during the previous 12 months. The episodes must meet both the duration and symptom number criteria for a major depressive, manic, or hypomanie episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapidcycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance. One of the following is present during the most severe period of the current episode; 1. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens). There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked brightening of mood. A depressed mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality. Mood reactivity is the capacity to be cheered up when presented with positive events. Increased appetite may be manifested by an obvious increase in food intake or by weight gain. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). This sensation is generally present for at least an hour a day but often lasts for many hours at a time. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods. With psychotic features: Delusions or hallucinations are present at any time in the episode. With mood-incongruent psychotic features: the content of delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks. Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. With seasonal pattern: this specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year. Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year. This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. Major depressive episodes that occur in a seasonal pattern are often characterized by prominent energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in recurrent major depressive disorder or in bipolar disorders. Specify if: In partial remission: Symptoms of the immediately previous manic, hypomanie, or depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanie, or major depressive episode following the end of such an episode. Mild: Few, if any, symptoms in excess of those required to meet the diagnostic criteria are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. In order to address concerns about the potential for the overdiagnosis of and treatment for bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, referring to the presentation of children with persistent irritability and frequent episodes of extreme behavioral dyscontrol, is added to the depressive disorders for children up to 12 years of age. Its placement in this chapter reflects the finding that children with this symptom pattern typically develop unipolar depressive disorders or anxiety disorders, rather than bipolar disorders, as they mature into adolescence and adulthood. Major depressive disorder represents the classic condition in this group of disorders. A diagnosis based on a single episode is possible, although the disorder is a recurrent one in the majority of cases. Bereavement may induce great suffering, but it does not typically induce an episode of major depressive disorder. When they do occur together, the depressive symptoms and functional impairment tend to be more severe and the prognosis is worse compared with bereavement that is not accompanied by major depressive disorder. Bereavement-related depression tends to occur in persons with other vulnerabilities to depressive disorders, and recovery may be facilitated by antidepressant treatment. A more chronic form of depression, persistent depressive disorder (dysthymia), can be diagnosed when the mood disturbance continues for at least 2 years in adults or 1 year in children. Almost 20 years of additional of research on this condition has confirmed a specific and treatment-responsive form of depressive disorder that begins sometime following ovulation and remits within a few days of menses and has a marked impact on functioning. A large number of substances of abuse, some prescribed medications, and several medical conditions can be associated with depression-like phenomena. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others. The diagnosis should not be made for the first time before age 6 years or after age 18 years. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanie episode have been met. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. Diagnostic Features the core feature of disruptive mood dysregulation disorder is chronic, severe persistent irritabihty. This severe irritability has two prominent clinical manifestations, the first of which is frequent temper outbursts. The second manifestation of severe irritability consists of chronic, persistently irritable or angry mood that is present between the severe temper outbursts. However, rates are expected to be higher in males and school-age children than in females and adolescents. Development and Course the onset of disruptive mood dysregulation disorder must be before age 10 years, and the diagnosis should not be applied to children with a developmental age of less than 6 years. Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (7-18 years). Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later.
Characteristics of those who were and were not deceased examined: older adults (Holwerda prostate 0 4 purchase genuine pilex, et al prostate cancer spread to bones order pilex once a day. It is also possible that anxiety may only predict mortality in men prostate extract cheap pilex online amex, as in one previous study where an association between anxiety disorders and mortality was found for men but not women (van Hout et al prostate nutrition buy pilex discount. This seems unfortunate given that it is a strong predictor of all-cause mortality in the present analyses prostate cancer fighting foods 60caps pilex mastercard. Some studies have examined the prognostic importance of both symptoms of anxiety and depression and mortality in cardiac patient groups man health care purchase pilex overnight. In a review of 25 studies of chronic heart failure patients prostate zonal anatomy diagram buy 60caps pilex amex, anxiety symptoms were measured along with depression in just three studies (Pelle prostate lobes discount pilex american express, Gidron, Szabo, & Denollet, 2008). Anxiety symptoms were not associated with mortality, whereas depressive symptoms significantly predicted death (Pelle, et al. A number of studies have examined both anxiety and depression symptoms and mortality in myocardial infarction patients. High depression and anxiety scores have both been found to predict all-cause mortality (Herrmann et al. However, in three studies, symptoms of depression but not anxiety in multivariate models predicted all-cause or cardiac mortality (Ahern et al. Finally, neither depression nor anxiety symptoms were found to predict mortality in myocardial infarction patients (Lane, Carroll, Ring, Beevers, & Lip, 2001). Thus, in prognostic studies, it would appear that depressive symptoms may be a more stable predictor of mortality than anxiety. However, it is unclear the extent to which the results of these studies of patients with chronic inflammatory disease relate to the present aetiological study where only 1% had a diagnosis of coronary heart disease at the medical examination. It is possible that the effects of depression on mortality and the underlying mechanisms may not be identical in patient versus population-based studies. Further, none of the prognostic studies that we know of have examined psychiatric comorbidity effects on mortality. However, we know of no previous studies that have examined the mortality risk associated with this comorbidity. Consequently, this argues that comorbidity should receive considerably more attention in future research on mental disorders and health outcomes, at least in studies of non-patient groups. Further, clinical interventions have tended to concentrate on single mental health diagnoses; these findings suggest that targeting comorbidity might be a fruitful new approach. Second, residual confounding as a consequence of un-measured variables cannot be wholly discounted. The present analysis, however, did adjust for a large number of potential confounding variables. It should be noted that the previous studies with null results tested women only in one case (Hallstrom et al. It is also worth noting, though, that these studies had much smaller samples, reducing their power to detect effects on mortality. In addition, it is possible that veterans differ in other ways from the broader population. For example, one study of stable coronary heart disease that included veterans found no evidence that depression was associated with elevated levels of inflammation (Whooley et al. Fourth, it has been suggested that the prevalence of mental health disorders in the Vietnam Experience Study are underestimated (Dohrenwend et al. Nevertheless, it is possible that severely depressed veterans were less likely to participate in the medical examination, which may have accounted for the attenuated associations for major depression in the present analyses. However, this seems unlikely given that only 10 (<2%) veterans were unable to attend on the basis of physical/mental disability, and only 372 (<6%) refused to attend, with the main reasons being a lack of interest or unwillingness to travel. In addition, future studies should attempt to measure and take account of a full range of factors likely to be associated with both mental and physical health. As the metabolic syndrome increases risk for cardiovascular and all-cause mortality (Isomaa, et al. The bulk of this research has focused on depression and although contrary indications exist (Herva et al. In a small study of outpatients, those who still had a diagnosis at 6-year follow-up showed a higher prevalence of the metabolic syndrome (Heiskanen, et al. Much less attention has been paid to anxiety and the metabolic syndrome and the three most recent studies reported null findings (Herva, et al. However, an earlier study of women found an association between the metabolic syndrome and increased anxiety seven years later (Raikkonen, et al. Generalised Anxiety Disorder, Mortality and Disease: A Stronger Predictor than Major Depressive Disorder 127 3. Full details of the characteristics of those with and without the metabolic syndrome are shown in Table 3. Thus, the apparent discrepancy between the present findings and those of others may be more illusory than real. If anxiety precedes metabolic syndrome, there are at least two pathways through which it might contribute to its aetiology. First, anxiety has been associated with unhealthy behaviour, such as smoking, binge drinking, physical inactivity, and unhealthy diet (Strine et al. Second, it has been postulated that hypothalamic-pituitary-adrenocortical dysregulation associated with affective disorders, including anxiety, may contribute over time to the metabolic syndrome (Raikkonen, et al. There is evidence linking anxiety with altered cortisol activity; high levels of anxiety symptoms were found to be associated with a less pronounced cortisol awakening response (Therrien et al. The metabolic syndrome has been shown to predict symptoms of anxiety seven years later (Raikkonen, et al. Further, it is reasonable to presume that diagnosis of some of the components of the metabolic syndrome may be anxiolytic. For example, irrespective of actual blood pressure levels, perceived hypertensive status was positively associated with anxiety (Spruill et al. A recent review concluded that evidence relating depression to the metabolic syndrome was stronger for women than men (Goldbacher & Matthews, 2007). Finally, although we adjusted for many possible confounders, residual confounding as a consequence of poorly measured or unmeasured variables cannot be wholly discounted. However, there is at least some cross-sectional and prospective evidence of a positive association (Patten et al. At the medical examination in 1986, with the participant in a sitting position, a registered nurse, using a standard mercury sphygmomanometer to blood pressure measured, twice consecutively, from both arms. Hypertension was defined by having one of the following: a reported physician-diagnosis at interview; reported taking antihypertensive medication; an average systolic blood pressure fl 140 mmHg; an average diastolic blood pressure fl 90 mmHg at the medical examination. There were 441 participants who indicated during the telephone interview that they had a physician diagnosis of hypertension and a further 98 who, although not reporting a diagnosis of hypertension, indicated that they were taking antihypertensive medication. Others have encountered individuals without an acknowledged diagnosis of hypertension who report taking antihypertensive medication and have designated them as hypertensive (Patten et al. The remainder and majority (N = 842) of those classified as hypertensive was as a result of the blood pressure assessment at the medical examination. This suggests that there was substantial undiagnosed and/or untreated hypertension. As our outcome measure is hypertension, it is essential to include participants with a physician diagnosis of hypertension in that outcome. Of the participants with a diagnosis of hypertension, 292 (66%) were taking anti-hypertensive medication. The effect of this would be to lower blood pressure, such that some of these participants (N = 108) no longer met a criterion solely based on measured blood pressure. Given that antihypertensive medication can be prescribed for conditions other than hypertension, hypertension was redefined based on only physician diagnosis and measured blood pressure. This reduced the sample to 4180 and the numbers classified as hypertensive as 1329 (32%). Generalised Anxiety Disorder, Mortality and Disease: A Stronger Predictor than Major Depressive Disorder 131 However, in the fully adjusted comorbidity competitive analysis, no statistically significant relationships emerged. The only association to approach significance was between co-morbidity and hypertension. This proportion is somewhat higher than that reported from studies with participants of a similar mean age. However, in part this could reflect different definitions of hypertension; relying solely on reported diagnostic and medication status, and not including measured blood pressure, will almost certainly lead to an underestimate of prevalence. In addition, the present sample was clustered at the low end of the socio-economic spectrum. Other analyses indicate an inverse gradient between socio-economic status and measured blood pressure, although a less consistent association between socio-economic position and hypertension treatment rates (Colhoun, Hemingway, & Poulter, 1998). In the present sample, however, household income in midlife was associated with hypertension. The latter result is consistent with the cross-sectional and prospective outcomes from the Canadian National Population Health Survey (Patten et al. It is possible that co-morbidity signals more severe psychiatric dysfunction and that it is the severity of dysfunction that is associated with physical health outcomes, similar to the findings for mortality above. However, it is also possible that comorbidity reflects a greater negative disposition, and it is this which is associated with hypertension (Suls & Bunde, 2005). In addition, in the majority of instances in the present study, hypertension was apparently undiagnosed. In the present analyses, the associations were still evident following adjustment for two of the most prominent unhealthy behaviours, smoking and high levels of alcohol consumption. That smokers have lower blood pressure and that alcohol consumption is positively related to hypertension are common observations (Beilin, 1987; Green, Jucha, & Luz, 1986). Although we have no data directly pertaining to the second route, others have observed altered activity of the hypothalamic132 Anxiety and Related Disorders pituitary-adrenal axis in approximately 50% of depressed patients (Brown, Varghese, & McEwen, 2004), which, in turn, may increase the risk of hypertension (Torpy, Mullen, Ilias, & Nieman, 2002). Indeed, in the Framingham study, symptoms of anxiety predicted hypertension in middle-aged men but not middle-aged women (Markovitz et al. In addition, the present participants were largely from the lower end of the socio-economic spectrum and thus our findings may not generalise to the population as a whole. Depression has been the main focus for studies of psychiatric disorders and physical health outcomes. Future research remains to determine the mechanisms underlying these associations with health outcomes, through prospective assessment and a thorough inclusion of both biological and behavioural covariates. The author would also like to acknowledge the involvement of Professor Douglas Carroll, Dr Catharine Gale, and Dr G. Generalised Anxiety Disorder, Mortality and Disease: A Stronger Predictor than Major Depressive Disorder 133 Beilin, L. Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Posttraumatic stress disorder and physical illness: results from clinical and epidemiologic studies. External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition. Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: research and clinical implications. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Depression: an important co morbidity with metabolic syndrome in a general population. Tension and anxiety and the prediction of the 10-year incidence of coronary heart disease, atrial fibrillation, and total mortality: the Framingham Offspring Study. The impact of negative emotions on prognosis following myocardial infarction: is it more than depressionfl Psychosocial factors and risk of ischaemic heart disease and death in women: a twelve-year follow-up of participants in the population study of women in Gothenburg, Sweden. Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients. Cooccurrence of metabolic syndrome with depression and anxiety in young adults: the Northern Finland 1966 Birth Cohort Study. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The relationship between generalized anxiety disorder, depression and mortality in old age. Longitudinal evidence from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. Depression and the metabolic syndrome in young adults: findings from the Third National Health and Nutrition Examination Survey. Metabolic syndrome predisposes to depressive symptoms: a populationbased 7-year follow-up study. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Depressive symptoms and metabolic risk in adult male twins enrolled in the National Heart, Lung, and Blood Institute twin study. The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Longterm medical conditions and major depression: strength of association for specific 136 Anxiety and Related Disorders conditions in the general population. Major depression as a risk factor for high blood pressure: epidemiologic evidence from a national longitudinal study. The relationship between psychological risk attributes and the metabolic syndrome in healthy women: antecedent or consequencefl Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Serum lipid concentrations in patients with comorbid generalized anxiety disorder and major depressive disorder. Generalised Anxiety Disorder, Mortality and Disease: A Stronger Predictor than Major Depressive Disorder 137 Suls, J. Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Awakening cortisol response in relation to psychosocial profiles and eating behaviors. Metabolic syndrome increases all-cause and vascular mortality: the Hong Kong Cardiovascular Risk Factor Study. Mental health status as a predictor of morbidity and mortality: a 15-year follow-up of members of a health maintenance organization. Panic disorder and cardiovascular/cerebrovascular problems: results from a community survey. Depression and inflammation in patients with coronary heart disease: findings from the Heart and Soul Study. Introduction Anxiety disorders are amongst the most common psychiatric disorders in all over the world. Its an emotion that prepares the individual to the environmental changes or helps to create a response to those changes. Also there are psychological symptoms such as distress, excitement and a precognition and fear of suddenly something bad going to happen. Anxiety is a symptom that could be seen in many organic disorder and can accompany almost any psychiatric disorder. Nowadays, the relationship between psychological factors and cardiac disease have been discussed. Because creation potential of the sudden death due to cardiac diseases are more sensitive to the psychiatric disorders and development of any cardiac disease might start serious mental issues. Anxious thoughts causes reduced autonomic variability condition which is a result of decrease in vagal tone. The first reaction to stress is muscle weakness and a feeling of heart stopping due to parasympathic activation. A short time later, the sympathetic system is activated, sweating, palpitation, tremors, rapid and deep breathing begin. When they do challenging activities or concerned there will be cardiovascular variability and falls occur phasic parasympathetic tone. Studies on this subject emphasize cardiac sensitization caused by sympathetic activity. According to this stimulation of central and peripheral adrenergic structures, catecholamine infusion and behavioral stress can cause cardiac sensitivity in both healthy and ischemic heart. Cardiac diseases within the psychiatric views (whether or syndromal levels of disorder matter), surely, should be recognized and addressed. Patients who work under heavy stressful conditions suffers from continuous excreting of catecholamine with the further aggravated cardiac disease. At the same time, anxiety is caused by a decrease in vagal control also increases the susceptibility to coronary cardiac disease. On most cardiac diseases cases, an intense anger and hostile attitude follows the anxiety. Anxiety came out tops as a leading emotional problem for cardiac patients when it unites with other negative emotions.
Tell the student that this information needs to be shared to ensure the safety of the student (and/or others) prostate qigong pilex 60caps with amex. This could be an opportunity to empower the student and help him or her to disclose the information to a mental health professional prostate with grief definition buy discount pilex on line. Tere are many possible reasons why a child or youth may be engaging in selfharm behaviour uw prostate oncology center buy pilex 60 caps without prescription. It may be used as a coping mechanism or a means of reducing internal tension androgen hormone x for hair order 60 caps pilex otc, feelings of distress prostate 24 reviews order pilex with visa, or other difcult emotions prostate cancer psa 003 quality pilex 60caps. It may be a cry for help man health warehouse buy discount pilex 60caps line, a form of self-punishment prostate cancer natural treatment discount pilex 60caps with mastercard, or a form of sensation seeking. Certain conditions may also put children and youth at increased risk for selfharm behaviour. For example, body-image issues, sexual/physical abuse, and loss have all been associated with self-harm. However, not all students who engage in self-harm have experienced these sorts of challenges. Occasionally, the behaviour is precipitated by more immediate life events, such as a confict with parents or peers, or other sources of stress. Research fndings from community samples indicate that between 13 and 29 per cent of adolescents engage in self-harm (Baetens et al. This behaviour typically begins between thirteen and ffeen years of age but increases in frequency in later adolescence (Hamza et al. It has been suggested that rates of self-harm appear to be highest in adolescent girls (see Hamza et al. The Relationship between Non-suicidal Self-injury/ Self-harm and Suicidal Thoughts and Behaviour Although non-suicidal self-harm and suicidal behaviour. With non-suicidal self-harm behaviour, there is no frm intention to die, and the person does not think the behaviour will lead to death (Andover & Gibb, 2010). With suicidal behaviour, there is some level of intent to die, although the strength of the intent may vary from person to person (Muehlenkamp, 2005). Despite some signifcant diferences between non-suicidal self-harm and suicidal thoughts and behaviour, research fndings indicate that the two types of behaviour can co-occur, though there is no frm agreement about how they are related (Cloutier et al. It is unclear whether non-suicidal self-harm behaviour actually increases the risk of later suicide attempts (Hamza et al. It is also important to note that both types of behaviour have a strong link to various types of mental illness. Tough not necessarily suicidal, a student who engages in self-harm is experiencing distress that requires professional help. Because of the potential link between self-harm and suicidal behaviour, it is imperative for all cases of self-harm to be referred for assessment by a mental health professional. Suicidal thoughts (also known as suicidal ideation) include both thinking of killing oneself and planning actions. Although suicidal thoughts are more common than suicide attempts and dying by suicide (Cusimano & Sameem, 2011), they are strongly associated with suicide attempts and should be recognized as an important sign of the need for intervention and prevention measures (Fergusson et al. Suicide attempts and death by suicide are both included in this defnition (Andover & Gibb, 2010; Hamza et al. Although suicidal behaviour involves some level of intent to die, the strength and clarity of the intent may vary. Youth who are suicidal are ofen ambivalent about living and dying and have doubts about whether suicide is a solution to their problems. This ambivalence is an important focus of intervention for people who are risk of suicide. Some common myths about suicide are outlined below, along with factual information to set the record straight. Talk that indicates a person is thinking about has never attempted it means it is unlikely that suicide should be taken very seriously, as this is one of the most he/she will attempt suicide. However, higher rates of suicidal behaviour have been found in identical twins if one twin has died by suicide. Studies of identical twins reared apart are needed to understand the role of genetic versus environmental infuences. Risk factors for certain mental health problems that are also known to increase the risk of suicidal behaviour, such as depression, do have a genetic component. Signs of suicidal thoughts and behaviour can be subtle and hard to recognize (Sellen, 2010). Signs and behaviour may difer from person to person depending on the level of stress experienced. Many youth who are suicidal do provide some indication of their distress or admit to having suicidal thoughts and feelings. Research indicates that approximately 80 per cent or more of youth who die by suicide provided some clues to their state of mind prior to the act (Sellen, 2010; Doan et al. Nevertheless, research also indicates that 33 per cent of young women and 45 per cent of young men with suicidal thoughts and/or behaviour do not talk about it to anyone. However, no matter how alert we may be for such warning signs, no one can predict suicidal behaviour with any certainty. Some of the warning signs listed below are the same as or similar to those that may be shown by a student who is experiencing symptoms of sadness, worry, or depression. Symptoms associated with depression are also risk factors that may contribute to suicidal thoughts and behaviour (Doan et al. Schools are in a good position to focus eforts on supporting students who may be struggling with mental health problems in order to intervene before it is too late. Educators are well placed to notice signs that students are exhibiting mental health problems or suicidal thoughts and behaviour. Because 90 per cent of all deaths by suicide are associated with having an untreated mental illness, it is critically important to recognize signs associated with mental health problems. Research fndings show that 40 to 80 percent of youth who have had suicidal thoughts or who have attempted suicide and 60 percent of youth who have died by suicide have had symptoms of depression (Barbe et al. Substance use problems and conduct disorder are also indicators that a student may be at risk for suicidal behaviour (Shafer et al. Educators can help individual students gain access to sources of support and treatment. Schools should ensure that information about resources such as crisis centres and help lines or hotlines is widely available. Help lines, in particular, provide quick and easy access while ensuring confdentiality (Doan et al. Tere are prevention programs and training programs available to help educators learn more about how to identify and support students who may be at risk. Some school jurisdictions also have programs to raise awareness among students through focused suicide-awareness education. However, to date there is limited information about the efectiveness of such programs (Doan et al. Tere is some evidence that school-based suicide-prevention programs can help to raise awareness and promote help-seeking behaviour; however, there are no data to indicate whether such programs actually decrease rates of suicide (Cusimano & Sameem, 2011). To Support Positive Mental Health in the Classroom Eforts to help students at risk begin with measures to create a classroom environment that will promote mental and emotional well-being among all students, as outlined below. These will help to promote wellness and decrease physical and mental health risks. Both the school administration and educators should know what to do if a student appears to be at risk. Allow the student an opportunity to speak, even if there are long periods of silence. Supportive listening can have a direct impact on decreasing immediate suicidal risk. This is especially important if the student has a previous history of suicidal thoughts or behaviour. Do not, for example, surprise the student by escorting him/her to a room where a ten-member crisis team is waiting. Make sure that you explain to the student what events and responses he/she can expect. By not providing and communicating structure in your response, you may unintentionally create more chaos and confusion, thereby increasing the likelihood that the student will refuse to cooperate. A possible risk-reduction strategy might be to help the student reconnect with an existing support or resource. Postvention Strategies The whole community needs to be involved in the response to a suicide. The response may include a trauma/ crisis response team deployed to the school to provide diferentiated support to students and staf, as well as a wider team of support personnel to help with logistics, media response, and decision making. Because of the risk of contagion, postvention must be planned and managed carefully. Educators should familiarize themselves with their board and school policies and procedures for responding afer a death by suicide. As young A variety of risk factors interacting in complex ways may trigger suicidal people are exposed thoughts or behaviour. In Canada, suicide is the second leading cause of death, afer accidents, for young people between ten and thirty-four years of age (Public Health Agency of Canada, 2012). Tere are strong diferences between rates of suicidal thoughts and behaviour in males and females, with adolescent girls being up to twice as likely to have suicidal thoughts as adolescent boys and three to four times more likely to attempt suicide. However, adolescent boys are up to fve and a half times more likely to die by suicide than girls (Hamza et al. Nonsuicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Nonsuicidal and suicidal self-injurious behavior among Flemish adolescents: A web-based survey. Characteristics and co-occurrence of adolescent non-suicidal self-injury and suicidal behaviours in pediatric emergency crisis services. Psychiatric impairment among adolescents engaging in diferent types of deliberate self-harm. An investigation of diferences between self-injurious behavior and suicide attempts in a sample of adolescents. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Youth risk behavior survey (2009): Trends in the prevalence of suicide-related behaviors. Psychopathology of adolescent suicide: Hopelessness, coping beliefs, and depression. Relationships of age and axis I diagnoses in victims of completed 139 Supporting Minds suicide: A psychological autopsy study. The efectiveness of middle and high school-based suicide prevention programmes for adolescents: A systematic review. Suicidal behavior in adolescence and subsequent mental health outcomes in young adulthood. Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. The role of teachers in school-based suicide prevention: A qualitative study of school staf perspectives. A West Sussex guide for professionals developed in collaboration with Horsham District Council, West Sussex Local Safeguarding Children Board. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Nightmares and sleep disturbances in relation to suicidality in suicide attempters. The decline of youth suicidal behavior in an urban, multicultural public school system following the introduction of a suicide prevention and intervention program. The former provides a review of the academic literature on school mental health and points to several evidence-based practices and programs that are associated with positive mental health and well-being for students. The Practice Scan is based on interviews with key senior leaders in Ontario schools and highlights both strengths and needs in school mental health in the province. Tese papers include policy and practice recommendations related to supporting student well-being in Ontario school boards. This is a cross-sectoral initiative by the Ministry of Children and Youth Services, the Ministry of Health and Long-term Care, and the Ministry of Education. It involves collaboration by boards across the province with community agencies and health providers in twenty-nine clusters. The goal is to improve communication and the integration of systems of care for child and youth mental health and to provide non-academic supports for promoting positive student behaviour. The program was designed to consolidate community partnerships through procedures to facilitate early intervention and assist people in navigating the system and gaining access to appropriate services. Both approaches recommend providing a range of instructional strategies, resources, activities, and assessment tools in order to meet the diferent strengths, needs, readiness levels, and learning styles or preferences of the students in a class. It calls, frst, for the creation of a positive and supportive environment in the school and classroom that will beneft all students; second, for prevention programming for students at risk; and third, for intervention, including outside referrals, for students in distress. The present document, Supporting Minds, outlines strategies that are most relevant at the level of universal and prevention programming, and is designed to help educators identify students who may be in need of extra support from a trained mental health professional.
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