Download B2B Mood Disorders and Suicide

Back to Basics; Mood Disorders
Margo Rioux
PGY2 psychiatry
With Thanks to Dr. Primeau, Dr. Petit
and Dr. Gray for their slides
April 8th, 2016
LMCC Objectives (1)
Given a patient with depressed mood or
hypomania/mania, the candidate will diagnose
the cause, severity and complications, and will
initiate an appropriate management plan. The
candidate should also pay particular attention to
assessment of (suicide) risk and the potential need
for urgent care.
LMCC Objectives (2)
• List and interpret critical clinical findings, including
▫ results of an appropriate history, physical examination and assessment
of the patient's mental state;
▫ Collateral information as appropriate
▫ a differential diagnosis based upon differentiation of clinical syndromes
presenting with mood dysregulation;
▫ specific risk factors that warrant immediate intervention;
• List and interpret appropriate investigations,
▫ including appropriate laboratory investigations (e.g., toxicology screen,
thyroid stimulating hormone);
• Construct an initial management plan including
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an assessment of safety (e.g., suicide risk, risk of harm to others);
initiation of appropriate pharmacotherapy, if indicated;
appropriate involvement of family and supportive resources;
determination as to whether a referral for specialized care is required.
LMCC Objectives (3)
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Major depressive disorder
Bipolar disorder (type I, type II)
Persistent depressive disorder (dysthymia)
Cyclothymic disorder
Normal grief
Substance-induced mood disorder
Mood disorder secondary to a general medical
condition
• Adjustment disorder
References
• CANMAT Guidelines
• Caplan et al. Mnemonics in a Mnutshell: 32 aids
to psychiatric diagnosis
• Stephan Stahl pharmacology
• Kaplan & Sadock`s Synopsis
• DSM-5
• Toronto Notes
Mood Disorders made overly simple
Important tips
• Must cause clinically significant distress or
impairment in function.
• Always consider substances or general medical
conditions your DDx.
• Cognitive Behavioural Therapy is indicated for
almost everything 
• Know the name and starting dose of at least one
medication from each class
▫ Ei: Citalopram 10mg
Lifetime prevalence
• Major Depressive Disorder
▫ Women 10-25%
▫ Men 5-12%
• Persistent depressive Disorder
▫ 6%
• Bipolar disorder
▫ Type 1: 0.4 – 1.6%
▫ Type 2: 0.5%
History Taking (1)
• Mood disorders are usually episodic
▫ May lead to opposite state
▫ May lead to partial or full remission
• Inquire about current episode and past episodes
▫ Confirms diagnosis
▫ Past Response to treatment
▫ Prognosis
History Taking (2)
• Substance Use and medication
• Family History
• ALWAYS ASK ABOUT SAFETY ISSUES
▫ Suicide
▫ Homicide
▫ Risk to physical health
Mental Status Examination
▫ Psychomotor retardation, catatonic features
▫ Psychomotor agitation such as fidgeting, moving about, handwringing, nail biting, hair pulling, lip biting
▫ Speech (slow  pressured)
▫ Affect
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Type (depressed  euphoric)
Lability
Range (flat  expansive)
Reactivity
▫ Thought process (paucity of content  flight of ideas)
▫ Thought content (worthlessness, hopelessness, grandiosity,
psychotic features, suicidal or homicidal ideation)
▫ Cognition, distractibility
▫ Insight, judgment
Physical Examination
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Vital signs
Weight
Skin (look for previous suicide attempt)
Stigmata of drug and/or alcohol use
Thyroid gland
Cardiopulmonary
GI including liver
Neurological exam (pupils)
Laboratory Workup
• CANMAT = when clinically indicated
• Routine screening
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Complete blood count
Thyroid function test
Liver function test
Electrolytes
B12, folates
Urinalysis, urine drug screen
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Neurological consultation
CXR
EKG
CT-scan
• Additional screening
Common Medical Conditions Associated
With Mood Disorders
• Pulmonary disease (COPD, asthma)
• Endocrine disorders
(Hypo/hyperthyroidism, diabetes)
• Cancer
• Cardiovascular disease, especially MI
• CNS (migraine, infection, tumour, stroke,
head injury, hypoxia)
• Neurological disorders(Epilepsy,
Parkinson's, Huntington's, Multiple
Sclerosis)
• B12, folate deficiency
• Chronic pain, back problems
• Sleep apnea
Drugs Commonly Associated With Mood
Disorders
• Antidepressant & somatic treatments for depression
▫ Manic “switch”
▫ FDA warning, increased suicidality in adolescents
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Psychostimulants
Steroids, corticosteroids
Isotretinoin (Accutane)
Oral contraceptives, progesterone
Interferon A
Parkinson’s Disease agents (mostly psychotic
symptoms)
Specific
Mood
Disorders
Major Depressive Disorder (1)
• Mean age of onset = 30 years
• 50% of all patients have an onset between the
ages 20-50
• At least 1 Major Depressive Episode
• Not better accounted by another disorder,
medical condition or substance
• No Manic, Hypomanic or Mixed episode
Major Depressive Episode (2)
• 5 or more for 2 weeks nearly every day:
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Mood depressed*
Sleep ↑↓
Interest ↓, libido ↓, social withdrawal*
Guilt, hopelessness, worthlessness
Energy ↓
Concentration ↓, indecisiveness
Appetite↑↓, weight ↑↓, loss of taste for food
Psychomotor ↑↓
Suicidal ideation, recurrent thoughts about death
Major Depressive Episode (3)
• Many patients with depression do not report feeling
depressed, but will have loss of interest
• Elderly patients often have new onset of somatic
complaints but may deny feeling depressed
• Patients can also present with panic attacks or obsessivecompulsive symptoms
• Physical symptoms (sleep, appetite, energy level,
psychomotor activity) are often referred to as “vegetative
symptoms”
▫ New onset of these symptoms can be a good predictor
to antidepressant response
Major Depressive Disorder (4)
• Etiology
▫ Genetics (65-75% monozygotic twins)
▫ Neurotransmitter dysfunction
▫ Psychosocial
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Low self-esteem
Negative thinking
Environmental ex: acute stressor
Co-morbid psychiatric disorders ex: substance use
Major Depressive Disorder (5)
• Risk factors
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Female > Male
Age (20-50 years old)
Rural > urban areas
Positive family history
Childhood experiences (loss of parent before age 11,
abuse)
Personality structure
Recent stressors ex: loss of spouse, unemployed
Postpartum
Lack of support network
Major Depressive Disorder (6)
• Treatment
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Pharmacotherapy (ie SSRIs, SNRIs…)
Electroconvulsive therapy
Light therapy if seasonal component
Psychotherapy
 Cognitive behavioral therapy
 Interpersonal therapy (grief, transitions, interpersonal
conflicts or deficits)
▫ Social
 Vocational rehabilitation
 Social skills training
Major Depressive Disorder (7)
• Light to moderate
▫ Psychotherapy, medication depending on patient
preference
• Moderate to severe
▫ Medication with or without psychotherapy,
electroconvulsive therapy (ECT)
• Depression with psychotic features
▫ Combination of antidepressant and antipsychotic,
gold standard is ECT
Ottawa Depression Algorithm
Major Depressive Disorder (8)
• Treat until remission is complete
• Duration of untreated illness affects future
treatment response (untreated depression can
last 6-12 months)
• Maintain treatment to prevent relapse (at least
6-12 months for a first episode)
▫ 50% recurrence after 1 episode
▫ 75% after 2 episodes
▫ > 90% after 3 episodes
Major Depressive Disorder (9)
• Up to 15% of patients with Mood Disorders will
die by suicide
• Prognosis at 1 year
▫ 40% still meet criteria
▫ 20% have partial symptoms
▫ 40% have no mood disorder
Particularities of Depression
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With Atypical Features
With Melancholic Features
With Catatonic Features
With Anxious Distress
With Psychotic Features
With Seasonal Pattern
With Postpartum Onset
Grief & Bereavement
With Atypical Features
• Mood reactivity
▫ Mood brightens in response to actual or potential
positive events
• At least two of
▫ ↑ appetite (carbohydrate cravings), weight gain
▫ Hypersomnia
▫ Leaden paralysis (heavy, leaden feelings in arms
or legs)
▫ Long-standing pattern of interpersonal rejection
hypersensitivity
With Melancholic Features
• At least one of
▫ Anhedonia (inability to find pleasure in positive
things)
▫ Lack of mood reactivity (mood does not improve with
positive events)
• At least three of
▫ Distinct quality of depression subjectively different
from grief
▫ Depression regularly worse in the morning
▫ Early morning awakening (at least 2 hours)
▫ Marked psychomotor agitation or retardation
▫ Severe anorexia or weight loss
▫ Excessive or inappropriate guilt
With Anxious Distress
• At least two of
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Feeling keyed up or on tense
Feeling unusually restless
Difficulty concentrating because of worry
Fear that something awful may happen
Feeling that individual might lose contr0l
With Catatonic Features
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At least 3/12
▫ Decreased motor activity
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Decreased engagement
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Stupor (No psychomotor response to the environment
Catalepsy (Keeps the posture you place them in)
Waxy Flexibility (slight even resistance to mvt)
Posturing (spontaneous and active maintenance of posture against gravity)
Mutism (No verbal response)
Negativism (no response to external stimuli)
Excessive or Peculiar motor activity
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Mannerism (odd circumstancial caricature of normal actions)
Agitation
Grimacing
Stereotypy
Echolalia
Echopraxia
With Psychotic Features
• Psychosis may be present in 10-15% of patients
with a Major Depressive Episode
• Associated with worse prognosis
• Increase risk of suicide and homicide
• Treatment implications
▫ Antidepressant +
antipsychotic
▫ Consider ECT
With Seasonal Pattern
• Regular temporal relationship between onset of
Major Depressive Episode and a particular time
of year, usually fall or winter
• Full remission (or switch to mania) also occurs
at a regular time of year, usually spring
• In the last 2 years, 2 Major Depressive Episodes
have occurred as above with no non-seasonal
episode
• More seasonal episodes than non seasonal
episodes during lifetime of the patient.
With Postpartum Onset
• 10% of postpartum women
• Etiology likely a combination of neuroendocrine
alterations and psychosocial adjustments
• Onset has to be during pregnancy or within 4 weeks after
childbirth (DSM)
• Distinguish from the “baby blues” (70%)
▫ During 10 days postpartum, transient, not impairing
functioning
• Severe ruminations or delusional thoughts about the
infant is associated with significantly increased risk of
harm to the infant
▫ Command hallucinations to kill the infant
▫ Delusional belief that the infant is possessed
Adjustment Disorder (1)
• Development of emotional or behavioural
symptoms in response to an identifiable
stressor (within 3 months)
• Clinically significant
▫ Distress (Out of proportion)
▫ Impairment in function
• Not meeting criteria for another M.I.
• Less than 6 months after end of stressor
Adjustment Disorder (2)
• Specifier
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Depressed mood
Anxiety
Mixed anxiety and depressed mood
Disturbance of conduct
Mixed disturbance of conduct and emotion
Grief & Bereavement (1)
• Normal grief or bereavement reaction versus
Major Depressive Episode
• Complicated or pathological grief or
bereavement (not in DSM-IV)
Grief & Bereavement (2)
• DSM-IV = Normal grief reaction can present
with depressive symptoms as long as it is < 2
months
• Red flags that point towards Depressive Disorder (HIP
GOD)
▫ Hallucinations (Other than hearing the voice/seeing the
deceased person)
▫ IADL/ADL impairement
▫ Psychomotor retardation
▫ Guilt: Unrelated to the loved ones death
▫ Overwhelming morbid preoccupation with worthlessness
▫ Death: Thought of death (other than wanting to have died
with the person.
Grief & Bereavement
Grief
Depression
Comes in waves
Continuous
Preserved self
esteem
Self Loathing
Unlikely to
impair function
Impairment in
function
Persistent Depressive Disorder (1)
• Female > Male (2-3:1)
• Depressed mood for at least 2 years, most days
than not
• Never without the symptoms for more than 2
months at one time
• No Major Depressive Episode is present for the
first 2 years
• Treatment with psychotherapy ±
antidepressants
Persistent Depressive Disorder (2)
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Hopelessness
Energy ↓
Self-esteem ↓
2 years of depressed, for more days than
not (1 year in kids, mood can be irritable)
• Sleep ↑↓
• Appetite ↑↓
• Decision-making ↓, concentration ↓
Premenstrual Dysphoric Disorder
• In the MAJORITY of menstrual Cycles
▫ 5 sx in week before menses and start to improve
within a few days of onset; minimal or absent in
week postmenses.
▫ Lability/irritability/depressed/anxiety
▫ Anhedonia/concentration/lethargy/
appetite/sleep/overwhelmed/physical symptoms
▫ Significant distress
▫ Prospective daily ratings
Premenstrual Dysphoric Disorder
• Lifestyle
▫ Exercise
▫ Decrease ETOH/caffeine
▫ Possible benefits from relaxation and stress
reduction
• Meds
▫ SSRI: similar or lower dose than MDD
 Intermittent vs continuous treatment
Bipolar Disorder (1)
• Bipolar I Disorder = at least 1 Manic or Mixed
Episode
▫ Commonly have more Major Depressive Episodes
but not required for diagnosis
• Bipolar II Disorder = at least 1 Major
Depressive Episode & 1 Hypomanic Episode
 No past Manic or Mixed Episode
• Not better accounted by another disorder, a
general medical condition, a substance or
medication
Bipolar Disorder (2)
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Male = Female (1:1)
Age of onset teens to 20s
Average age for first Manic Episode = 32
Family history of a major Mood Disorder in 6065% of patients with Bipolar Disorder
• Untreated Manic Episode can last 3 months
• Untreated Major Depressive Episode can last 613 months
Bipolar Disorder (3)
• Pharmacotherapy (Bipolar I)
▫ Acute Manic Episode
 Lithium, divalproex, olanzapine,risperidone, quetiapine,
quetiapine XR, Asenapine, aripiprazole, ziprasidone
 Taper and discontinue antidepressants
▫ Acute Major Depressive Episode
 Lithium, lamotrigine, quetiapine, quetiapine XR
 Combo: Li + SSRI or divalproex or buproprion
Divalproex + SSRI or Li or Buproprion
Olanz + SSRI
 Do not use antidepressant as monotherapy
▫ Maintenance treatment
 Lithium, divalproex, olanzapine, quetiapine, risperidone LAI,
aripiprazole (mainly for preventing mania, Lamotrigine
(limited in preventing mania)
With Rapid Cycling
• Can be applied to Bipolar I and II
• At least 4 mood episodes in previous 12 months
(Major depressive, Manic, Hypomanic or Mixed
episodes)
• Episode demarcated by either switch to the opposite
state or 2 months of partial or full remission
between episodes
• Rapid cycling diagnosis has treatment implications
Cyclothymia
• Numerous periods of hypomanic and
depressive symptoms for at least 2 years
• Never without symptoms for more than 2
months
• No Major Depressive, Manic or Mixed episodes
• No evidence of psychotic symptoms
Back to Basics: Suicide
LMCC Objectives
Given a patient with suicidal behavior, the
candidate will determine the degree of risk and
institute appropriate management
LMCC Objectives
• List and interpret critical clinical findings, including
▫ potential contributing conditions identified through an appropriate
history and physical examination;
▫ assessed and quantified risk for suicide, including imminent risk, recent
stresses and life events;
• List and interpret critical investigations, including
▫ illicit drug and alcohol screen, where appropriate;
• Construct an effective initial management plan, including
▫ ensuring the safety of patient at imminent risk for self harm (e.g., urgent
hospitalization), including continuous observation while arrangements
are being made;
▫ assessing capacity to make decisions if patient demands to leave;
▫ initiating management of underlying problems if the risk for suicide is
not imminent (e.g., depression, psycho-social stressor);
▫ maintaining confidentiality while recognizing the benefits of support
networks;
▫ referring the patient for specialized care, if necessary.
Epidemiology
• 1 death every 40 seconds
• 1 attempt every 3 seconds
• In all countries, 1/3 leading cause of death
among 15-34 year olds
• 3 men: 1 Women
Who Data 2000
Distribution of methods by sex
Suicide by age group and sex
Suicide as a percentage of all deaths
by age group
Percentage distribution of method
used in suicide by age group
Etiology
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Biochemical Factors
Genetics and Family Variables
Psychiatric diagnosis
Personality
Psychosocial Environmental Factors
Chronic Medical Illness
Etiology- Biochemical Factors
• 5HT (serotonin) dysregulation
▫ association between aggression, impulsivity and
5HT dysregulation
▫ relative deficiency of 5HT has been found in CNS
of suicide completers
▫ 5HIAA (metabolite of 5HT) is decreased in the
CSF of depressed patients and even more
decreased in suicide attempters and completers
(especially violent suicides)
Genetics
• Roy and colleagues (1991)
• Reviewed the world literature of case reports of
twin suicides
• Found a much higher concordance for suicide
among monozygotic than dizygotic twins (11.3
percent vs. 1.8 percent)
Etiology - Genetic and Family
Variables
• Family history of suicide is a significant risk
factor for suicide
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identification with/imitation of family member
family stress/contagion effect
transmission of genetic factors for suicide
transmission of genetic factors for psychiatric
illness
Psychiatric Illness and Suicide
• 90% of suicide completers have a major
psychiatric illness
▫ 50% to 80% are clinically depressed
▫ 25-50% are substance abusers
• BUT it is a small percentage of patients with
psychiatric illness who commit suicide
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Mood Disorder
Schizophrenia
Alcohol Dependence
Borderline PD
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2 – 8% commit suicide
4 – 5%
5 – 7%
5 – 10%
Bostwick, JM. Pankratz VS. 2000; Hor, K, Taylor, M. 2010; Palmer BA, Pankratz VS, Bostwick JM. 2005;
Inskip HM, Harris EC, Barraclough B, 1998 ; Oumaya M, Friedman S, Pham A, et al. 2008;
Psychiatric Illness and Suicide
• Psychiatric diagnosis in completers tends to vary
with age
• suicide completers <30 years old
▫ substance abuse disorders or antisocial PD
▫ Stressors: separation, rejection, unemployment,
legal troubles
• suicide completers >30 years old
▫ mood disorders and cognitive disorders
▫ Stressors: illness
Personality Traits and Disorders
• Important contributory risk factors
• antisocial and borderline personality disorders
are particularly associated with suicidal
behaviour in adults
• conduct disorder and borderline traits in
adolescent suicides
• add depression to any of these -- lethal
combination
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Decreased social supports
Bereavement
Separation/divorce
Humiliation
▫ interpersonal discord, job loss, impending
disciplinary crisis, threat of incarceration
• Retirement
• Stressful life events
Chronic Medical Illness
• About 5% of suicide completers have serious
physical illness
• elevated suicide rates in patients with
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brain trauma, epilepsy
MS, Huntington’s, Parkinson’s
AIDS, cancer
Cushings, Klinefelter’s syndrome, porphyria
Peptic ulcer, cirrhosis (likely related to Etoh)
Prostatectomy, hemodialysis
• Elevated rates of suicide have been found in
patients with diagnoses of
▫ Neurological disorders
 Seizures, MS, Huntington’s chorea, Brain injury
▫ Cancer
▫ Asthma, bronchitis
▫ CHF
▫ End
stage
renal
disease
Druss,
B., Pincus,
H. 2000;
Jurrlink,
DN, Herrmann N, Szalai JP, et al. 2004; Kurella, M, Kimmel PL,
Young BS, et al. 2005 ;Carrico, A, Johnson, M, Morin, et al., 2007; Berger, D. 1995;
▫ HIV
• The first week after a patient's discharge from a
psychiatric hospital is of particularly high risk
for a suicide (Hunt IM, Kapur N, Webb R, et al. 2009)
▫ 43% of suicides occurred within a month of
discharge
▫ 47% of these patients died before their first followup appointment
• 40% of those who die by suicide have made a
previous attempt (Cavanagh J, Carson A. Sharpe M, et al. 2003)
• Of those who make an attempt
 7% go on to die by suicide
 23% go on to make further attempts
 70% make no further attempts (Owens D, Horrocks J,
House A. 2002)
In children and youth who make a suicide
attempt
▫ 25 to 66% will make another attempt (Stewart SE, Manion IG,
Davidson S, et al. 2001; Rosewater KM, Burr BH.1998)
• Increases risk for suicide
• Study of adolescent suicide completers
▫ Were twice as likely to have firearms in the home
(Brent DA, Perper JA, Allman CJ, et al, 1991)
• Overall, 50.7% of suicide completers use
firearms (Karch DL, Dhalberg LL, Patel N, 2007)
• Highlights importance of removing access to
firearms in the homes of suicidal patients
Attempters vs. Completers
• Difficult to know exactly how many people
attempt suicide
▫ don’t seek help, not reported
• estimates are 8 to 10 attempters for each
completer
• up to 40% or more of attempters have
personality disorders
Suicide Attempters
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Female
Younger
Depression, Alcoholism, Personality D/O
Impulsive
Low lethality (overdose)
High availability of help
Suicide Completers
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Male
Older
Depression, Alcoholism, Schizophrenia
Careful planning
High lethality (firearms)
Low availability of help, socially isolated
30% have history of suicide attempts
Suicide completers
• Approximately 1 in 6 completers leave a suicide
note
• 50% of people who commit suicide have been
seen by a primary care MD within one month
prior to their deaths
• with older suicide victims, this rises to 70%
Risk Factors for Suicide-SADPERSONS scale
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Sex (Male)
Age (very young or very old)
Depression
Previous attempt
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking
Organized plan
No spouse
Sickness (chronic illness)
SADPERSONS Scale
• 1 point for each if present
• 7-10 points then hospitalize or commit
• 5-6 points strongly consider hospitalization,
depending on confidence in follow up
arrangement
• 3-4 points then close follow up, consider
hospitalization
• 0-2 points send home with follow up
Risk Factors
• BUT people don’t kill themselves because
statistics suggest they should
• people kill themselves because of unbearable
psychological pain
• statistics are good for large populations, but not
so good when applied to an individual
• patients can have very few risk factors and still
decide to kill themselves
• Introducing the topic in a sensitive manner
▫ Sometimes when people are feeling down, it can be
hard to get up and greet the day – do you ever feel
this way?
▫ Do you ever feel like you don’t want to go on
living?
▫ Have you ever had thoughts of wanting to end
your life?
▫ Can you tell me about these thoughts?
▫ Have you ever thought of a plan to kill yourself?
• Degree of hopelessness is more
predictive of future suicidal
behaviour than severe depression
▫ Do you have hope that things will get
better?
• Passive
▫ “I wish I could disappear”
▫ “I’d like to go to sleep and not wake up”
▫ “It would be okay with me if I were to be hit by a
bus”
• Active
▫ “I want to die”
▫ I am going to go and kill myself”
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Patient felt their attempt would kill them
Low chance of being found following attempt
Concrete suicidal plans, with access to means
A wish to be reunited with a dead loved one
Putting affairs in order
“Things would be better for everyone if I were
dead”
• Reluctant to communicate and/or accept help
• Lack of social support
When to send suicidal patients to the
Emergency Department
• Acute suicidal ideation
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With plan and intent
With poor social supports
With lack of future orientation
Use of scales from 1-10
Hopelessness
Contracts
• Safety Safety Safety
• If at all unsure about patient’s ability to control
his/her suicidal behaviour, then admit patient to
hospital
• Can admit voluntarily or involuntarily
• Can order a sitter for 1:1 observation on the ward
When to refer suicidal patients to a
mental health professional
• Patients not at imminent risk
• Use of contracts
• Always ensure patient knows they can use the
ED if situation changes
• Ensure close follow up or bridging until
appointment
• No evidence to support “contracting for safety”
▫ Having suicidal patient agree to no longer be
suicidal
• Safety planning makes much more sense
▫ Developed in collaboration with the patient
▫ List of things patient agrees to try when feeling
suicidal
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Potential triggers for suicidal thinking
Potential coping strategies
Social supports
Phone numbers for crisis lines
Instructions on when to return to ED
How to make environment safe (removing
firearms)
• Suicide is a major public health issue
• BUT there is hope!
▫ < 1% of people who have had suicidal ideation go
on to kill themselves
▫ suicidal ideation is transient for most people
• SO, if we an detect the acutely suicidal patient
and provide an alternative that delays the act,
there is a reasonable chance the patient will
change their mind
Ethics and Legal Considerations
Consent to Treatment (1)
• MCC objectives:
▫ Patients who are depressed can meet the criteria
for decision capacity, but their preferences are
clouded by their mood disorder
▫ Overriding the wishes of a seemingly capable
patient who is depressed is a serious matter and is
one situation in which psychiatric involvement
should be sought
▫ Decisions to limit care should be deferred if
possible until depression has been adequately
treated
Consent to Treatment (2)
• MCC objectives (continued):
▫ If time pressures dictate the need to make a
prompt choice, the physician should seek
surrogate involvement
▫ If the surrogate has previously discussed the
patient's wishes at a time when he or she was not
depressed, the surrogate will be able to explain
whether the patient's choice is consistent with
previously stated beliefs or has changed since the
onset of depression
Consent to Treatment (3)
• Specific to the issue
• Informed – no misrepresentation
• Voluntary – no coercion or persuasion
• Capable
Consent to Treatment (4)
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Diagnosis and nature of treatment
Purpose of proposed treatment
Anticipated risks and benefits of treatment
Alternative treatments and their risks and
benefits
• Prognosis, with and without treatment
Duty to Warn & Protect
• Criteria for involuntary admission
▫ Serious bodily harm to himself/herself
▫ Serious bodily harm to another person
▫ Serious physical impairment
• Child in harm’s way  Warn Children’s Aid
Society (CAS)
• Dangerous driving  Warn Ministry of
Transportation (MOT)
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