Psychiatric Emergencies in Bipolar and Related Disorders
By Alan C. Swann, MD |
November 1, 2007
Dr Swann is Pat R. Rutherford Jr Professor and
vice chair for research in the department of psychiatry
at the University of Texas Health Science
Center in Houston. An earlier version of this article
originally appeared in Psychiatric Issues in
Emergency Care Settings.
He reports that he receives grant support from
Bristol-Myers Squibb; is a consultant to Abbott,
Bristol-Myers Squibb, AstraZeneca, GlaxoSmith-
Kline, Pfizer, Cyberonis, and Sanofi Aventis; and
is a speaker for Abbott, AstraZeneca, Glaxo-
SmithKline, Eli Lilly, and Sanofi Aventis.
Published evidence for effectiveness in agitation and/or mania supports risperidone(Drug information on risperidone),33 olanzapine,34 ziprasidone,35,36 quetiapine,37 and aripiprazole(Drug information on aripiprazole).38 For rapid treatment, the availability of oral liquid or intramuscular forms is valuable (see Table 3).39,40
Clozapine may be effective in severe, impulsive aggression41; its clinical antiaggressive effects may be partially independent of its antipsychotic effects.42 Furthermore, clozapine(Drug information on clozapine) is most effective as an antipsychotic in more aggressive patients in contrast to risperidone or olanzapine(Drug information on olanzapine).43 Clozapine is not generally a feasible first treatment, however, and the dose cannot be rapidly escalated. The addition of clozapine at low to moderate dosages (average of 150 mg/d) is a valuable potential augmentation strategy for patients who do not experience adequate response to ongoing treatment44; however, because of the need for regular hematological and clinical monitoring, the institution of clozapine is not generally feasible in emergency settings.
Anticonvulsants. Anticonvulsants may work by altering the g-aminobutyric acid (GABA)-excitatory amino acid balance in favor of GABA by protecting against overstimulation, and—when aggression is associated with a seizure disorder or with the potential for alcohol(Drug information on alcohol) or sedative withdrawal— by raising the convulsive threshold. Evidence has shown that valproate(Drug information on valproate) is effective as both an acute and long-term treatment, and it can be administered by rapid oral dose escalation or intravenously.
Valproate has been reported to be effective against impulsive aggression and/or hostility in patients with bipolar disorder45 or borderline personality disorder46 and in adolescents with aggression and labile mood.47,48
Anticonvulsants are generally considered to be suitable for subacute or long-term treatment, although rapid stabilization with intravenous valproic acid has been reported in severe agitation49 and catatonia.50 Rapid escalation of the dose of oral valproic acid can also bring about more rapid resolution of manic episodes.51
Other anticonvulsants, including phenytoin(Drug information on phenytoin) in violent prison inmates52 and carbamazepine(Drug information on carbamazepine) in patients with head injuries,53 have been reported to be effective in reducing aggression or agitation but do not have an onset of action that is rapid enough to warrant emergency use. Gabapentin(Drug information on gabapentin)54 and lamotri- gine55,56 have been reported to cause disinhibition or behavioral activation in some patients, generally in those who have neurological disorders.
Sedatives. Benzodiazepines, generally considered to be the safest sedatives, may reduce agitation and behavioral problems associated with severe overarousal or anxiety.26 Benzodiazepines that are more lipid-soluble can have a relatively rapid onset of action. However, disinhibition can also occur with these agents, especially in patients who are older or who have an organic disorder,57 or in those who have a history of aggressive behavior.58 There is also cross-dependence between benzodiazepines and ethanol, leading to recommendations that benzodiazepines not be used in patients who abuse ethanol.59 Benzodiazepines may act synergistically in combination with antipsychotic agents, making it possible to use lower doses than would be required in using either agent alone.39,60
Benzodiazepines are potentially useful for acute treatment, alone with relatively mild agitation and in combination with antipsychotics in more severe agitation. Cognitive effects, tolerance, and potential for abuse limit the value of subacute or long-term treatment.
Antinoradrenergic agents. Norepinephrine(Drug information on norepinephrine) may be involved in impulsivity or agitation. Drugs that block the binding or release of norepinephrine can be useful, generally as adjunctive treatment. They include clonidine(Drug information on clonidine)61 and β-noradrenergic antagonists.62 Clonidine can be a useful treatment in opiate withdrawal.63 β-Blocking agents have been used both to reduce neurological adverse effects of antipsychotic drugs and to reduce aggressive behaviors. Nadolol was found to reduce extrapyramidal effects and aggressive behaviors relative to placebo.64 Pindolol(Drug information on pindolol) was found to reduce aggression, as measured by the Overt Aggression Scale, but did not alter symptoms of psychosis.65
Transition to maintenance treatment. After patients' acute symptoms have improved, there can be several months during which their functional impairment is still substantial.22 When patients with bipolar disorder decompensate, clinicians should be alert to the possibility that they may be in this stage of illness and that a useful agent may have recently been discontinued too early or too rapidly.
Pharmacological agents for subacute and long-term management
Lithium66 and, perhaps to a lesser extent, serotonin enhancers, including SSRIs, 5-hydroxytryptamine (5HT) 1A agonists, and 5HT2 antagonists26,67 are useful for long-term treatment but are not generally part of emergency treatment because of their slower onset of action and the need for more extensive evaluation before beginning treatment. It may be feasible to start such treatment if a patient has already been taking 1 of these agents and the recent discontinuation is believed to have contributed to the current exacerbation of symptoms. Even then, acute symptoms that are severe enough to result in a psychiatric emergency will probably require other treatments.39 In bipolar disorder, psychosis, or other situations in which overstimulation is prominent, serotonin-enhancing drugs may cause activation or mood destabilization.23 Patients with bipolar disorder should, in essentially all cases, be receiving a mood stabilizer before any antidepressive agent is prescribed. It is somewhat disturbing that one study reported that 32% of patients with positive screens for bipolar disorder were taking an antidepressant alone.68
The decision to add a new long-term treatment should be made in consultation with the patient's regular physician (if available), and a definitive follow-up should be scheduled with the prescribing physician, a collaborator, or preferably, the patient's psychiatrist. Unfortunately, follow-up appointments to monitor or continue new treatment are unlikely to be kept by the patient.69
Combinations of agents with different mechanisms may be more effective than treatment with single agents. The major classes of medications that are used in conjunction with antipsychotics are lithium(Drug information on lithium), anticonvulsants, serotonin-enhancing drugs, and β-noradrenergic antagonists.
Combination therapy may take advantage of regulatory interactions between transmitter systems involved in agitation and impulsivity. For example, increased GABA function might reduce overstimulation.70 GABA interneurons also inhibit the firing of mesolimbic and mesocortical dopamine(Drug information on dopamine)rgic cells.71 Enhancement of GABA function, therefore, might interact synergistically with the dopaminergic receptor blockade in reducing severe agitation, psychosis, or impulsive aggression.71
Antipsychotic treatments have been combined with mood-stabilizing drugs. Lithium was shown to provide a modest benefit when combined with antipsychotic agents.72 Carbamazepine has been used as an adjunct in aggression associated with psychosis or severe agitation, but a critical review of studies that used the drug concluded that the evidence did not support its use, at least in part because of pharmacokinetic interactions.73 Valproate has the best documented results, including augmentation of response to haloperidol(Drug information on haloperidol) and to atypical antipsychotics in placebo-controlled trials.74 These results are consistent with synergistic effects of dopamine blockade and GABA enhancement.71
Sedatives, especially benzodiaze-pines, are commonly combined with antipsychotic medications. A recent study by Allen and associates39 found that physicians generally used conventional antipsychotic agents in combination with benzodiazepines but were more likely to use atypical antipsychotics without benzodiazepines.
Pharmacological and nonpharmacological strategies have synergistic roles in the management of aggressive behavior. Acute and long-term treatments have overlapping but different needs. Staff members must be consistent in communications, in setting limits on patient behavior, and in maintaining appropriate interpersonal boundaries. Patient outcome is influenced by interpersonal styles of nursing staff, with empathic, consistent styles of intervention having better outcome.75,76
The patient should have privacy and an appropriate level of environmental stimulation. In general, this means protection against excessive or variable stimulation. Acutely agitated patients were found to have better treatment outcome in settings in which individual attention was maximized and group interaction was reduced.76 Severe overstimulation can require seclusion and/or restraint, but caveats include medical complications such as hyperthermia and difficulty in monitoring the patient.27
Pharmacological treatments with rapid action can reduce aggression or impulsivity and normalize arousal by shifting the balance of amino acid neurotransmission away from excitatory transmission and toward inhibitory transmission (GABA), reducing dopaminergic activity, enhancing serotonergic function, and/or reducing or stabilizing noradren- ergic effects. Combinations of these approaches, such as GABA enhancement and dopaminergic blockade, may be optimal.
Optimal treatment also requires an appropriate environment, with protection against overstimulation and harm, consistent communication, and effective but empathic limit setting. The same principles apply across many psychiatric emergencies in bipolar disorder. They include empathy and respect for the patient and for his situation, assurance of safety, rapid assessment of medical and behavioral risk, use of all sources of information, treatment of problems that compromise safety and health, and establishment of a more definitive long-term plan.
Long-term success requires effective pharmacological and nonpharmacological treatment of underlying chronic or recurrent illnesses, combined when needed with behavioral strategies aimed at reducing aggressive or impulsive behaviors.
1. Cuesta MJ, Gil P, Artamendi M, et al. Premorbid personality and psychopathological dimensions in first-episode psychosis. Schizophr Res. 2002;58:273-280.
2. Krauthammer C, Klerman GL. Secondary mania: manic syndromes associated with antecedent physical illnesses or drugs. Arch Gen Psychiatry. 1978;35: 1333-1339.
3. Fava GA, Kellner R. Prodromal symptoms in affective disorders. Am J Psychiatry. 1991;148:823-830.
4. Lam D, Wong G, Sham P. Prodromes, coping strategies and course of illness in bipolar affective disorder--a naturalistic study. Psychol Med. 2001;31:1397-1402.
5. Miklowitz DJ. Longitudinal outcome and medication noncompliance among manic patients with and without mood-incongruent psychotic features. J Nerv Ment Dis. 1992;180:703-711.
6. Lieberman PB, Strauss JS. The recurrence of mania: environmental factors and medical treatment. Am J Psychiatry. 1984;141:77-80.
7. Jamison KR. Suicide and bipolar disorder. J Clin Psychiatry. 2000;61(suppl 9):47-51.
8. Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry. 1999;156:181-189.
9. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry. 1985;142:559-563.
10. Swann AC, Dougherty DM, Pazzaglia PJ, et al. Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder. Am J Psychiatry. 2005;162:1680-1687.
11. Simon TR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(suppl 1):30-41.
12. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry. 2003;64:14-19.
13. Barratt ES, Patton JH. Impulsivity: cognitive, behavioral, and psychophysiological correlates. In: Zuckerman M, ed. Biological Basis of Sensation-Seeking, Impulsivity, and Anxiety. Hillsdale, NJ: Lawrence Erlbaum Associates; 1983:77-116.
14. Peterson LG, Peterson M, O'Shanick G, Swann AC. Violent suicide attempts: lethality of method vs intent. Am J Psychiatry. 1985;142:228-231.
15. Goodman LA, Salyers MP, Mueser KT, et al. Recent victimization in women and men with severe mental illness: prevalence and correlates. J Trauma Stress. 2001; 14:615-632.
16. Simon TR, Anderso M, Thompson MP, et al. Assault victimization and suicidal ideation or behavior within a national sample of US adults. Suicide Life Threat Behav. 2002;32:42-50.
17. Dilsaver SC, Chen YR, Swann AC, et al. Suicidality in patients with pure and depressive mania. Am J Psychiatry. 1995;151:1312-1315.
18. Swann AC, Stokes PE, Secunda S, et al. Depressive mania vs agitated depression: biogenic amine and hypothalamic-pituitary-adrenocortical function. Biol Psychiatry. 1994;35:803-813.
19. Kotin J, Goodwin FK. Depression during mania: clinical observations and theoretical implications. Am J Psychiatry. 1971;129:55-62.
20. Schweizer E, Dever A, Clary C. Suicide upon recovery from depression. A clinical note. J Nerv Ment Dis. 1988; 176:633-636.
21. Craig TJ, Ye Q, Bromet EJ. Mortality among first- admission patients with psychosis. Compr Psychiatry. 2006;47:246-251.
22. Sachs GS. Bipolar mood disorder: practical strategies for acute and maintenance phase treatment. J Clin Psychopharmacol. 1996;16(suppl 1):32S-47S.
23. Teicher MH, Glod CA, Cole JO. Antidepressant drugs and the emergence of suicidal tendencies. Drug Saf. 1993;8:186-212.
24. Sachs GS, Yan LJ, Swann AC, Allen MH. Integration of suicide prevention into outpatient management of bipolar disorder. J Clin Psychiatry. 2001;62(suppl 25):3-11.
25. Pinto OC, Akiskal HS. Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder. J Affective Disord. 1998;51:333-343.
26. Allen MH, Currier GW, Hughes DH, et al. The expert consensus guideline series. Treatment of behavioral emergencies. Postgrad Med. 2001;(spec no):1-88.
27. Allen MH, Currier GW. Use of restraints and pharmacotherapy in academic psychiatric emergency services. Gen Hosp Psychiatry. 2004;26:42-49.
28. Cure S, Rathbone J, Carpenter S. Droperidol for acute psychosis. Cochrane Database Syst Rev. 2004;4: CD002830.
29. Gerlach J, Larsen EB. Subjective experience and mental side-effects of antipsychotic treatment. Acta Psychiatr Scand Suppl. 1999;395:113-137.
30. Kinghorn WA, McEvoy JP. Aripiprazole: pharmacology, efficacy, safety and tolerability. Expert Rev Neurother. 2005;5:297-307.
31. Ghelber D, Belmaker RH. Tardive dyskinesia with quetiapine. Am J Psychiatry. 1999;156:796-797.
32. Adverse effects of the atypical antipsychotics. Collaborative Working Group on Clinical Trial Evaluations. J Clin Psychiatry 1998;59(suppl 12):17-22.
33. Chengappa KN, Levine J, Ulrich R, et al. Impact of risperidone on seclusion and restraint at a state psychiatric hospital. Can J Psychiatry. 2000;45:827-832.
34. Tohen M, Jacobs TG, Grundy SL, et al. Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. The Olanzapine HGGW Study Group. Arch Gen Psychiatry. 2000;57:841-849.
35. Keck PE Jr, Versiani M, Potkin S, et al. Ziprasidone in the treatment of acute bipolar mania: a three-week, placebo-controlled, double-blind, randomized trial. Am J Psychiatry. 2003;160:741-748.
36. Brook S. A pilot study of intramuscular ziprasidone in the short-term treatment of patients with acute exacerbation of schizophrenia. Hum Psychopharmacol. 2000; 15:521-524.
37. Bowden CL, Grunze H, Mullen J, et al. A randomized, double-blind, placebo-controlled efficacy and safety study of quetiapine or lithium as monotherapy for mania in bipolar disorder. J Clin Psychiatry. 2005;66: 111-121.
38. Keck PE Jr, Marcus R, Tourkodimitris S, et al. A placebo-controlled, double-blind study of the efficacy and safety of aripiprazole in patients with acute bipolar mania. Am J Psychiatry. 2003;160:1651-1658.
39. Allen MH, Currier GW, Carpenter D, et al. Treatment of behavioral emergencies 2005. J Psychiatr Pract. 2005; 11(suppl 1):5-108.
40. Altamura AC, Sassella F, Santini A, et al. Intramuscular preparations of antipsychotics: uses and relevance in clinical practice. Drugs. 2003;63:493-512.
41. Chengappa KN, Vasile J, Levine J, et al. Clozapine: its impact on aggressive behavior among patients in a state psychiatric hospital. Schizophr Res. 2002;53:1-6.
42. Buckley P, Bartell J, Donenwirth K, et al. Violence and schizophrenia: clozapine as a specific antiaggressive agent. Bull Am Acad Psychiatry Law. 1995;23:607-611.
43. Volavka J, Czobor P, Nolan K, et al. Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or halo-peridol. J Clin Psychopharmacol. 2004;24:225-228.
44. Fehr BS, Ozcan ME, Suppes T. Low doses of cloza-pine may stabilize treatment-resistant bipolar patients. Eur Arch Psychiatry Clin Neurosci. 2005;255:10-14.
45. Swann AC, Bowden CL, Calabrese JR, et al. Pattern of response to divalproex, lithium, or placebo in four naturalistic subtypes of mania. Neuropsychopharmacology. 2002;26:530-536.
46. Hollander E, Tracy KA, Swann AC, et al. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology. 2003;28:1186-1197.
47. Donovan SJ, Stewart JW, Nunes EV, et al. Divalproex treatment for youth with explosive temper and mood lability: a double-blind, placebo-controlled crossover design. Am J Psychiatry. 2000;157:818-820.
48. Steiner H, Petersen ML, Saxena K, et al. Divalproex sodium for the treatment of conduct disorder: a random- ized controlled clinical trial. J Clin Psychiatry. 2003;64: 1183-1191.
49. Vitiello B, Behar D, Hunt J, et al. Subtyping aggression in children and adolescents. J Neuropsychiatry Clin Neurosci. 1990;2:189-192.
50. Kruger S, Braunig P. Intravenous valproic acid in the treatment of severe catatonia. J Neuropsychiatry Clin Neurosci. 2001;13:303-304.
51. McElroy SL, Keck PE, Jr, Stanton SP, et al. A randomized comparison of divalproex oral loading versus haloperidol in the initial treatment of acute psychotic mania. J Clin Psychiatry. 1996;57:142-146.
52. Barratt ES, Stanford MS, Felthous AR, Kent TA. The effects of phenytoin on impulsive and premeditated aggression: a controlled study. J Clin Psychopharmacol. 1997;17:341-349.
53. Chatham-Showalter PE. Carbamazepine for combativeness in acute traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1996;8:96-99.
54. Posey DJ, McDougle CJ. The pharmacotherapy of target symptoms associated with autistic disorder and other pervasive developmental disorders. Harv Rev Psychiatry. 2000;8:45-63.
55. Devarajan S, Dursun SM. Aggression in dementia with lamotrigine treatment. Am J Psychiatry. 2000;157: 1178.
56. Beran RG, Gibson RJ. Aggressive behaviour in intellectually challenged patients with epilepsy treated with lamotrigine. Epilepsia. 1998;39:280-282.
57. Little JD, Taghavi EH. Disinhibition after lorazepam augmentation of antipsychotic medication. Am J Psychiatry. 1991;148:1099-1100.
58. Ben Porath DD, Taylor SP. The effects of diazepam (valium) and aggressive disposition on human aggression: an experimental investigation. Addict Behav. 2002; 27:167-177.
59. Hollister LE. Interactions between alcohol and benzodiazepines. Recent Dev Alcohol. 1990;8:233-239.
60. Garza-Trevino ES, Hollister LE, Overall JE, Alexander WF. Efficacy of combinations of intramuscular antipsychotics and sedative-hypnotics for control of psychotic agitation. Am J Psychiatry. 1989;146:1598-1601.
61. Janicak PG, Sharma RP, Easton M, et al. A double-blind, placebo-controlled trial of clonidine in the treatment of acute mania. Psychopharmacol Bull. 1989; 25: 243-245.
62. Haspel T. Beta-blockers and the treatment of aggression. Harv Rev Psychiatry. 1995;2:274-281.
63. Pozzi G, Conte G, De Risio S. Combined use of trazodone-naltrexone versus clonidine-naltrexone in rapid withdrawal from methadone treatment. A comparative inpatient study. Drug Alcohol Depend. 2000;59:287-294.
64. Allan ER, Alpert M, Sison CE, et al. Adjunctive nadolol in the treatment of acutely aggressive schizophrenic patients. J Clin Psychiatry. 1996;57:455-459.
65. Caspi N, Modai I, Barak P, et al. Pindolol augmentation in aggressive schizophrenic patients: a double-blind crossover randomized study. Int Clin Psychopharmacol. 2001;16:111-115.
66. Grof P, Grof E. Varieties of lithium benefit. Prog Neuropsychopharmacol Biol Psychiatry. 1990;14:689-696.
67. Fava M. Psychopharmacologic treatment of pathol- ogic aggression.. Psychiatr Clin North Am. 1997;20: 427-451.
68. Frye MA, Calabrese JR, Reed ML, et al. Use of health care services among persons who screen positive for bipolar disorder. Psychiatr Serv. 2005;56:1529-1533.
69. Ernst CL, Bird SA, Goldberg JF, Ghaemi SN. The prescription of psychotropic medications for patients discharged from a psychiatric emergency service. J Clin Psychiatry. 2006;67:720-726.
70. Soltis RP, Cook JC, Gregg AE, Sanders BJ. Interaction of GABA and excitatory amino acids in the basolateral amygdala: role in cardiovascular regulation. J Neurosci. 1997;17:9367-9374.
71. Benes FM. The role of stress and dopamine-GABA interactions in the vulnerability for schizophrenia. J Psychiatr Res. 1997;31:257-275.
72. Juhl RP, Tsuang MT, Perry PJ. Concomitant administration of haloperidol and lithium carbonate in acute mania. Dis Nerv Syst. 1977;38:675-676.
73. Leucht S, McGrath J, White P, Kissling W. Carbamazepine for schizophrenia and schizoaffective psychoses. Cochrane Database Syst Rev. 2002;3:CD001258.
74. Wassef AA, Hafiz NG, Hampton D, Molloy M. Divalproex sodium augmentation of haloperidol in hospitalized patients with schizophrenia: clinical and economic implications. J Clin Psychopharmacol. 2001;21:21-26.
75. Lancee WJ, Gallop R, McCay E, Toner B. The relationship between nurses' limit-setting styles and anger in psychiatric inpatients. Psychiatr Serv. 1995;46:609-613.
76. Melle I, Friis S, Hauff E, et al. The importance of ward atmosphere in inpatient treatment of schizophrenia on short-term units. Psychiatr Serv. 1996;47:721-726.
77. Dilsaver SC, Chen YR, Swann AC, et al. Suicidality, panic disorder, and psychosis in bipolar depression, depressive-mania, and pure mania. Psychiatry Res. 1997; 73:47-56.
78. Coryell W, Leon AC, Turvey C, et al. The significance of psychotic features in manic episodes: a report from the NIMH collaborative study. J Affect Disord. 2001;67: 79-88.
79. Schatzberg AF, Rothschild AJ. Psychotic (delusional) major depression: should it be included as a distinct syndrome in DSM-IV? Am J Psychiatry. 1992;149:733-745.
80. Smith KM, Larive LL, Romanelli F. Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and g-hydroxybutyrate. Am J Health Syst Pharm. 2002;59:1067-1076.
81. Fergusson DM, Horwood LJ, Swain-Campbell NR. Cannabis dependence and psychotic symptoms in young people. Psychol Med. 2003;33:15-21.
82. Freedman R, Schwab PJ. Paranoid symptoms in patients on a general hospital psychiatric unit. Implications for diagnosis and treatment. Arch Gen Psychiatry. 1978; 35:387-390.
83. Dalton EJ, Cate-Carter TD, Mundo E. Suicide risk in bipolar patients: the role of co-morbid substance use disorders. Bipolar Disord. 2003;5:58-61.
84. Links PS, Heslegrave RJ, Mitton JE, et al. Borderline personality disorder and substance abuse: consequences of comorbidity. Can J Psychiatry. 1995;40:9-14.
85. Beck AT, Steer RA, Trexler LD. Alcohol abuse and eventual suicide: a 5- to 10-year prospective study of alcohol-abusing suicide attempters. J Stud Alcohol. 1989; 50:202-209.
86. Fishbein DH, Herman-Stahl M, Eldreth D, et al. Mediators of the stress-substance-use relationship in urban male adolescents. Prev Sci. 2006;7:113-126.
87. Sher L, Oquendo MA, Galfalvy HC, et al. The relationship of aggression to suicidal behavior in depressed patients with a history of alcoholism. Addict Behav. 2005; 30:1144-1153.
88. King EA, Baldwin DS, Sinclair JM, et al. The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides. Br J Psychiatry. 2001;178:531-536.
89. Beck AT, Brown G, Berchick RJ, et al. Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry. 1990;147: 190-195.
90. Beck AT, Brown GK, Steer RA, et al. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav. 1999;29: 1-9.
91. Brent DA, Oquendo M, Birmaher B, et al. Familial pathways to early-onset suicide attempt: risk for suicidal behavior in offspring of mood-disordered suicide attempters. Arch Gen Psychiatry. 2002;59:801-807.
92. Scocco P, Marietta P, Tonietto M, et al. The role of psychopathology and suicidal intention in predicting suicide risk: a longitudinal study. Psychopathology. 2000;33: 143-150.
93. Koller G, Preuss UW, Bottlender M, et al. Impulsivity and aggression as predictors of suicide attempts in alcoholics. Eur Arch Psychiatry Clin Neurosci. 2002;252: 155-160.
94. Stanniland C, Taylor D. Tolerability of atypical antipsychotics. Drug Saf. 2000;22:195-214.
SearchMedica SEARCH RESULT
Find peer-reviewed literature and websites for practicing medical professionals