Innovations In Clinical Neuroscience

SEP-OCT 2014

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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[ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ] Innovations in CLINICAL NEUROSCIENCE 63 someone who says "I have the thoughts but I definitely will not do anything about them" (lines 493–494). 4 This exclusion is p roblematic because there are at least two ways to interpret it. One interpretation is that the patient will not act on the suicidal thoughts in a way that is suicidal (i.e., no suicidal intent). This patient should properly be excluded from the category. But consider a patient who has been thinking for quite a while about "doing something" about these thoughts in terms of seeking treatment. This patient might respond that indeed it is at the top of his mind to do something (i.e., get treatment). In this case, the rater would be forced to include the patient in this category when in fact the patient has no suicidal intent. The authors of this paper have encountered this issue clinically. "Active suicidal ideation: method, intent, and plan." Here, there is a mismatch between the FDA-CASA 2012 title and the definition since the definition only requires intent and plan. This definition is inconsistent with the title since the title requires method as well as intent and plan. "Passive suicidal ideation: wish to be dead." The definition for this category limits passive ideation to "a wish to be dead or not alive anymore, or wish to fall asleep and not wake up" (lines 472–473). 4 But patients may experience passive suicidal ideation in other ways. All three of the authors of this article (D.S., J.G., and K.S.) have frequently heard from patients that they experienced the thought or feeling that they would be "better off dead." Unfortunately, the FDA-CASA 2012 does not allow experiences like this to be captured. In fact, one of the authors of the C–SSRS, on which the FDA-CASA 2012 appears to be based, has specifically stated "[...] we don't consider better off dead to be anything [...]" and should not be counted as suicidal ideation. 16 In addition to feeling they would be better off dead, some patients reported to the first and second authors of this article (D.S. and J.G.) that they felt a need to be dead. 17 This also does not fit the current d efinition of passive suicidal ideation. This restrictive definition limits reporting of passive suicidal phenomena. In our opinion, both of these omitted phenomena should be viewed as danger or warning signals, because they have been shown to be associated with impulsive suicidality. 1 7 OTHER ISSUES Confusing conceptions of passive and active ideation. In general, the phrases "passive suicidal ideation" and "active suicidal ideation" suggest meanings that do not align with the FDA-CASA 2012 category definitions. 4 The word passive suggests that an event or experience is not willful while active suggests a level of willfulness. In the case of passive suicidal ideation, the definition indicates that the patient must have "thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up." 4 This clarification creates confusion for patients and clinicians (personal communication to the authors by suicidal study subjects). How should one classify an event that includes a hallucination about killing oneself that is not at all willful? In our view, different phrases may need to be used to avoid this confusion (e.g., inactive suicidal ideation versus proactive suicidal ideation). Alternately, the observation that willfulness is not central to the distinction between active and passive suicidal ideation needs to be widely communicated in training. Can there be no intent in the presence of a plan within a time frame? Another source of confusion is found in footnote 6 of the FDA 2012 Draft Guidance with the statement "the definition of plan includes intent." 4 Here the document fails to precisely define "plan" and appears to make the assumption that if there is a plan there must be intent. The FDA 2012 Draft Guidance may assert these phenomena are linked; however, in reality a patient can have ideation about a plan, such as the location or date of an attempt, w ithout intending at all to act upon the plan (examples of this may include a suicidal delusion, suicidal hallucination, or suicidal dream). This also raises the issue of the term intent not being defined precisely. The FDA-CASA 2012 definition of the "Active suicidal ideation: method and intent, but no plan" category suggests that intent refers to the intent to act. 4 It is also possible for patients to experience the intent to plan or the intent to die. There is the potential that a patient intends to act years into the future and does not intend to act anytime soon. One is left questioning what combination of these ways of interpreting the word intent the creators of FDA-CASA 2012 intended. The lack of definition of these terms even further complicates the many ways a rater or clinician may interpret the FDA- CASA 2012 categories. The patient's suicidal experience. The FDA-CASA 2012 does not allow a clinician to properly capture the suicidal experience of a patient. It does not enable a clinician to track if the suicidal ideation presented, for example, with impulsivity or as a delusion or a hallucination. There is the potential of one medication effective in treating the suicidality in major depressive disorder to also, at the same time, trigger impulsive suicidality. Some suicidal patients have reported to the first and second authors of this article (D.S. and J.G.) that their experience of suicidality is different while they are taking antidepressants and can "shift" from active suicidal ideation to ideation with more acute urgency and impulsivity that seems more automatic in nature. We believe it is possible that this "shift" in the experience of suicidal ideation may be one reason why younger patients taking antidepressants report an increase in suicidality. If such a change in the experience of the

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