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Needs Assessment: Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are prescribed as first-line treatments for depression and other medical and psychiatric disorders.
CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities.
This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine. To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation.
The selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, drugs originally introduced as treatments for depression, are now extensively prescribed for a variety of other medical and psychiatric disorders as well. The introduction of selective serotonin reuptake inhibitors (SSRIs) in the 1980s revolutionized the treatment of depressive illness.
It is difficult to arrive at accurate estimates of the true incidence of antidepressant side effects in clinical practice, even if the drugs are extensively prescribed. Once a drug has been approved, it is assumed to be safe, and reports of safety and tolerability problems arise from the clinical setting. The examples of less common but potentially serious side effects that follow are discussed because there are a sufficient number of cases reported in the literature to warrant further scrutiny about their effects on important aspects of diverse physiologic systems. Platelets cannot synthesize aggregtion and serotonin; they store serotonin and release it in response to vascular injury, causing changes to the shape of the platelets. Movig and colleagues6 presented evidence of the clinical relevance of bleeding and SSRIs in the surgical setting.
Most cases of SSRI- or SNRI- associated bleeding events are not life threatening (eg, bruising, heavy menses, and gastrointestinal bleeds. Unfortunately, there is little to no guidance in the literature as to how to avoid potential bleeding problems with these drugs.
In mild cases, management of the syndrome of inappropriate antidiuretic hormone involves discontinuing the medication (if possible) and water restriction.
In 1997, Amsterdam and colleagues14 reported significant rates of breast enlargement among women during treatment with SSRIs and venlafaxine. SSRI-associated gynecomastia can occur in males and is probably related to degree of reuptake inhibition.
Severe hypertriglyceridemia secondary to SSRIs and SNRIs has been reported frequently in the literature.18 In one case series,19 cholesterol levels were measured during an 8-week trial of paroxetine in healthy men. Increases in LDL cholesterol levels have been reported among patients taking SSRIs for panic disorder.
In the same study, the effect of a challenge with an inflammatory agent that stimulated osteoclast-mediated bone resorption was investigated. Two major studies published in 2007 raised alarms because they were prospective, involved human subjects (not mice), were large (involving thousands of patients), and showed that there was significant bone loss among the elderly taking SSRIs. Unlike the neuroleptic malignant syndrome associated with use of antipsychotics, serotonin toxicity (ie, serotonin syndrome) is not idiosyncratic, but an extension of the SSRIs and SNRIs pharmacologic effect.
Most often the sydrome is dose dependent, often occurring at high doses when combining these drugs with other serotonergic agents or adding serotonergic agents to ongoing SSRI therapy.
A potentially frequent drug combination in clinical practice is the use of a triptan to treat migraine along with an SSRI or SNRI to treat anxiety, depression, or pain. One report27 presents evidence that the SSRIs may have varying degrees of spermicidal and antitrichomonas activity in vitro.
Treatment-emergent physiologic changes associated with use of SSRIs and SNRIs, while rare, are nevertheless clinically significant.
Needs Assessment: Suicide prevention is a public health priority but is hampered by the scarcity of data on the relationship between ethnicity and suicidal behaviors. This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Suicide is one of the leading causes of death, and suicidal ideation and attempts are a major public health concern. Studies have consistently documented that women2-5 and young adults2,5-7 are at increased risk for suicidal behavior. This article uses the five racial classifications used by the US Census Bureau to collect and present federal data on race and ethnicity.
Although the reasons for the high rates of suicidal ideation and attempts among American Indians are unknown, they are likely related to the high prevalence of depression, substance use disorders, including alcohol, and posttraumatic stress disorder in this population.44,45 Chester and collegues45 studied 235 off-reservation Native Americans and found high rates of mental health problems, but low levels of service use. Some studies have found that a greater percentage of American Indians had attempted suicide in their lifetime than had reported suicidal ideation or planning.
Regarding subgroups within the Black community, Joe and colleagues16 reported that the lifetime prevalence of suicide attempts among Caribbean black men (7.5%) was the highest among the four ethnic-sex groups analyzed (African American and Caribbean American men and women). The variability in suicide attempt rates across Hispanic subgroups is consistent with the differences in the prevalence of major depressive disorder (MDD) observed among Hispanic subgroups. Acculturation may also be related to suicidal behavior among Hispanics.10,67 Fortuna and colleagues10 observed that different aspects of acculturation, such as language spoken as a child, current English proficiency, and parental US nativity may be risk factors for suicidal behaviors.
The findings of studies examining suicide attempt and suicidal ideation rates in specific ethnic groups should be viewed with two limitations in mind.
The published studies indicate that the prevalence of suicidal ideation and attempts vary widely across ethnic groups.
Another key issue is the identification of protective factors that may act upon individuals of different ethnicities and may help explain the lower rates of suicide attempts found among some of them.
Despite recent progress in the area, the examination of the relationship between ethnicity and suicidal ideation and attempts is still in its infancy. Telemedicine is generally viewed as use of video conferencing in the delivery of health care.
The 1990s were the beginnings of telemedicine that grew along side of the development of the World Wide Web.
One of the major benefits of telemedicine is its ability to reach special populations such as rural patients who need deaf services.
Zarate and colleagues3 studied the use of video conferencing for evaluating patients with schizophrenia, with particular emphasis on the impact of the video quality on assessment rating measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS), and the Scale for the Assessment of Negative Symptoms (SANS). Shea and colleagues,4 in the Informatics for Diabetes Education and Telemedicine project, studied the difference in diabetes management for usual care versus telemedicine intervention in an older, ethnically-diverse, and medically underserved patient population in New York City. Video transmission standards have made it possible to decrease costs by utilizing public networks such as the Internet in lieu of direct connections as well as utilizing different equipment at each site. Although the Internet provides an existing and inexpensive infrastructure to conduct telemedicine, security is of concern. Backup systems need to be in place to address potential failures in areas such as data transmission, video and audio, and power. Nesbitt and colleagues15 noted that in California, reimbursement was one barrier to the use of telemedicine, and in 1996, the Welfare and Institutions Code 14132.72 was passed that mandated reimbursement of telemedicine services. Licensure is a particularly significant barrier to the adoption of telemedicine by many practitioners.
Emergencies, disasters, accidents, injuries, and crime can occur without warning at any time. Activities you usually do during a normal day such as getting in and out of bed, bathing, dressing, eating, and using the bathroom.
Employee of nursing home who helps coordinate admission of new residents into their nursing home.
A federal agency that oversees the regulation of nursing facilities that are paid with medical assistance (Medicaid) or Medicare funds.
A determination that a nursing facility meets the federal care standards for operating a home with medical assistance or Medicare funds.
CNA’s are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom. Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or a chair, moving around, and using the bathroom. The social worker at the hospital or rehabilitation facility who helps find the right nursing home for a patient and coordinates the transfer of that patient into a nursing home.
A joint federal and state program that helps with medical costs for eligible Rhode Islanders based on income and assets.
The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease.
Division of the Rhode Island Department of Health that inspects and regulates nursing homes. A pay-per-visit health plan that lets you go to any doctor, hospital or other health care provider who accepts Medicare.
A group of residents in a nursing home who meet regularly to improve the quality of life in their facility. A State program that gets money from the Federal Government to give free health insurance counseling and assistance to people with Medicare. A State agency that is in charge of the State’s Medicaid program and can provide information about programs to help pay medical bills for people with low incomes. The periodic inspection of a nursing home by staff of the Rhode Island Department of Health, Division of Facilities Regulation. The Ontario Mass Evacuation Plan is a supporting plan to the Provincial Emergency Response Plan (PERP). For more information on the legislative framework and authorities, see the PERP available on the EMO website.
This plan supports the agreement between the Governments of Ontario and Canada (through the Department of Aboriginal Affairs and Northern Development Canada) to provide emergency response support to First Nation communities in the province. An EMO planning team in consultation with non-governmental organizations, provincial and federal partners developed the plan. This plan is meant to be used to respond to a request for a partial or complete evacuation from one or more communities to one or more host communities. Provincial coordination will involve the evacuating community, host communities, relevant Ontario ministries, federal departments, non-governmental organizations, and others, as required. This plan is for Ontario’s far north, encompassing municipalities, unorganized territories2 and First Nation communities. This is an overarching plan for carrying out mass evacuations and as such, many aspects are general in nature4.
The Far North of Ontario spans the width of the province, from Manitoba in the west, to James Bay and Quebec in the east.
The far north is subject to several hazards covered under Ontario’s Hazard Identification and Risk Assessment. The geography of the far north may complicate evacuations or efforts to manage or suppress the hazard. Maintain family and community unity, which is integral to maintaining community cohesion and supports. Potential threats to the communities and emergency responders are critical in determining the urgency of the evacuation and for planning resource mobilization.
Real-time threat assessment should be ongoing and coordinated among partners, particularly ministries with relevant OIC responsibilities and the community(ies) at risk.
An OIC ministry or the PEOC may recommend evacuation, or that it is safe to return, based on a real-time threat assessment.
The availability, duration, type, and location of host community facilities affect planning for the evacuation.
Consideration should be given to maintaining the readiness of host communities for future hosting.
Evacuating communities should identify Community Evacuation Liaisons for each host community. The decision to deploy is typically based on requests from impacted communities, the mandate of the organization deploying staff, and staff member’s level of expertise.
Depending on the scale and complexity of the operation, a senior provincial official may be deployed to coordinate the provincial response and to liaise with community and other deployed officials. Situational awareness requires continuous coordination to help collect, collate, evaluate, and disseminate information.
When planning for the return of evacuees, the number and location of host communities, and the distance to evacuated communities are key planning considerations. Roles and responsibilities may pertain to transportation hubs, host communities, support from ministries or the federal government, or responsibilities of evacuating communities. Determine the financial and legislative roles and responsibilities for the evacuation and comply with applicable policies, agreements, procedures, etc.
Emergency information needs to be coordinated among the affected communities, province, and federal government.
Once it has been decided that a community needs complete or partial evacuation, the parties involved must establish who the evacuees are, where the host locations are, and what the means of evacuation will be. Following the judgement of the authorized entity that it is safe for evacuees to return, the order of return and the methods of transportation must be established using an inclusive planning process that involves affected communities, provincial and federal partners, and other partners (i.e. Real-time threat assessment is a critical component of evacuation operations and should be ongoing. All responders involved in managing the hazard or participating in the evacuation must regularly communicate situational awareness information to those conducting real-time threat assessments and must report a changing situation as soon as feasible. OIC ministries are responsible for assessing the threat for the types of emergencies they have been assigned. EMO is responsible for real-time threat assessments for hazards that have not been assigned to an OIC ministry.
The PEOC is responsible for assessing the threat based on the real-time threat assessment and characteristics of the community(ies) or region under threat.
During routine monitoring, the PEOC duty officer performs the function of real-time threat assessment. OIC ministries routinely monitor conditions in the province according to their assigned type of emergency.
Uncertainty in real-time threat assessment is unavoidable, which is why persons with appropriate knowledge of the threat causing the emergency should be involved in the assessment. During emergencies, the PEOC links with the local community and the OIC ministry acting as provincial lead to coordinate real-time threat assessment information.
Emergency managers must understand the makeup of the population who are to be evacuated before they can make key decisions about transportation modes, route selections, hosting destinations, and the many other elements of an evacuation. Medevac is used for those individuals receiving home care or residing in a health-care facility in the evacuating community that qualify for medical transfer as per the Ambulance Act (evacuation by emergency medical services (EMS) or Ornge). This stage is typically orchestrated through the existing health procedures used in the community. This includes persons with disabilities, seniors, children, pregnant women, and those with medical conditions. Among these, some require attendant care, which means both the caregiver and the Stage 1 evacuee they care for should be on the Stage 1 evacuation list. The designation of evacuees into the different stages will be determined by the First Nation Chief and Council, Head of Council, or appointed person, with the assistance of the on-site health care organization. Different types of hazards may dictate variations in the criteria for these categories (e.g.
The decision to evacuate a community is the responsibility of the First Nation Chief, Head of Council, or appointed person.
For First Nations communities, AANDC and PS approve federal assistance to support an evacuation.
The urgency of an evacuation is determined based on the immediacy of the threat to the community (life, safety, health, and welfare), the resilience of the community, and (depending on the nature of the threat) the availability of resources for evacuation or shelter-in-place10. Evacuations may take place prior to (pre-emptive), during, or after an incident has occurred.
Given adequate warning about a hazard, adequate resources, and the likelihood of the threat actually impacting a community, it is advisable to conduct pre-emptive evacuations.
If adequate resources are not available to conduct a pre-emptive evacuation, it may still be possible and necessary to carry out an evacuation even while a threat is already affecting a community. If recommending enhanced monitoring or activation of the PEOC, consider what positions must be staffed to conduct the evacuation. Alert PS of the situation and advise them if Government of Canada support may be required to assist.
Establish a regular information cycle and contact for evacuating communities, host communities, and other parties assisting with the evacuation. Consider requesting additional host communities stand-by to receive evacuees if the situation appears likely to escalate rapidly.
Establish the PEOC Command, and if it is an area or unified command, consider including additional organizations in the command meetings to better inform and coordinate the response.
Determine financial accountabilities in consultation with partners and communicate the information. Determine at the outset of the operations which organization will be responsible for information management and the manner in which information will be shared.
Initiating media contacts or directing the appropriate position to do this according to established plans and procedures (e.g. Adopting an extended operational cycle in which extra positions are staffed beyond the normal working day.
Alerting other emergency responders in the province, including non-governmental organizations, that they may be requested to provide assistance. Marshalling transportation resources, including the recall of deployed resources in preparation for redeployment. Collecting and analyzing the data necessary to fully understand the potential impact and threat.
Weather, resource availability, and the scale of an incident can significantly affect the time required to mobilize resources.
Emergency information is primarily the community’s responsibility, but may be supplemented by the province according to the provisions of the Provincial Emergency Information Plan. Communications between the field and the PEOC, between the PEOC and partners, and within the PEOC is critical.
The PEOC (or other EOC) may request deployments to fulfil specific incident management functions, as needed (e.g. Where the scale of the incident, evacuation timeline, or availability of staff prevents the physical deployment of staff, relevant incident management functions may be performed remotely using available technology.
Information technology in the far north is not universally accessible and may be further compromised by the nature of the emergency.
All partners (but with specific reference to PEOC) should recognize the potential limitations to information technology in these regions of the province. The priorities for evacuation will be determined by the Chief and Council (for a First Nation), the Head of Council (for a municipality), or an authorized entity.
Transportation planning for the evacuation will be undertaken by a joint planning team as described in Annex 7.
The evacuating community should identify community evacuation liaisons at each of the host community sites to support evacuees. If an evacuation involves a First Nation community, the JEMS Service Level Evacuation Standards provides a sample flight manifest.
Service Level Evacuation Standards11 are in place for hosting First Nations community members in the event of an evacuation.
Through the PEOC, EMO works with the evacuating First Nation to identify a host community or communities for its evacuees. The selection and preparation of host facilities should be driven by the needs of the evacuees. Another key consideration is the availability of personnel and other resources to support the host facilities.
Potential conflicts with the longer-term use of accommodations in the host community should be considered and mitigated if possible (e.g. The PEOC should begin contingency planning with partners for longer-term evacuations if it appears likely that evacuees will be displaced from their community for longer than the period discussed below. When evacuees are members of a First Nation, the use of any facility that was used as, or could evoke comparisons to, residential schools should be avoided.
Communities considering acting as a host community during an evacuation should identify emergency shelter facilities.
Short-Term Basic Shelter Services: for a period of 1-14 days, in arenas, gymnasiums, recreation halls, etc.

Special Accommodations: to address the requirements of medically vulnerable individuals or those with special needs. Host communities may be limited in the types of accommodations that they are able to provide. Planning for hosting evacuees builds on information already available (typically from the manifest).
Host communities are responsible for registering evacuees that are entering into their care. Registration records should only be shared with organizations providing services to the evacuees (e.g.
Before the return of evacuees, the evacuated community should be in a safe and ready state. Services have resumed and are sufficient to support returning evacuees – for example, power, water, sanitation, security, food and essential supplies, and medical services.
If a community was completely evacuated it may be advisable to begin the return of evacuees with essential workers to restart systems and assess the readiness of the community to receive other returning evacuees. Once approval has been given for all or a part of the population to return home, community leaders, working with community evacuation liaisons, will develop priorities and manifests for the return flights. Ground transportation arrangements may be made by the host community or the provincial government. The evacuated community will take the lead for communicating re-entry procedures, with assistance from partners as required. What media sources can evacuees use for the most up-to-date information on re-entry procedures? Following a regional evacuation, multiple communities may decide at the same time that they are ready to return evacuees.
The PEOC and partners will commence demobilization as host communities are cleared of evacuees. The Quick Reference Guide is a condensed version of the Ontario Mass Evacuation Plan Part 1: Far North. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylo- coccus aureus infections in adults and children. How do you treat an abscess in the era of increased community-associated methicillin-resistant Staphylococcus aureus (MRSA)?
Diagnostic and therapeutic evaluation of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA) skin and soft tissue infections in the emergency department.
While most side effects are relatively minor, some uncommon complications may present in a medical or surgical context. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Physicians should only claim credit commensurate with the extent of their participation in the activity. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Hollander reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Sussman is the editor of this journal as well as professor of psychiatry and associate dean for Postgraduate Medical Programs at New York University School of Medicine in New York City.
Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Their appeal as first-line agents derives from their simplicity of use and relative absence of life-threatening side effects. Better tolerated in terms of cholinergic and cardiovascular side effects, safer in overdose, and effective in treating a broad range of anxiety disorders, the SSRIs supplanted not only older classes of antidepressants such as the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors, but anxiolytics such as benzodiazepines as well. Even rigorous clinical trials routinely fail to detect treatment emergent events that are quite common. For example, patients who suffer from mild depression (ie, Hamilton Rating Scale for Depression score <18), those with a history of non-response to antidepressant treatment, and placebo cannot be enrolled. This article covers bleeding abnormalities, hyponatremia, hormonal disturbances, lipid elevation, bone loss, serotonin syndrome, and male reproductive effects. SSRIs and SNRIs inhibit the serotonin transporter (responsible for the uptake of serotonin into platelets), depleting platelet serotonin. Their study of 520 patients admitted for orthopedic surgery found that patients on SSRIs had twice the volume of intra-operative blood loss and an odds ratio (OR) of 3.7 for requiring blood transfusions during the admission.
In one published case report20 of a patient with panic disorder before and after successful treatment with sertraline, fasting baseline concentrations of serum total (total-C), low-density lipoprotein (LDL-C), and high-density lipoprotein cholesterol (HDL-C) and triglycerides were determined prior to and after successful naturalistic treatment with SSRIs in 11 medically healthy patients.20 All patients studied were free of psychotropic medication and were not heavy smokers, coffee drinkers, excessive alcohol users, or street drug users.
There have been numerous animal studies showing an interaction between the inhibition of serotonin reuptake and osteoblast (bone-forming cells) and osteoclast (bone resorbing cells). The effect of on bone loss following a lipopolysaccharide (LPS)-mediated inflammatory challenge was also investigated.
One study was an investigation of 2,722 women with an average age of approximately 80 years.22 Checks on bone mineral density were made initially and again approximately 5 years later. Ostensibly, it is caused by an excess of serotonin, with the susceptibility to this side effect varying considerably among individuals, with some patients experiencing symptoms even at modest therapeutic doses of a single agent at the start of treatment. Adding some opioids such as meperidine, fentanyl, tramadol, and pentazocine to SSRIs and SNRIs has been associated with the serotonin toxicity. Concurrent use of a triptan and an SSRI or SNRI is normally uneventful, but serotonin toxicity occurs occasionally. The best approach is to be aware of potential interactions, and weigh the benefits and risks of treatment.
Several recent reports raise the possibility that SSRIs and SNRIs may have an effect on sperm. The possibility of these side effects should not deter clinicians from diagnosing and treating depression or anxiety with these a drugs. Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something? Relationship of serotonergic antidepressants and need for blood transfusion in orthopaedic surgical patients. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. Association of risk of abnormal bleeding with degree of serotonin reuptake inhibition by antidepressants. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs.
Hyperprolactinemia and galactorrhea induced by serotonin and norepinephrine reuptake inhibiting antidepressants. Effects of selective serotonin reuptake inhibitors on cholesterol levels in patients with panic disorder.
Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Association of low bone mineral density with selective serotonin reuptake inhibitor use by older men.
Serotonin syndrome from the interaction of cyclobenzaprine with other serotoninergic drugs.
The fda alert on serotonin syndrome with combined use of ssris or snris and triptans: an analysis of the 29 case reports. An important first step is to identify groups at increased risk for suicidal ideation and attempts. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest. Perez-Rodriguez is clinical researcher in the Department of Psychiatry at Ramón y Cajal University Hospital in Madrid, Spain. Perez-Rodriguez, Baca-Garcia, and Oquendo report no affiliation with or financial interest in any organization that may pose a conflict of interest. In contrast, much less is known about the relationship between ethnicity and suicidal ideation and attempts.
The article reviews the rate of suicidal ideation and attempts across races and ethnic groups in the US as well as the specific risk factors associated with suicide attempts in each race and ethnic group. In a study of a sample of urban Native Americans ≥50 years old, 31% of those who had been physically abused and 12% of those who had not been abused reported a history of depression or suicide attempts. Among women, the rate of hospitalization for suicide attempts was highest among Whites, while rates for Asian and African American women were lower (Table 1). The authors of this article have not found any other studies comparing suicide attempts in different groups within the African American community. Non-Hispanic Whites and Puerto Ricans have higher rates of MDD compared to other Hispanic ethnic groups.9,65 Fortuna and colleagues10 observed that any lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,66 psychiatric diagnoses were associated with an increased risk of lifetime suicidal ideation and suicide attempt among Hispanics. The prevalence of suicidal ideation and attempts appear to be higher among Puerto Ricans and Mexican Americans17 with higher levels of acculturation than among those with lower levels of acculturation. First, some of the groups analyzed are heterogeneous in terms of ethnicity, geography, acculturation, education, migration patterns, socioeconomic status, and access to health care.9,10 The second limitation is that studies have different designs and target populations. However, many of these studies were focused on a single ethnic group or used relatively small or local samples sizes, suggesting caution in their interpretation.
More research is needed to examine which aspects of the prevention programs can be universally applied and which have to be tailored for the specific target groups. For example, Oquendo and colleagues69 found that several factors protective against suicidal behaviors (those regarding survival and coping beliefs, responsibility to family, and moral objections to suicide) were significantly more common among Hispanics than non-Hispanics. As the ethnic diversity of the US continues to increase, the identification of common and specific risk and protective factors for suicidal ideation and attempts and the development of effective preventive interventions offer important opportunities and challenges for clinicians, researchers, and policy-makers.
Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Suicide ideation and attempts in Hispanics and non-Hispanic whites: demographic and psychiatric disorder issues.
Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the United States.
Prevalence and correlates of lifetime suicidal ideation and suicide attempts among Latino subgroups in the United States. Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population.
Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States. Prevalence of suicide attempts in a Mexican-American population: prevention implications of immigration and cultural issues. Suicidal ideation and suicide attempts among Mexican Americans, Puerto Ricans and Cuban Americans.
Outcome evaluation of a public health approach to suicide prevention in an American Indian tribal nation. Health care utilization as a marker for suicidal behavior on an American Indian Reservation.
Additive impact of childhood emotional, physical, and sexual abuse on suicide attempts among low-income African American women.
Similarities and differences in precipitating events between black and anglo suicide attempts. Social environment factors associated with suicide attempt among low-income African Americans: the protective role of family relationships and social support. Childhood, adolescent, and young adult predictors of suicidal behaviors: a prospective study of African Americans. Factors that mediate and moderate the link between partner abuse and suicidal behavior in African American women. Risk factors for suicide attempts among African American women experiencing recent intimate partner violence. Reviewing suicide in Native American communities: situating risk and protective factors within a transactional-ecological framework. Suicide attempts among American Indian and Alaska Native youth: risk and protective factors. Suicidal behavior in urban American Indian adolescents: a comparison with reservation youth in a southwestern state. Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Mental health needs assessment of off-reservation American Indian people in Northern Arizona. Lifetime physical and sexual abuse, substance abuse, depression, and suicide attempts among Native American women.
The internal struggle between the wish to die and the wish to live: a risk factor for suicide.
Do sociocultural factors predict suicidality among persons of African descent living in the U.S.? Conceptual, methodological, and sociocultural issues in black youth suicide: implications for assessment and early intervention. Ethnic and sex differences in suicide rates relative to major depression in the United States. Nativity and DSM-IV psychiatric disorders among Puerto Ricans, Cuban Americans, and non-Latino Whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
A re-examination of cultural factors that mitigate risk and promote resilience in relation to African American suicide: a review of the literature and recommendations for future research. Luo reports no affiliation with or financial interest in any organization that may pose a conflict of interest. However, it encompasses the various technologies, including E-mail and the telephone, in creating a connection between the provider and patient.
Balch and Tichenor1 described how at East Carolina University (ECU) School of Medicine telemedicine was used to reach rural areas of eastern North Carolina, where there was a shortage of healthcare providers.
In South Carolina, the program for the Deaf and Hard of Hearing used a video conferencing program to provide psychiatric care.2 Jill Afrin, MD, an American Sign Language fluent psychiatrist, would normally travel 14 hours per week to treat clients around South Carolina.
Patients in the intervention group had home telemedicine units installed with dial-up Internet access, which also had blood glucose monitors attached to upload data. A direct data transmission connection between setups using ISDN provided security since the network was private although quite expensive. The International Telegraph Union (ITU),11 a United Nations agency, creates international standards for telecommunications services.
For consultations conducted between urban and rural health clinics, the use of a virtual private network (VPN) connection ensures that any data exchange is conducted over a private channel on the public Internet. Balch and Tichenor1 indicated that their center had to employ staff at each site in order to manage the daily operation of their network in order to troubleshoot any difficulties.
Pre-visit testing to validate a connection is important, particularly if telemedicine is conducted over the Internet with equipment from different manufacturers. The experience at University of California (UC) Davis Telemedicine Program is that in rural areas, the majority of patients had Medicaid insurance coverage, whereas in suburban and urban areas private insurance and Medicare were the majority. Most state medical boards have agreed that the practice of medicine occurs in the state where the patient is located.17 Therefore, physicians who wish to practice telemedicine are required to obtain a license in the state where the patient is located, which may be an expensive and time-consuming endeavor.
Panic or failure to act are major obstacles to safe and effective response in an emergency situation.Advance planning, preparation, and practice are the most effective ways of ensuring that individuals can respond calmly and effectively in an emergency.
In the Original Medicare Plan, the coinsurance payment is a percentage of the approved amount for the service.
In most plans, you can only go to doctors, specialists, or hospitals on the plan’s list.
You may go to any Medicare approved doctor or hospital that accepts the plan’s payment. They are paid by the Federal government to check and improve the care given to Medicare patients. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.
In addition, this plan references the Service Level Evacuation Standards1 developed by the Joint Emergency Management Steering (JEMS) Committee.
Updates to the plan will be undertaken as required based on lessons learned from exercises and incident responses. It is a provincial coordination plan outlining how Ontario would coordinate its response and collaborate with federal and municipal governments, First Nations, non-governmental organizations, and ministry partners.
It is not intended for internal evacuations of one part of a community to another part of the same community. This plan does not replace a community’s own emergency response plans, which should contain provisions for evacuations if they consider evacuations likely.
A detailed action plan that addresses the specific scenario, hazard, and threat will still be required. Evacuations are most frequently caused by forest fires and flooding (most often from spring break-up along the James Bay coast). Communities in the far north may be located significant distances from communities with road access or from regional centres where services may be available (e.g. Damage to property or the environment may also trigger an evacuation if it poses a risk to the safety, health, and welfare of people. It also dictates what level of activation, and how many and what type of resources will be required for the evacuation. If the evacuation is for one or a few communities, planning may be restricted to movements within the same general geographic area. Therefore, planning should include post-hosting needs, such as financial reconciliation, demobilization support, and reports on issues to be resolved before hosting evacuees in the future.
This allows the incident management team, and all partners, to take informed, effective and consistent actions in a timely manner. However, as the level of activation increases, the PEOC duty officer transfers this function to a technical specialist or team, if available. These ministries have processes in place for transferring the responsibility for real-time threat assessment to specialists within their ministry when required.
All activities and efforts should be focused on moving these people from the at-risk area to places of safety in a timely manner. This list should contain the names of persons needed to restart systems that must be in place before evacuees can return home (e.g. If an authorized entity decides on a partial or complete community evacuation, the community should declare an emergency. A pre-emptive evacuation may be undertaken when it is clear that if delayed, conditions (weather or other hazard) would impede evacuation. Evacuations of this nature are done when life safety is at extreme risk and a rescue becomes essential. For example, evacuations of large populations to one or more host communities may require logistics support to secure modes of transportation from a receiving aerodrome or transportation hub to the host community. Communities are encouraged to make the decision to evacuate as soon as a significant or imminent threat is identified. In widespread evacuations, emergency information may need to be coordinated amongst all involved partners. To assist with streamlining communications, an operational cycle should be established and communicated by the PEOC to partners so they know when they are expected to provide updates on the situation from their perspective. Partners should have back-up technologies available, particularly for their deployed staff. It is preferable to host community members together, even if it means hosting them farther away from their home community. Evacuation liaisons represent the needs of evacuees when attending meetings with the host community and other agencies. If the information is not collected on the manifest, registration services can collect and provide this more detailed information. Depending on the scale of the incident, and the numbers and locations of persons to be evacuated, the needs may exceed the capacity of available resources.
The Standards provide guidance on allowable expenditures, hosting arrangements, health services, emergency social services, etc. If requested, the PEOC could assist other communities in identifying potential host communities.

It is worth noting that community health services and hospitals in the host community may experience an increased demand for their services.
Representatives from provincial (through the PEOC) and federal organizations may be available to assist a host community in providing services to evacuees.
It is generally understood that time of year may affect the host community’s ability to provide accommodations during an evacuation.
This allows the host community to better coordinate services and seek reimbursement for expenses incurred due to hosting. The recommendation and the decision to return should be based on the results of the ongoing real-time threat assessment, plus a determination that the home community is ready to support the returning evacuees. This may involve the coordination of an advance team that is given sufficient time and other resources to return the community to a pre-evacuation state. It is critical that at the end of an evacuation, there is a full accounting of the operation in the form of after-action and financial reports. Doctors who prescribe these medications should become aware of these adverse events and closely monitor these patients. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.
Early submission of this posttest is encouraged: please submit this posttest by February 1, 2010 to be eligible for credit. The most common adverse events associated with the use of these drugs tend to affect quality of life issues such as sexual function and desire, body weight, sleep, and emotional reactivity. Perhaps the best examples of such failures involving SSRIs are the belated recognition that sexual dysfunction and weight gain are quite common. Excluded as well are alcohol or drug abusers, children, the elderly, pregnant women, those who are acutely suicidal, those with psychotic symptoms, subjects taking concomitant medications, and those with comorbid psychiatric or other medical illnesses.
The first-line spontaneous reporting system is the Food and Drug Administration’s MedWatch.
It has never been clear how clinically significant the effects of serotonergic drugs might be on platelet function.
The risk greatly increased by concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin. Risk factors for hyponatremia, other than older age, include female gender, use of other medications, or medical conditions. In more extreme cases (sodium <110), sodium replacement may be necessary, but the intervention should not be too aggressive in order to avoid risk of central pontine myelinolysis. In 16 of 18 patients, paroxetine administration induced an 11.5% increase in low-density lipoprotein cholesterol (LDL-C). Mice with genetic disruption of the serotonin transporter gene have lower bone-mineral density when compared with wild-type mice.
Subcutaneous injections of LPS over the calvariae for 5 days increased the numbers of osteoclasts and net bone loss, but new bone formation and a net gain in bone mass was seen when LPS was given together with fluoxetine.
The authors adjusted for other factors, such as the severity of depression and use of calcium supplements. Serotonin syndrome symptoms include restlessness, hallucinations, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea. There is a pharmacodynamic (additive effects on the serotonin system) as well as pharmacokinetic (inhibition of triptan metabolism by SSRIs) interaction between triptans and SSRIs.
The authors28 report that 14 patients reported reduction in sperm counts from antidepressants.
These are serious and debilitating disorders that need to be treated, with the benefits of treatment well established.
This article provides an update on the relationship between ethnicity and suicidal ideation and attempts. Some studies have suggested that non-Hispanic Whites have significantly higher risk for suicide attempts than other ethnic groups,4 such as Blacks2 and Hispanics,8 although some9 but not all10 studies have suggested that different subgroups among Hispanics have divergent rates of suicide attempts. May and colleagues21 observed that two-thirds of all self-destructive acts in the Western Athabaskan Tribal Nation reservation were alcohol related and occurred among unemployed individuals. Among men, the rate of hospitalization for suicide attempt was highest among Whites, intermediate among African Americans, and lowest among Asians. Overall, these existing findings underscore the need to conduct large studies in general population samples that include enough individuals from all ethnic groups and that are large enough to detect significant effects among those groups. Projections of the Resident Population by Race, Hispanic Origin, and Nativity: Middle Series, 2016 to 2020. Despite its clear potential to deliver health care to patients in rural settings or facilitate the reach of specialty providers to a larger patient population, telemedicine has somewhat faded in the technology and medicine limelight. Using a desktop video conferencing system from PictureTel, she could communicate with patients in three community health centers without leaving her office, instead of traveling 50% of her time and seeing significantly fewer patients. Patients with schizophrenia were actually quite satisfied with their virtual visit and preferred the telemedicine visit over the in-person visit. Nurses made visits via telemedicine to check on patients and implemented both direct video conference-based educational modules and store-forward self-paced modules from the Website established for the project.
This setup requires knowledgeable staff to setup the VPN hardware or software as well as a fast Internet connection and video system to compensate for the performance degradation secondary to the encryption. In addition to technical staff, healthcare staff needed time to develop familiarity with the equipment, and good interpersonal communication between the technical staff and clinical staff is essential. Their experience has been that many private insurance companies have not developed a reimbursement policy for telemedicine and have made it difficult to get reimbursement by requiring significant explanation of the telemedicine visit, the role of the presenting provider, the role of the consultant, and paying the telecommunications costs. Only 15 states have adopted an abbreviated licensing process for the purpose of telemedicine. The original Medicare plan has two parts: Part A (hospital insurance) and Part B (medical insurance). The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. Medicare pays its share of the Medicare approved amount, and you pay your share (coinsurance). They must review our complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare Private Fee-for Service plans, and ambulatory surgical centers. Examples of skilled nursing care are: getting intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound.
As many of the communities in the far north are First Nations, coordination with the federal government is crucial.
Two communities falling within the focus area have road access (Mishkeegogamang and Pickle Lake) and there is a rail link to one municipality (Moosonee).
However, the evacuation of multiple communities due to an area-wide emergency is likely to require out-of-area movements for hosting, particularly when the goal is to keep families and communities together.
The size and demographics of the population are significant factors in determining how to conduct an evacuation.
This would include: scheduling such that staff do not become overly fatigued by the operation and providing as much advance notice of scheduling as is possible given the nature of the incident.
In addition, up-to-date contact lists should be maintained by all organizations for use in an emergency. Alternate technologies that may be utilized in an evacuation include satellite phones and amateur radio. They should also be identified to the host community as resources that may be called upon to assist evacuees. This mitigates the risk of families being separated and makes the return of evacuees less complicated.
Evacuation liaisons also assist with creating manifests and determining the order of the return of evacuees in consultation with the Chief, Head of Council, or appointed person from the home community.
Once a flight manifest is prepared, it should be sent to the PEOC, which can in turn forward it to other organizations that require the information.
Receiving the information in advance can help ensure that needed services are delivered quickly. In this situation, evacuations may need to be prioritized and contingency plans implemented. While the Standards provide guidance on hosting First Nations, they may also be applied to municipal or unorganized territory evacuations as they pertain to hosting arrangements. While agreements may exist between EMO and a host community, the community retains the option of not hosting during a particular evacuation.
Emergency planners should assess proposed facilities based on location, capabilities, capacity, accessibility, and resources, as well as how they would route evacuee traffic. Municipal departments involved in the development of the host facility plan may be able to provide resources to support the set-up and operation of a host facility. Registration involves creating a municipal record, which is covered under municipal privacy legislation. Since the degree of damage will likely vary within the affected area, it might be beneficial to initiate a phased re-entry process. In most instances, people are returned in the reverse order of when they were evacuated (i.e. As with the initial evacuation, numerous resources, especially personnel and transportation related resources will be required to return evacuees to their home community.
It also shows the various partners likely to be involved in an evacuation, broadly reflecting the actions that fall within their jurisdiction. However, there are some side effects that, while uncommon, can produce complications that present in a medical or surgical context.
These side effects include sexual dysfunction, weight gain, emotional blunting, and discontinuation syndrome. Another problem with pre-marketing clinical trials is that they are invariably too small or too short to detect rare side effects. The risk is highest during the first weeks of treatment, so early lab tests are recommended.
These were the first findings to suggest that there might be clinical correlations between the presence of functional serotonin transporters in osteoblasts, osteocytes, and osteoclasts, and treatment with compounds that inhibit the serotonin reuptake transporter. Although peak bone mass develops during adolescence, it remains to be seen if there is a need for monitoring when prescribing SSRIs to children, adults, or premenopausal women. Responding to multiple reports of serious reactions, in 2006 the FDA issued a Public Health Advisory.25 The FDA requested that all manufacturers of triptans, SSRIs, and SNRIs update their prescribing information to warn of the possibility of serotonin syndrome when triptans and SSRIs or SNRIs are taken together.
Few if any studies have been performed on the effects of prescription medication on sperm chromatin. The authors speculate that because SSRI drugs affect both sperm count and the ability of sperm to move, the antidepressants may be preventing sperm from reaching the semen.
However, those who prescribe or are prescribed antidepressants should be aware of what can go wrong during treatment. Blanco receives grant support from the American Foundation for Suicide Prevention, the National Institutes of Health, and the New York State Psychiatric Institute. This is particularly relevant given that in some reservations 80% of those ≥16 years of age are unemployed. By contrast, Kennedy and colleagues14 reported no differences in rates of suicide attempts across Europeans, Chinese, and Indo-Asians.
Although most suicide prevention strategies so far have been aimed at decreasing the suicide risk factors, research should also focus on increasing the effects of factors that protect against suicide. This column reviews some of the early promises for telemedicine, examines various barriers in implementation and adoption of telemedicine, and explores the opportunities to return telemedicine to the forefront of medical care. In addition to consultations to rural clinics, specialists at ECU provided consultations to the emergency rooms. Total scores on the BPR and SAPS were comparable to live rating for both low and high quality.
Although both groups demonstrated reductions in hemoglobin A1C, blood pressure, and low-density lipoprotein levels, the telemedicine intervention group achieved statistically significantly greater levels. Today, Web cameras which transmit video and audio are quite inexpensive at $30, but in 1996, Creative Labs Inc. H.263 is an ITU standard, designed for low bitrate communications such as video-conferencing and video-telephony applications, but it can be used for a wide range of bitrates. This technical demand is one barrier to why telemedicine visits have largely been between medical facilities and not direct to patients in the comfort of home. The Center for Telehealth and E-Health Law notes that only five states have a statutory requirement that private insurance cover telehealth services.
Even this legislation does not help in eleven states that have laws explicitly requiring physical examination before the physician can prescribe. Read the guide before an emergency occurs, become acquainted with its contents, and refer back to it as needed. The Original Medicare Plan has two parts: Part A (hospital insurance) and Part B (medical insurance).
Any service that could be safely done by an average non-medical person (or one’s self) without the supervision of a Registered Nurse is not considered skilled care. This plan supports the activities being undertaken related to mass evacuation planning for ministry and community emergency management programs. There are two municipalities that fall within the focus area (Moosonee and Pickle Lake) plus more than 30 First Nation communities.
This is facilitated through liaison that may be in place between OIC ministries and federal departments - for example, between the Ministry of Health and Long-Term Care, Health Canada and Local Health Integration Networks (LHIN). Alternatively, the Chief of the First Nation, Head of Council, or an appointed person may decide to conduct a complete or partial evacuation based on an assessment of the threat to area residents. This approach minimizes potentially having people in harm’s way and enables a more controlled evacuation and optimization of resources. Where possible, identify the positions, rather than individuals who may be involved in the operation.
Notwithstanding this recommended practice, a host community’s capacity may be such that it is unable to accommodate an entire community. In the event that the list of potential host communities is insufficient for the size of evacuation pending, the PEOC will solicit additional host communities. Details on the set-up and operation of the shelter should be provided in the community’s emergency response plan.
Each municipality has the responsibility for managing the record in accordance with the applicable legislation and their municipal policies. The Chief of a First Nation, Head of Council of a municipality, or appointed person, will decide when to allow evacuees to return to the community. Looper1 called attention to other treatment-associated adverse events that, if undetected, can have potentially serious consequences for the patient. In addition, after the first case reports and letters to the editor are published, the number of new reports decline.
As sodium levels drop, patients progress from confusion, to stupor, to coma, and then seizures.
According to the authors, the magnitude of the paroxetine-induced increase in LDL-C would lead to a minor increase in coronary heart disease (CHD) risk in a minority of healthy male volunteers without associated CHD risk factors but might increase LDL-C sufficiently to warrant therapeutic intervention in patients with established CHD. A more recent animal study21 suggests that there may be multiple factors involved in bone mass changes during SSRI treatment. In a second study,23 readings of the hip and bone density of approximately 6,000 men ≥65 years of age were conducted.
In view of the FDA position on triptans, physicians should monitor patients for signs and symptoms of serotonin syndrome (eg, restlessness, sweating, tremor, shivering), particularly during treatment initiation, with dose increases, or with the addition of another serotonergic medication.
In general, FDA studies conducted before approval of a new medication address only limited assays of sperm counts and motility, not the health of the sperm’s DNA. A controlled study by investigators at Cornell has been completed, but the results have not been published by the time this issue went to press. When problems arise, closer monitoring and use of an appropriate alternative intervention is indicated. SANS was comparable to live rating only at high quality since at low quality sessions there is difficulty rating negative symptoms. Although many pilot studies demonstrate the impact of telemedicine, this study had much more statistical power with its 1,665 participants, 884 of whom had the telemedicine intervention. The bandwidth requirement for video and audio is certainly not met with dial-up Internet speeds of 56 Kbps. H.264, also an ITU standard, is a high-quality video compression algorithm and is suited for all types of applications with different ranges of bit rates. It draws linkages to various hazard management plans and procedures developed by ministries.
The exact population at any one time is difficult to report as people who are recorded in the census may be away from the community and some who are not recorded may be in the community. Unorganized territories, fly-in lodges and camps, and mining operations also fall into the plan area. The seasonal roads cannot be relied on for evacuation operations given the short and sometimes unpredictable length of time that they are available.
Local populations often provide the best information on the threat to their community and the region. Emergency responders may require personal protective equipment, as responder safety will be critical. Where an entire community may not be hosted together in close proximity to the home community, and if the situation allows, the community’s preference should be discussed with the Head of Council, First Nation Chief, or appointed person.
The primary reason for returning the most vulnerable people last is to help ensure that support services are in place when they return. Manufacturer-initiated postmarketing (Phase 4) trials represent another means for determining a drug’s safety profile, but these are usually undertaken with a focus on efficacy and new clinical uses.
Systemic fluoxetine, administered to mice for 6 weeks, was shown to increase trabecular bone volume and bone volume fraction in femurs and vertebrae.
Blanco is associate professor of clinical psychiatry at Columbia College of Physicians and Surgeons in New York City. This product worked over regular analog phone lines but was compatible only with other ShareVision setups.
All telephone numbers listed in the flipchart, with the exception of 9-1-1, are telephone numbers for resources located on the Eugene campus.
For example, there may be people staying at fly-in lodges that do not report year-round population. All may be a source of significant anxiety and unpleasant memories for the patient and may result in needless referral for consultation with medical specialists (who also may not be aware of these side effects) and subsequent medical tests. The statistical interaction is of similar magnitude to that seen with concurrent aspirin and NSAID use.
This correlated with an increase in trabecular number, connectivity, and decreased trabecular spacing. Once the offending medication is discontinued there is usually dramatic improvement within 24–48 hours. From the epidemiologic point of view, these findings underscore the need to conduct large studies in general population samples that include enough individuals from all ethnic groups and that are large enough to detect significant effects among those groups. Programs at other locations may wish to list local emergency telephone numbers specific to their area.
Similarly, there may be community events that draw tourist and other visitors to the community.
From the clinical point of view, mental health professionals should focus on factors consistently found to be strongly associated with suicide attempts across different populations, including major depressive disorder and other psychiatric disorders, female gender, and young age.
Clinicians should caution patients about combining SSRIs with aspirin, NSAIDs, or anticoagulants.
However, the study found that fluoxetine-treated mice were not protected against bone loss after ovariectomy. The risk of bleeding is not predicted by standard blood tests and requires platelet aggregation studies (for patients with evidence of abnormal bleeding or bruising or who are pre-surgery). This obviously raises a question about whether the anabolic effect of SSRIs require the presence of estrogen.

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