Atypical Agents Medications considered atypical include venlafaxine, lithium salts, and anticonvulsants, which are effective mood stabilizers used for bipolar disorders (126–130). Bupropion is available in a once-a-day preparation. It lowers the seizure threshold slightly more than other antidepressants and should be avoided or used with caution in patients who have a history of head trauma. It is used, under a separate trade name, for smoking cessation, and is particularly useful for smokers who are depressed. Bupropion seems to cause fewer sexual side effects than the SSRIs and may decrease these side effects when added to an SSRI regimen.
Suicide The most acute issue in the assessment and referral of depressed patients is the possibility of suicide (131). Following are the risk factors for suicide:
Previous suicide attempts, even if seemingly not serious
Family history of suicide  A plan to commit suicide
Access to the means to carry out the plan
Women attempt suicide more frequently than men, but men complete the act more frequently than women (131,132). This is probably because men use more drastic or irreversible means, such as firearms, whereas women tend to overdose, which can be treated if discovered. It might seem that someone who repeatedly makes suicidal gestures is more interested in the responses of others than in ending her life. However, past attempts or gestures increase the risk of completed suicide. Patients who made a suicide attempt should be queried about the following risk factors: the intent to die (rather than escape, sleep, or make people understand her distress); increasing numbers or doses of drugs taken in a progression of attempts; and drug or alcohol misuse, especially if it, too, is increasing. Inquiry about suicidal ideation and behavior is an inherent part of every mental status examination and is mandatory for every patient with past or current depression or evidence of self-destructive behavior. The inquiry can follow from discussion of difficulties in the patient’s life or mood or be introduced with a comment that almost everyone has thoughts of death at one time or another. Nonsuicidal patients will immediately volunteer that they have had such thoughts and that they have no intention of acting on them. They will often add reasons: they have too much to look forward to, it is against their religion, or it would hurt their family.
It is important to distinguish among thoughts of death, the wish to be dead, and the intention to kill oneself (132). A patient in a painful life situation—a chronic, painful, or terminal medical condition, the birth of a severely damaged child, or a grievous loss—may express a wish to die, and even refuse recommended medical care but emphatically and honestly disavow any intention of actively harming herself. The patient must be directly asked (132).
If the patient previously engaged in impulsive self-destructive behavior, without a plan or warning, it is wise to consult a psychiatrist. If a patient is actively contemplating suicide, she must see a psychiatrist immediately (132,133). Other mental health professionals may be helpful but are less likely to have dealt extensively with and assumed responsibility for suicidal patients, to be able to determine whether the patient should be hospitalized, and to have admitting privileges. Until she is in the physical presence of a psychiatrist, or in a safe environment such as a hospital emergency room, a suicidal patient should be observed and protected at all times— every second—whether she is in the consulting room or the bathroom. The staff member assigned to remain with her may not leave to make a telephone call, go to the bathroom, or get a cup of coffee. Family members may offer to monitor the patient and can sometimes be effective, but the health care professional is responsible for ensuring that they understand and implement this level of supervision. It is better to risk inconvenience and possible embarrassment to both the gynecologist and the patient than to risk a fatal outcome. When suicide is an immediate consideration, only a psychiatrist can make the decision that a patient is safe (133). Psychiatric referral can be useful in less dramatic cases: when the gynecologist lacks experience or is overloaded with patients, when a first trial of treatment is unsuccessful or there is uncertainty about the diagnosis, when domestic violence or substance abuse may be present, and when the depression is recurrent.