Antidepressants suicidality

Great care must be taken with any suicidal patient receiving an antidepressant Some of these drugs take several weeks to have a therapeutic effect, and suicide is a possibility even if the patient is taking an antidepressant. 

Full therapeutic effect of the antidepressant may not be attained for 10 days to 4 weeks. Patients with suicidal tendencies must be monitored closely. Report any expressions of guilt, hopelessness helplessness insomnia, weight toss and direct or indirect threats of suicide. 

If the drug is prescribed on an outpatient basis, the primary health care provider may prescribe only a week s supply of the antidepressant to reduce the risk of suicide... 

Muller-Oerlinghausen B, Berghofer A (1999). Antidepressants and suicide risk. J Clin Psychiatry 60 (suppl. 2), 94—9. 

Psychiatric adverse effects occur frequently and may include irritability, depression, and rarely, suicidal ideation. Individuals with a history of uncontrolled psychiatric disorders must weigh the risk versus benefit of treatment, as interferon may exacerbate or worsen the psychiatric condition. Patients who develop mild to moderate symptoms may require antidepressants or anxiolytics. Those with severe symptoms including suicidal ideation should have the treatment discontinued immediately.43... 

Differentiating between depression and dementia can be difficult, so symptoms of depression should be documented for several weeks prior to initiating therapy for the treatment of depression with AD. Citalopram and sertraline are recommended as first-line agents because of their efficacy in placebo-controlled trials.49 Indications for the use of antidepressants include depression characterized by poor appetite, insomnia, hopelessness, anhedonia, withdrawal, suicidal thoughts, and agitation. 

The FDA is in the process of analyzing data to determine whether there is an increased risk of suicidality in adult patients similar to that seen in pediatric patients (see above). Even though the suicidality risk for adults taking antidepressant medications... 

Patient may become suicidal while taking the antidepressant. 

The clinician should bear in mind the toxic potential for the various antidepressant medications when patients already have or develop suicidality. The TCAs and MAOIs have narrow therapeutic indices, whereas the SSRIs, SNRIs, nefa-zodone, and mirtazapine have wide therapeutic indices.22... 

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Now there are a number of problems with relapse-prevention studies. One is the fact that many people who are taken off antidepressants experience withdrawal symptoms, which in severe cases can last for months. Some of these withdrawal symptoms - sadness, suicidal thoughts, crying spells, trouble concentrating, irritability, anxiety, agitation and insomnia, for example - are also symptoms of depression.12 These withdrawal symptoms could lead both patients and researchers to think that the patient has relapsed. 

Hammad, Tarek A., Thomas Laughren and Judith Racoosin, Suicidality in Pediatric Patients Treated with Antidepressant Drugs , Archives of General Psychiatry 63 (2006) 332-39... 

Stone, Marc B. and M. Lisa Jones, Clinical Review Relationship between Antidepressant Drugs and Suicidality in Adults (2006) http / /www.fda.gov/ohrms/dockets/ ac/06/briefing/ 2006-4272b1-01-FDA.pdf... 

Non-motor signs of the disorder are also treatable with symptomatic medications. The frequent mood disorder can be treated with standard antidepressants, including tricyclics (such as amitryptiline) or serotonin reuptake inhibitors (SSRIs, such as fluoxetine or sertraline). This treatment is not without risks in these patients, as it may trigger manic episodes or may even precipitate suicide. Anxiety responds to benzodiazepines, as well as to effective treatment of depression. Long-acting benzodiazepines are favored over short-acting ones because of the lesser abuse potential. Some of the behavioral abnormalities may respond to treatment with the neuroleptics as well. The use of atypical neuroleptics, such as clozapine is preferred over the typical neuroleptics as they may help to control dyskinesias with relatively few extrapyramidal side-effects (Ch. 54). 

The FDA has established a link between antidepressant use and suicidality (suicidal thinking and behaviors) in children, adolescents, and young adults 18 to 24 years old. All antidepressants carry a black box warning advising caution in the use of all antidepressants in this population, and the FDA also recommends specific monitoring parameters. The clinician... 

Lithium is effective for acute mania, but it may require 6 to 8 weeks to show antidepressant efficacy. It may be more effective for elated mania and less effective for mania with psychotic features, mixed episodes, rapid cycling, and when alcohol and drug abuse is present. Maintenance therapy is more effective in patients with fewer episodes, good functioning between episodes, and when there is a family history of good response to lithium. It produces a prophylactic response in up to two-thirds of patients and reduces suicide risk by eight- to 10-fold. 

Patients should be monitored for emergence of suicidal ideation after initiation of any antidepressant, especially in the first few weeks of treatment. 

Pharmacological clinical activity bias. An AE that is already present due to the disease may be increased if it is also an ADR of the drug or vice versa. For example, the diarrhea of gastroenteritis may be alleviated by codein-containing preparations given to relieve pain while the inertia of a severely depressed patient may be sufficiently resolved by an antidepressant to enable the patient to commit suicide. 

Tricyclic Antidepressants (TCAs). Because of their effectiveness not only for depression but for anxiety disorders such as panic disorder as well, TCAs were the first medications formally tested in the treatment of PTSD. Three TCAs, amitriptyline, imipramine, and desipramine, have been studied in small trials, producing modest benefit for reexperiencing and hyperarousal symptoms, without any relief of avoidance/numbing symptoms. Given this limited benefit in conjunction with the side effect burden and potential for toxicity in a suicide prone population, TCAs are infrequently used in the treatment of PTSD. Please refer to Chapter 3 for more information regarding TCAs. 

The serotonin-boosting antidepressants are a reasonable first choice in the treatment of impulsivity and mood lability in patients with BPD. They have proved effective in the limited studies conducted thus far and are also easy to tolerate and safe in overdose. This last factor is an important consideration when treating BPD patients prone to impulsivity and at times suicidal behavior with little advance warning. When these antidepressants are used, they should be started and titrated in a similar fashion to that used in the treatment of major depression and other mood... 

The full spectrum of depressive symptoms including depressed mood, anhedonia, lack of energy, and even suicidal thoughts may strike as many as 25% of patients who experience a TBL Depression in these patients not only exacts a tremendous psychosocial toll but also interferes with their participation in physical and occupational rehabilitation. As a result, long-term functional recovery from TBl can be sorely compromised by depression. Potential treatments for post-TBl depression include conventional antidepressants and stimulants (see Table 12.1). 

The excellent clinical efficacy of the TCAs has been well documented and the pharmacokinetic profiles are favourable. The most serious disadvantage of the TCAs lies in their cardiotoxicity. Thus, with the exception of lofepramine, all the tricyclic antidepressants, including maprotiline, block the fast sodium channels in the heart which can lead to heart block and death. Approximately 15% of all patients with major depression die by suicide and a high proportion of these (up to 25%) do so by taking an overdose of TCAs. Such a dose can be as low as 5-10 times the recommended daily dose. 

Milnacipran is also a dual-action antidepressant which, like venlafaxine, has been shown to be more effective than the SSRIs in the treatment of severe, hospitalized and suicidally depressed patients. At lower therapeutic doses, milnacipran blocks the noradrenaline transporters and therefore resembles the NRI antidepressants. Higher doses result in the serotonergic component becoming apparent (i.e. an SSRI-like action). The main problem with milnacipram appears to be its lack of linear kinetics with some evidence that it has a U-shaped dose-response curve (Figure 7.3). 

These mediators probably play significant roles in CNS functions consistent with the stimulant effects of MAO inhibitors on mood and psychomotor drive and their use as antidepressants in the treatment of depression (A). Tranylcypromine is used to treat particular forms of depressive illness as a covalently bound suicide substrate, it causes long-lasting inhibition of both MAO isozymes, (MAOa, MAOb). Moclobemide reversibly inhibits MAOa and is also used as an antidepressant. The MAOb inhibitor selegiline (deprenyl) retards the cat-obolism of dopamine, an effect used in the treatment of parkinsonism (p. 188). 

Apart from symptomatic, general measures (gastric lavage, cooling with ice water), therapy of severe atropine intoxication includes the administration of the indirect parasympathomimetic physostigmine (p. 102). The most common instances of atropine" intoxication are observed after ingestion of the berry-like fruits of belladonna (children) or intentional overdosage with tricyclic antidepressants in attempted suicide. 

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