Suicide medications

Anxiety disorders and insomnia represent relatively common medical problems within the general population. These problems typically recur over a person s lifetime (3,4). Epidemiological studies in the United States indicate that the lifetime prevalence for significant anxiety disorders is about 15%. Anxiety disorders are serious medical problems affecting not only quaUty of life, but additionally may indirecdy result in considerable morbidity owing to association with depression, cardiovascular disease, suicidal behavior, and substance-related disorders. 

The preadministration assessments of the outpatient are basically die same as diose for the hospitalized patient. The nurse obtains a complete medical history and a history of die symptoms of the depression from die patient, a family member, or die patient s hospital records. During die initial interview, die nurse observes die patient for symptoms of depression and die potential for suicide The initial physical assessment also should include the patient s vital signs and weight. 

Few papers have looked at the economic implications of bipolar affective disorder. Most of the published studies look at direct medical costs over the course of a year. Industry-sponsored studies focus on the benefits of a new treatment over older treatments. However, factors individual to a particular patient are likely to be more important than the average cost of a particular treatment. These include selection of patients who are likely to respond to a particular treatment, and psychoeducation coupled with encouragement during follow-up and carefial monitoring, to avoid such expensive outcomes as ftill-blown relapse, serious toxicity or suicide. 

Disulfiram works by irreversibly blocking the enzyme aldehyde dehydrogenase, a step in the metabolism of alcohol, resulting in increased blood levels of the toxic metabolite acetaldehyde. As levels of acetaldehyde increase, the patient experiences decreased blood pressure, increased heart rate, chest pain, palpitations, dizziness, flushing, sweating, weakness, nausea and vomiting, headache, shortness of breath, blurred vision, and syncope. These effects are commonly referred to as the disulfiram-ethanol reaction. Their severity increases with the amount of alcohol that is consumed, and they may warrant emergency treatment. Disulfiram is contraindicated in patients who have cardiovascular or cerebrovascular disease, because the hypotensive effects of the disulfiram-alcohol reaction could be fatal in such patients or in combination with antihypertensive medications. Disulfiram is relatively contraindicated in patients with diabetes, hypothyroidism, epilepsy, liver disease, and kidney disease as well as impulsively suicidal patients. 

To date, clozapine remains the only drug with proven and superior efficacy in treatment-resistant patients, and it is currently the only drug approved for the treatment-resistant schizophrenic. Studies have shown a response of approximately 30% to 50% in these well-defined treatment-resistant patients. Clinical trials have consistently found clozapine to be superior to traditional antipsychotics for treatment-refractory patients, and it is efficacious even after nonresponse to other SGAs and in partially responsive patients. It is often rapidly effective even in those who have had a poor response to other medication for years. Recent studies have demonstrated that it has a beneficial effect for aggression and suicidality, which led to the Food and Drug Administration (FDA) approval for the treatment of suicidal behavior in people with psychosis.41... 

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... 

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... 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Hospitalized at age 15 for physical aggression towards parents, suicidality, and running away does not remember if she was placed on medication or if she was given a diagnosis admits history of sleep disturbance that alternates between hyposomnia and hypersomnia and moodiness, when she shifts from feeling "on top of the world" to very depressed, "like I m a nobody."... 

Assess for the safety of others and potential for violence. If accompanied by friends or family with whom the patient is living, ask them to remove from the home all guns, caustic chemicals, medications, and objects the person might use to harm self or others. Risk factors for suicide include severity of depression, feelings of hopelessness, comorbid personality disorder, and a history of a previous suicide attempt.19... 

Following initial assessment, including evaluation of potential suicidality, support systems, and need for inpatient versus outpatient treatment, MW was hospitalized briefly, then followed in the community on medication along with psychotherapy. She has abstained from illicit substances and has returned to her job. She has responded well to treatment with sustained-release lithium carbonate 900 mg once daily at bedtime with a snack. Steady-state 12-hour serum lithium concentrations have stabilized at 0.9 mEq/L (0.9 mmol/L). She now returns to clinic for routine followup. She has tolerated the lithium except for a mild tremor and a gain of 7 pounds (3.2 kg). She is willing to accept these side effects for now, but asks about how long she must take medication since she is now feeling well. 

Fergusson, Dean, Steve Doucette, Kathleen Cranley Glass, Stan Shapiro, David Healy, Hebert Paul and Brian Hutton, Association between Suicide Attempts and Selective Serotonin Reuptake Inhibitors Systematic Review of Randomised Controlled Trials , British Medical Journal 330 (2005) 396-99... 

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). 

Lithium was the first established mood stabilizer and is still considered a first-line agent for acute mania and maintenance treatment of both bipolar I and II disorders. It is the only bipolar medication approved for adults and children 12 years and older. Long-term use of lithium reduces suicide risk. Patients with rapid cycling or mixed states may not respond as well to lithium monotherapy as to some anticonvulsants. 

An analysis of 19 deaths from PCP overdose that occurred in two California counties from 1970 to 1976 showed that 12 were accidental, five suicidal, and two homicidal. Eight of the 12 accidental deaths were from drowning. Blood concentrations ranged from 1,250 to 2,300 ng/ml. Virtually all patients with levels of 1,000 ng/ml or more had coma, with the possible evolution of death due to medical complications, seizures, or respiratory depression. Levels greater than 2,000 ng/ml were almost always fatal (12). 

Anorexia nervosa sufferers can exhibit sudden angry outbursts or become socially withdrawn. One in ten cases of anorexia nervosa leads to death from starvation, cardiac arrest, other medical complications, or suicide. Clinical depression and anxiety place many individuals with eating disorders at risk for suicidal behavior. 

How can good pharmacotherapists be found First, check with experienced and respected colleagues, take note of which pharmacotherapists are referring patients to you, attend local educational meetings with psychiatrists, or, if there is a medical school nearby, attend the psychiatry department s grand rounds. Local patient advocacy and support groups, such as the Depression and Bipolar Support Alliance (DBSA), the National Alliance for the Mentally HI (NAMI), the American Foundation for Suicide Prevention (AFSP), and the Anxiety Disorders Association of America (ADAA), are valuable sources of information from the patient s perspective. 

Mood disorders represent a major public health concern around the globe. In the United States alone, the annual cost of major depression is over 40 billion dollars. Less than 30% of the total cost of depression is incurred through direct treatment. The remainder consists of the indirect hidden costs of lost productivity due to absenteeism and poor work efficiency, premature death from suicide or medical illness, and the uncounted losses related to a poor quality of life. 

Depressed mood is the hallmark symptom of MDD, but it is neither required nor sufficient for the diagnosis of major depression. In addition to depressed mood, the key symptoms of a major depressive episode include anhedonia, changes in sleep or appetite, psychomotor retardation or agitation, poor concentration or indecisiveness, and recurrent thoughts of death or suicide. The DSM-IV definition of major depression requires that five or more of these symptoms be present for at least 2 weeks in the absence of an identifiable cause such as medication, medical illness, or the death of a loved one. Refer to Table 3.2 for the DSM-IV criteria for MDD. 

Female gender Prior history of depression Family history of depression Active substance abuse Recent stressful life event Poor social supports Previous suicide attempt Postpartum period Chronic medical illness... 

Of greater concern is the safety of the TCAs. Toxic levels of these medications can produce lethal cardiac arrhythmias, seizures, and suppression of breathing. An overdose of a 1-2 week supply of most TCAs is often fatal, a serious consideration when prescribing medication to depressed patients with suicidal thoughts. Children taking imipramine for treatment of ADHD have died from sudden cardiac death consequently, child psychiatrists seldom use TCAs. Likewise, patients with heart disease or seizure disorders are more likely to have dangerous complications from TCAs and should avoid them. 

Lithium toxicity can occur as a result of intentional overdose therefore, care must be taken when administering lithium to potentially suicidal patients with BPAD. Inadvertent lithium toxicity may also occur. For example, diuretics and nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) slow the excretion of lithium and can lead to accidental toxicity. Consequently, the patient should be advised not to take such commonly available medications while treated with lithium. In addition, dehydration resulting from varied causes such as diarrhea, vomiting, and profuse sweating can lead to accidental lithium toxicity. One should advise the patient who takes lithium to be careful to remain well hydrated at all times and to contact his/her physician if any medical condition arises that may cause rapid fluid losses (e.g., stomach virus, high fevers). 

The result is that panic disorder, particularly when associated with agoraphobia, confers considerable social impairment. Patients with panic disorder are less productive at work, are prone to absenteeism, are less satished in family roles, and have higher mortality and suicide rates. In addition, the physical symptoms of panic disorder are frequently misattributed to medical conditions such as emphysema or heart disease and lead to the costly and inappropriate use of emergency room and other medical services. Panic disorder is costly both from an economic and a social perspective. 

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 cocaine addict most often presents during withdrawal after a binge of cocaine use. Cocaine withdrawal is not life threatening and does not require medical intervention in the same sense as alcohol or opiate withdrawal. It is, however, associated with a profound depression that can render the addict suicidal for 24-48 hours. The crashing cocaine addict should be assessed for suicide risk and, if indicated, the patient should be monitored in an emergency psychiatric setting or may require a brief 1-2 day inpatient psychiatric admission until the withdrawal resolves and the suicide risk is relieved. 

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