Suicide methylphenidate

The best-known products come from the amphetamine group (see Table 1.12) Dexedrine1 1 (generic name d-amphetamine) and Pervitin 1 (methamphetamine) were particularly used in the 1950s and 1960s as stimulants and also as appetite suppressants, but today play hardly any role in medical practice. Ritalin (methylphenidate) has some relevance its psychostimulant action is said to be weaker than that of amphetamines and it is apparent ) less abused than the latter. Because methylphenidate also possesses mild antidepressant activity, in some countries it is used to combat not only narcolepsy and ADHD but also mild depressions without suicide risk (Satel and Nelson, 1989). 

Most of the symptoms described in my previous publications and by the FDA in its new label are the result of activation or stimulation, a syndrome similar to that caused by stimulants such as amphetamine, methamphetamine, and methylphenidate, especially in high doses. Compared to antidepressant-induced suicidality, activation is bolstered by a much larger scientific literature and poses a far more common, and often disastrous, level of risk (see subsequent discussion). 

The process of beginning to reassess the risks of stimulants began in June 2005, when the FDA (2005d) first gave notice that it was receiving a large number of reports of adverse psychiatric reactions, including suicidality, for methylphenidate products such as Concerta and Ritalin ... 

Post-marketing reports received by FDA regarding Concerta and other methylphenidate products [e.g., Ritalin] include psychiatric events such as visual hallucinations, suicidal ideation, psychotic behavior, as well as aggression or violent behavior. 

Like any addictive stimulant, methylphenidate and amphetamine can cause withdrawal symptoms such as crashing with depression, exhaustion, withdrawal, irritability, and suicidal feelings. However, parents and teachers almost never recognize a withdrawal reaction when their student or child gets upset after missing a single dose. Instead, they mistakenly believe that the child needs to be kept on the medication. 

Emergence or worsening of activation and agitation may represent the induction of a bipolar state, especially a mixed dysphoric bipolar II condition sometimes associated with suicidal Ideation, and require the addition of a mood stabilizer and/or discontinuation of d,l-methylphenidate... 

A stimulant such as d-amphetamine or methylphenidate (with caution may activate bipolar disorder and suicidal ideation may elevate blood pressure)... 

A novel metabolite of methylphenidate, ethylphenidate, has recently been detected in human blood and liver samples obtained from two suicide victims who had taken a large dose of methylphenidate and ethanol (49). The concentrations of ethylphenidate were small relative to those of methylphenidate and ritalinic acid. Nevertheless, given the frequent occurrence of methylphenidate and ethanol co-ingestion, the detection of ethylphenidate warrants further studies on the extent of its formation, as well as any associated toxicity associated with normal doses. A transesterification reaction, analogous to that known to produce cocaethylene after cocaine and ethanol co-ingestion (50), has been described with methylphenidate (51). 

A 17-year-old girl attempted suicide with methylphenidate (Concerta ) 270 mg since more than 3 hours had elapsed, charcoal was not used. All vital signs and laboratory findings were normal, except for the heart rate, which was 132/minute. 

Fettahoglu EC, Satilmis A, Gocken C, Ozatalay E. Oral megadose methylphenidate ingestion for suicide attempt. Pediatr Int 2010 51 844-5. 

Ozdemir E, Karaman MG, Yurteri N, Erdogan A. A case of suicide attempt with long-acting methylphenidate (Concerta). Atten Deflc Hyperact Disord 2010 2 103-5. 

In a study based on the UK General Practice Research Database (GPRD) in patients with ADHD, aged 2-21 years, from 1993 to 2006 with prescriptions for methylphenidate, dexamfetamine, or atomoxetine, there was no increase in the risk of sudden death but there was an increased risk of suicide [55 ]. Seven patients died in a cohort of 18 637 patient-years, and cause of death was obtained in six none was deemed to be a case of sudden death (incident rate ratio 1.63 95% Cl = 0.04, 9.71). The standardized mortality ratios for suicide were 162 (95% Cl = 20, 585) in patients aged 11-14 years and... 

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