Suicide risk

Depression occurring as part of bipolar disorder may be severe and accompanied by ideas of guilt and hopelessness, an inability to function at work because of poor concentration and psychomotor retardation or agitation, poor judgement and suicidal ideation. The lifelong risk of suicide in people with this condition is as high as 15%. Factors associated with suicide risk include alcohol misuse, marital separation or divorce, living alone and unemployment, and these are all common secondary consequences of the illness. 

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

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... 

Suicide risk even in patients without psychiatric disease Avoid in uncontrolled narrow-angle glaucoma (causes mydriasis) Hepatotoxic avoid in alcoholics even if signs/symptoms of hepatic disease are absent. 

Suicide risk is higher than any other psychiatric disorder... 

Bipolar patients with substance abuse disorders are more likely to have an earlier onset of illness, mixed states, higher relapse rates, poorer response to treatment, higher suicide risk, and more hospitalizations. 

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. 

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. 

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. 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of trazodone or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Trazodone not approved for use in pediatric patients (see Clinical worsening and suicide risk and Children sections in Warnings). 

Suicide risk Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. 

Paroxetine increases the risk of birth defects in women taking the drug during their first trimester of pregnancy. Evidence from case studies, epidemiological studies, experimental research, and theory supports the view that SSRIs increase suicide risk for some patients. 

These are usually treated with sedative neuroleptics (as for schizophrenia, above). Treatment must also aim to support the patient socially including for instance advising on legal protection from the financial or other consequences of mania. One of the risks of treatment is the sudden mood swing at the end of the manic episode, with acute depression possibly triggered by the neuroleptics. Because of the concern for the manic episode and symptoms, return to normal is viewed with relief, and the downswing may go un-noticed, with the concomitant suicidal risk. 

Suicidal risk. Data from 36,689 adult men and women (25-64 years of age) who participated in a population survey between 1972 and 1992 indicated that clustering of the heavy use of alcohol, cigarettes, and coffee could serve as a new marker for increased risk of suicide. The mortality of the cohort was monitored for a mean of 14.4 years, which yielded 169 suicides. Criteria for heavy use of each psychoactive substance were defined as alcohol more than 120 g/ week, cigarettes more than 21/day, and coffee more than 7 cups/day. Approximately... 

Supervise suicidal-risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicidal potential)... 

There is no empirical evidence available for clinical use in children and adolescents. Yet, Hypericum seems to be used for the treatment of mild to moderate depression in the young (Walter et ah, 2000). St. John s wort should be avoided in young patients with severe depression and bipolar disorder (given the lack of adult data about effectiveness and risk of manic induction, respectively) and in those who have significant suicide risk. Treatments of proven efficacy (e.g., SSRIs, mood stabilisers) should be preferred in these cases. However, St. John s wort may be considered in cases of unipolar depression where conventional treatments have failed and prior to the use of combinations of drugs that have an increased risk of side effects and whose efficacy has not been demonstrated. 

Khan, A., Warner, H.A., and Brown, W.A. (2000) Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials an analysis of the Food and Drug Administration database. Arch Gen Psychiatry 57 311-317. 

TCAs in more serious forms of depression such as melancholic or psychotic depression. Some studies have suggested that the SSRls do not work as well as the TCAs in melancholic depression (Roose et al. 1994]. Likewise, one study has suggested that venlafaxine, a drug with a mechanism of action similar to that of the TCAs, was superior to fluoxetine in the treatment of inpatients with melancholic depression (Clerc et al. 1994]. Still, other metaanalyses have failed to find a difference in the efficacy of SSRls versus TCAs in serious forms of depression [Nierenberg 1994]. Nonetheless, given that most studies have employed TCAs, and some debate exists about the utility of SSRls in severe subtypes, it may be prudent to start with a TCA in most patients until the debate is further resolved. For patients who present a significant suicide risk or who have not been able to tolerate TCAs, the SSRls in combination with a standard antipsychotic appears an effective option. 

Psychiatr Chn North Am 19 179-200, 1996 Fava M, Rosenbaum JF, McGrath PJ, et al Dthium and tricyclic augmentation of fluoxetine treatment for resistant major depression a double-blind, controlled study. Am J Psychiatry 151 1372-1374, 1994 Fawcett J Suicide risk factors in depressive disorders and panic disorder. J Clin Psychiatry 53 [suppl 3) 9-13, 1992... 

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). 

Treatment of patients with high suicidal risk who are excluded from Phase I, O and m trials, especially from placebo-controlled studies. 

BZDs may exacerbate depression and possibly increase suicide risk. Case reports and clinical trials also indicate that BZD treatment of generalized anxiety and panic may result in emergence of depression (215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225 and 226). In some of these reports, depression is ill-defined, but in others, it met DSM-III criteria for a major depressive disorder, requiring treatment with an antidepressant ( 225, 226). Depression has been reported with a variety of BZDs (alprazolam, bromazepam, clonazepam, diazepam, lorazepam), but there is no evidence that one is more likely than another to cause or aggravate depressive illness. 

Whereas tertiary amine TCAs are more potent than secondary amine TCAs in terms of sites of action mediating adverse effects, they are less potent than secondary amine TCAs in terms of antidepressant efficacy based on the results of the plasma drug level studies reviewed earlier in this chapter. That fact further increases the safety and tolerability of secondary amine versus tertiary amine TCAs (411). Nevertheless, secondary amine TCAs are still toxic when taken in overdose, and this issue must always be considered when applying treatment in a patient who poses a substantial suicide risk. 

In addition to a different side-effect profile, SSRIs differ from TCAs by virtue of their wider safety margin, because they do not cause life-threatening toxic effects (e.g., patients having survived acute ingestion of amounts equal to 10 times the daily dose) (434). For this reason, many clinicians prefer these drugs in patients who may be a significant suicide risk. 

For more than 40 years, lithium has been the standard drug therapy for bipolar disorder, primarily because of the quantity and the quality of evidence supporting its role as an effective maintenance and prophylactic treatment. This latter point is a very important consideration, given the recurrent nature of this disorder. Thus, clinicians must choose the optimal strategy for acute treatment with the realization that most patients will need to continue drug therapy indefinitely. In addition, there is support for maintenance lithium s beneficial impact on the suicide rate in bipolar patients ( 73, 74). The author of these reports notes that the lower suicide risk associated with lithium treatment may be due to the following ... 

A lower suicide risk per se in patients who remain in treatment... 

Tondo L, Baldessarini RJ. Reduced suicide risk during lithium maintenance treatment. J Clin Psychiatry 2000 61(suppl 9) 97-104. 

Fawcett J. Suicide risk factors in depressive disorders and in panic disorder. J din Psychiatry 1992 5[3, Suppl] 9-13. 

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