Suicidal antidepressant overdoses: a comparative analysis by antidepressant type

Current Utilization of Bupropion Treatment in Children, Young Adults, and Adults in the United States

Introduction: While available for decades, the use of bupropion has increased in recent years. To provide an updated review on the use of bupropion, this article aimed to describe bupropion prescription details, potential indication, and treatment duration in children, young adults, and adults starting bupropion treatment. Methods: Individuals aged 6-64 newly initiating bupropion hydrochloride treatment were identified from commercial claims data (MarketScan, 1/1/2016-12/31/2022). New bupropion use was defined as at least 1 year without any prior bupropion dispensed prescription. Potential indications for bupropion treatment were identified from inpatient/outpatient records (ICD-10-CM diagnoses) in the 30 days prior to bupropion initiation. All analyses were stratified by age: children (6-17 years), young adults (18-29 years), and adults (30-64 years) and treatment duration up to 1 year was estimated with Kaplan-Meier estimation. Results: The study sample included 39,833 children, 177,710 young adults, and 548,557 adults newly initiating bupropion treatment. Bupropion extended-release 24-hour 150 mg was the most common (62%) formulation and dose at initiation. Depression was the most prevalent potential indication (children = 57%, young adults = 47%, adults = 36%) and attention-deficit/hyperactivity disorder (ADHD) was the next most common potential indication in children (25%) and young adults (12%); tobacco cessation and weight loss also identified as potential indications. Twenty-two percent of bupropion initiators were on concurrent selective serotonin reuptake inhibitor treatment. In children, suicidal ideation (16.3%), poisoning (5.9%), and anorexia or bulimia nervosa (2.2%) were relatively common diagnoses prior to bupropion initiation. Overall, 39%-45% remained on bupropion treatment for at least 6 months, with variation by potential indication. Conclusion: The antidepressant bupropion is prescribed to children, young adults, and adults for a variety of indications in the United States, with depression and ADHD the most common indications in children. As the prescribing of bupropion becomes more widespread, additional safety and effectiveness data will be necessary to inform prescribing decisions, particularly in populations with unknown efficacy.

Assessing suicide risk in chronic pain management: a narrative review across drug classes

INTRODUCTION

Chronic pain presents a multifaceted challenge in clinical practice, necessitating a nuanced understanding of pharmacological interventions to optimize treatment outcomes. This review provides an outline of various pharmacological agents commonly used in chronic pain management and highlights their safety considerations, particularly regarding suicide risk.

AREAS COVERED

This review discusses the role of antidepressants, anticonvulsants, GABA receptor agonists, NMDA receptor antagonists, corticosteroids, cannabis and cannabinoids, bisphosphonates, calcitonin, and alpha-2 adrenergic receptor agonists in chronic pain management. It assesses their therapeutic benefits, potential for misuse, and psychiatric adverse effects, including the risk of suicide. Each pharmacological class is evaluated in terms of its efficacy, safety profile, and considerations for clinical practice. We searched peer-reviewed English literature on the topic using the MEDLINE database without time restrictions.

EXPERT OPINION

While pharmacological interventions offer promise in alleviating chronic pain, healthcare providers must carefully weigh their benefits against potential risks, including the risk of exacerbating psychiatric symptoms and increasing suicide risk. Individualized treatment approaches, close monitoring, and multidisciplinary collaboration are essential for optimizing pain management strategies while mitigating adverse effects. Ongoing research efforts are crucial for advancing our understanding of these pharmacological interventions and refining pain management practices.

Three safety indices for the fourteen most prescribed antidepressants in the US, 2013-2020

OBJECTIVE

This study provides three prevalence-based metrics of potential harm, the fatal toxicity index (FTI), serious morbidity index (SMI) and healthcare utilization index (HUI) for fourteen of the most prescribed antidepressants in the US.

METHOD

For the years 2013-2020, adverse events for single drug exposures were obtained from the National Poison Data System. Prescription estimates were taken from the Agency for Healthcare Research and Quality's Medical Expenditure Survey. 95% confidence intervals were calculated using a Poisson distribution. Chi-square testing was used where significance was not clear.

RESULTS

SSRIs and SNRIs had the lowest overall indices (FTI 0.02-0.26). Bupropion's FTI (0.27-0.43) was not statistically significantly different from that of imipramine (FTI 0-1.3, p = .62) or nortriptyline (FTI 0.25-0.78, p = .22), though its SMI and HUI were significantly greater. There was a statistically significant difference in all indices between TCAs (p < .0047). The difference between the FTI of all SSRIs did not remain significant after correction (p = .045).

CONCLUSION

SSRIs and SNRIs are safer than alternative agents on all measures. Bupropion exposure was as likely to cause mortality, and more likely to cause morbidity or require treatment in a healthcare facility, than TCAs nortriptyline and imipramine.

The cardiovascular safety of tricyclic antidepressants in overdose and in clinical use

Tricyclic antidepressants (TCAs) remain widely prescribed for depression and many other conditions. There may be important differences between individual TCA in regard to their overdose toxicity and their cardiac toxicity in clinical use. We conducted a systematic review to compare the toxicity of individual TCA in overdose and the risk of serious adverse cardiac events occurring with therapeutic doses. We used the fatal toxicity index (FTI) and case fatality ratio as markers of fatality in overdose, and hazard ratios or odds ratios for the risk of cardiovascular adverse events during normal clinical use. In all, 30 reports of mortality in overdose and 14 observational studies assessing the risk of cardiovascular adverse events in clinical use were included. FTI values were of the same order of magnitude (101-102) for all TCAs except lofepramine. Desipramine appears to be somewhat more likely than other TCAs to lead to death in overdose. Amitriptyline, clomipramine, dothiepin/dosulepin, doxepin, trimipramine and imipramine showed broadly similar toxicity and were usually reported to be less toxic than desipramine. Data on nortriptyline were contradictory. Lofepramine had the lowest risk of death in overdose. The rank order of overdose toxicity was broadly consistent between different FTI definitions and between markers used. With respect to the risk of cardiovascular events at clinically relevant exposure, amitriptyline, nortriptyline and lofepramine were associated with a greater risk of in-use cardiotoxicity. All measures of overdose toxicity were subject to external influences and confounding. The continued use of TCAs in depression and other conditions should be minimized when considering their undoubted toxicity in overdose and possible toxicity in normal clinical use.

Fatal concentrations of antidepressant and antipsychotic drugs in postmortem femoral blood

Antidepressants and antipsychotics are both an important class of prescription drugs within postmortem (PM) toxicology because most of the substances are toxic in overdose and the mental disorders being treated may be associated with suicidality. A wide range of antidepressants and antipsychotics are currently included in up-to-date PM toxicology analysis protocols. However, apart from case studies, few reports on fatal concentrations based on large number of cases have been published in the literature. Based on PM investigations in Finland between 2000 and 2020, this study provides fatal reference concentrations in poisonings due to an antidepressant or an antipsychotic drug assigned as the principal intoxicant. Summary statistics for drug concentrations in PM femoral blood (min, max, mean, 10th, 25th, 50th, 75th, 90th percentile) were calculated for 17 antidepressant (N = 2,007) and for 12 antipsychotic drugs (N = 1,161). The proportion of suicide, accident and undetermined manner of death is indicated for each drug. Further, the fatal concentrations obtained in this study were evaluated by comparison with fatal and "normal" PM concentrations reported by two previously published approaches, the grouped causes of death approach and the all causes of death approach, respectively. This study shows that, despite the well-known variation in PM drug concentrations, competently generated fatal concentration results for the drugs studied are consistent to such an extent that they can be used as a reference in the interpretation process.

Understanding the mechanism of action and clinical effects of neuroactive steroids and GABAergic compounds in major depressive disorder

The pathophysiology of major depressive disorder (MDD) is thought to result from impaired connectivity between key brain networks. Gamma-aminobutyric acid (GABA) is the key inhibitory neurotransmitter in the brain, working primarily via GABAA receptors, with an important role in virtually all physiologic functions in the brain. Some neuroactive steroids (NASs) are positive allosteric modulators (PAMs) of GABAA receptors and potentiate phasic and tonic inhibitory responses via activation of synaptic and extrasynaptic GABAA receptors, respectively. This review first discusses preclinical and clinical data that support the association of depression with diverse defects in the GABAergic system of neurotransmission. Decreased levels of GABA and NASs have been observed in adults with depression compared with healthy controls, while treatment with antidepressants normalized the altered levels of GABA and NASs. Second, as there has been intense interest in treatment approaches for depression that target dysregulated GABAergic neurotransmission, we discuss NASs approved or currently in clinical development for the treatment of depression. Brexanolone, an intravenous NAS and a GABAA receptor PAM, is approved by the U.S. Food and Drug Administration for the treatment of postpartum depression (PPD) in patients 15 years and older. Other NASs include zuranolone, an investigational oral GABAA receptor PAM, and PH10, which acts on nasal chemosensory receptors; clinical data to date have shown improvement in depressive symptoms with these investigational NASs in adults with MDD or PPD. Finally, the review discusses how NAS GABAA receptor PAMs may potentially address the unmet need for novel and effective treatments with rapid and sustained antidepressant effects in patients with MDD.

Trends in calls to a state poisons centre and presentation to emergency departments for intentional antidepressant overdose in Victoria, Australia

OBJECTIVE

To describe the rates and trends of emergency department presentations and calls to a state poisons centre for antidepressant overdose.

METHODS

A retrospective cohort study utilising the Victorian Emergency Minimum Dataset and Victorian Poisons Information Centre call registry between January 2009 and December 2018 was conducted. This captured all presentations to Victorian emergency departments and calls to the Victorian Poisons Information Centre. Any intentional overdose involving an antidepressant was included. Annual rates of emergency department presentations and calls per 100,000 persons and 100,000 prescriptions for antidepressants overall and individual antidepressant classes, in addition to age-group-specific rates, were reported.

RESULTS

A total of 3650 presentations to emergency department and 7096 calls to the poisons centre were included. No changes were seen in overall emergency department presentation rates when controlled for population or prescription numbers, but large and significant increases were seen for younger age groups. The 10-14- and 15-19-year age groups had average annual increases of 13.1% (95% CI = [6.5%, 19.7%], p < 0.001) and 7.2% (95% CI = [2.8%, 11.5%], p < 0.001) per 100,000 persons, respectively. Increases were seen in overall annual call rates of 6.7% (95% CI = [5.2%, 8.1%], p < 0.001) per 100,000 persons and 7.5% (95% CI = [4.9%, 10.1%], p < 0.001) per 100,000 prescriptions.

CONCLUSION

Overall, emergency department presentation rates remained stable during the study period. Overall poisons centre call rates increased moderately. However, when examining younger persons, large increases were seen in both emergency department presentations and poison centre call rates. These findings highlight the need for future interventions to mitigate against intentional overdose in younger populations.

T-Wave Inversion After Escitalopram Overdose: A Case Report

Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used due to their comparatively less cardiotoxic effects than tricyclic antidepressants. Corrected QT interval (QTc) prolongation is the most common electrocardiography (ECG) change that has been encountered with SSRI overdose. This case report is about a 22-year-old woman who was brought to the emergency department (ED) with an alleged history of consumption of 200 mg of escitalopram. Her ECG showed T-wave inversions in anterior leads one to five, which reverted (in leads four and five) the next day with supportive management. After 24 hours, she developed dystonia, which resolved with mild doses of benzodiazepine. Hence, ECG changes like T-wave inversions may occur even with a small overdose of an SSRI without any significant adverse effects.

Successful Treatment of Amoxapine-Induced Intractable Seizures With Intravenous Lipid Emulsion

BACKGROUND

Amoxapine is a second-generation tricyclic antidepressant with a greater seizure risk than other antidepressants. If administered in large amounts, amoxapine can cause severe toxicity and death. Therefore, it is necessary to terminate seizures immediately if amoxapine toxicity occurs. However, intractable seizures often occur in these patients. We describe a case of intractable seizures caused by amoxapine poisoning, in which intravenous lipid emulsion (ILE) was used successfully.

CASE REPORT

A 44-year-old woman with a history of depression ingested 3.0 g of amoxapine during a suicide attempt. Although she was initially treated with intravenous diazepam, her seizures persisted. Levetiracetam and phenobarbital were then administered, but seizures persisted. Hence, ILE was injected for over 1 min. At 2 min after ILE administration, the patient's status seizures ceased. Recurrence of seizures was observed 30 min after ILE, and the seizures disappeared after re-administration of ILE. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ILE may be effective in amoxapine intoxication. Emergency physicians may consider ILE as an adjunctive therapy for amoxapine poisoning with a high mortality rate. ILE should be implemented carefully with monitoring of total dosage and adverse events.

Single-substance trazodone exposures reported to US poison centers from 2000 to 2019

BACKGROUND

Individual case reports describe trazodone overdose resulting in QTc prolongation and cardiac arrhythmias. The clinical effects and outcomes associated with trazodone exposures on a large-scale basis are less well known.

OBJECTIVE

The primary objective was to characterize the severity of single substance trazodone exposures and identify any relationships that may exist between dose of trazodone and severity of exposure. The secondary objective was to describe these exposures from a demographic and clinical symptom standpoint.

METHODS

A retrospective review of single-substance trazodone exposures reported to the National Poison Data System (NPDS) from 1 January 2000 to 31 December 2019 was performed. The primary objective was to characterize the severity of trazodone exposures and relationships between ingested dose and level of care required or medical outcome.

RESULTS

A total of 118,773 cases were included in the analysis of demographics and level of care required. A majority (59.5%) of cases did not require medical admission. Of the 81,698 cases with known medical outcomes, the most common clinical effects included mild-moderate CNS depression (49.7%), QTc prolongation (12.2% of cases in 2019), vomiting (9.0%), hypotension (7.0%), and tachycardia (7.0%). The median ingested dose associated with treatment, and release from the emergency department was 600 mg compared to 1500 mg in those admitted to the intensive care unit (ICU). Regarding medical outcome, median ingested dose ranged from 600 mg in those experiencing no effect to 1500 mg in those experiencing major effects. Cardiac-related clinical effects and the need for cardiac-specific interventions were overall infrequent. A dose-response relationship was identified for level of care and medical outcome.

CONCLUSIONS

Many trazodone exposures can be characterized as low severity due to the infrequent need for healthcare facility admission and large proportion of cases that experienced no effects or only minor effects.

Surveillance of drug overdose and identification of its risk factors by a multivariate analysis using the Japanese Adverse Drug Event Report database

BACKGROUND

Limited information is currently available on drug overdose in Japan. Therefore, the present study examined drug overdose using the Japanese Adverse Drug Event Report (JADER) database.

METHODS

The records of drug overdose in patients were extracted from the JADER database. Risk factors for drug overdose in patients with bipolar disorders were examined using a multiple logistic regression analysis.

RESULTS

Overdoses of 1327 medicines in 784 patients were registered in the JADER database. An overdose of lithium carbonate was the most frequently reported in 144 patients, followed by zolpidem tartrate in 88, and then quetiapine fumarate, sodium valproate, risperidone, and paroxetine hydrochloride hydrate. The number of overdoses was higher in females, and peaked in patients aged with 30-39 years. The dosages of overdosed lithium carbonate ranged between 1800 and 60,000 mg, with a median of 8400 mg, while those of overdosed zolpidem tartrate ranged between 15 and 600 mg, with a median of 105 mg. Forty-one drug overdose cases were registered in 3521 patients with bipolar disorder, bipolar I disorder, or bipolar II disorder in the JADER database. A multivariate analysis of these cases identified female sex, an age younger than 50 years, and the use of lithium carbonate as risk factors for drug overdose. Lamotrigine reduced its odds, and no relationship was observed with aripiprazole or sodium valproate.

CONCLUSION

The present study represented a surveillance of drug overdose, and identified risk factors in patients with bipolar disorders by a multivariate analysis using the JADER database.

[Prevention of impulsive suicide with antidepressants in outpatients]

Self-poisoning is a common method of suicide, for which various medications are used, including antidepressants. A non-systematic review of Russian-language and English-language publications, by keywords, in the databases: ELibrary.ru, PubMed, Cochrane Database of Systematic Reviews. The purpose of the review was to analyze the literature on new risk factors and methods of their reduction in suicides with self-poisoning with antidepressants. Every fifth (20%) self-poisoning performed with antidepressants. In self-poisoning attempts, one drug used in 55% of cases, and more than one drug was used in 45% of cases. Impulsive suicides account for up to half of all suicide cases. Risk factors for impulsive suicides include the presence of impulsive character traits, female gender, young age, and the use of psychostimulants. The WHO Regional Office for Europe's mhGAP-IG guidelines recommend limiting access to a patient at risk of suicide to a weekly dose of an antidepressant. Preferably, the use of antidepressants from the group of SSRIs in small forms of release.

Distribution of Fluvoxamine and Identification of the Main Metabolite in a Fatal Intoxication

Fluvoxamine is a selective serotonin reuptake inhibitor, with a half-life of about 30 hours, that is commonly prescribed in the treatment of depression and obsessive and compulsive disorders. Though its more favorable adverse effect profile in comparison to tricyclic antidepressants, overdosages could lead to severe central nervous system depression. We hereby report the case of a 48-year-old woman with psychiatric disorders, who died in the Protected Community where she lived. An autopsy, during which multiorgan congestion and aspiration of gastric content were found, was performed 9 days after the death. Femoral and cardiac blood, urine and bile were collected for toxicological analysis. GC-MS, LC-MS-MS and LC-HRMS screenings were performed on blood samples. The analysis allowed to identify the following drugs: fluvoxamine, clotiapine, 7-aminoclonazepam, propranolol, gabapentin and haloperidol. Quantification of the detected drugs in blood was performed by means of a validated LC-MS-MS analytical procedure, and the following results were achieved: fluvoxamine (2.20 mg/L), gabapentin (41.00 mg/L), 7-aminoclonazepam (0.24 mg/L), clotiapine (0.07 mg/L), haloperidol (<0.01 mg/L) and propranolol (0.24 mg/L). Fluvoxamine concentration in blood exceeded ~10 times the upper limit of therapeutic blood levels (0.23 mg/L). Contributory causes of death, such as due to multiple drug use, however, cannot be excluded. The distribution of fluvoxamine in all biological fluids was evaluated and a postmortem redistribution effect was observed (C/P blood ratio: 1.86). Fluvoxamine acid metabolite was identified in urine, bile and in cardiac blood, through an LC-QTOF analytical procedure.

Antidepressants and Risk of Sudden Cardiac Death: A Network Meta-Analysis and Systematic Review

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

Factors associated with seizure development after bupropion overdose: a review of the toxicology investigators consortium

BACKGROUND

Bupropion is an aminoketone antidepressant. A major concern in bupropion toxicity is seizure activity, which can occur up to 24 h from ingestion. It is difficult to predict which patients will have seizures. The purpose of this study is to identify clinical features associate with seizure after bupropion overdose.

METHODS

We searched the Toxicology Investigators Consortium registry for a cases of poisoning by bupropion between January 1, 2014 and January 1, 2017 in patients aged 13-65. Demographic variables and clinical features were compared between patients who did and did not experience a seizure and presented as unadjusted odds ratios (OR). Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) between clinical features and seizures.

RESULTS

There were 256 cases of bupropion overdose remaining after inclusion/exclusion criteria were applied. Clinical features associated with seizure were QTc >500 (OR = 3.4, 95% CI: 1.3-8.8, p = 0.012), tachycardia (p > 140) (OR = 1.9, 95% CI: 1-3.561, p = 0.05), and age 13-18 years (2.4, 95% CI: 1.3-4.3, p = 0.005). The mean QTc value for patients experiencing a seizure was 482 ms (N = 95 IQR: 59 ms) versus 454 ms (N = 103, IQR: 43) in patients who did not experience seizure, however, it was not possible to identify a QTc cutoff with sensitivity or specificity to predict seizures.

CONCLUSION

Based on our analysis of data from the ToxIC registry, age (13-18), tachycardia (p > 140) and QTc >500 ms are associated with seizures in bupropion overdose; however, a specific QTc value may not be a useful predictor of seizures.

Antidepressant Screening Demonstrated Non-Monotonic Responses to Amitriptyline, Amoxapine and Sertraline in Locomotor Activity Assay in Larval Zebrafish

Antidepressants are well-known drugs to treat depression and major depressive disorder for humans. However, the misuse and abuse of antidepressants keep increasing with several side effects reported. The aim of this study was to assess the potential adverse effects of 18 antidepressants by monitoring zebrafish larval locomotor activity performance based on the total distance traveled, burst movement count, and total rotation count at four dark-light intercalated phases. In general, zebrafish larvae displayed sedative effects after antidepressant exposure by showing a significant reduction in all of the locomotor activity-related endpoints. However, three antidepressants i.e., amitriptyline, amoxapine, and sertraline were able to trigger a significantly high locomotor activity in zebrafish larvae during the light cycle. These differences might be due to the pharmacologic differences among the antidepressants. In addition, since each antidepressant possesses a different dosage range from the other, overdoses of these antidepressants might also be the causes of these differences. Furthermore, based on these results, a further study was conducted to observe the effect of these three antidepressants in lower concentrations. From the results, biphasic effects in terms of zebrafish larval locomotor activity were demonstrated by these drugs. Even though further studies are still required to validate the mechanism, these findings indicate that these antidepressants might share a common mechanism responsible for their effects on zebrafish larval locomotor activity although there were some differences in potency of these effects.

Dermestes maculatus (Coleoptera: Dermestidae) development under fluoxetine effect using two drug administration models

Fluoxetine is a selective serotonin reuptake inhibitor, commonly used for the treatment of a variety of psychopathological conditions. As such, fluoxetine may be expected to appear in clinical and forensic cases. Dermestes maculatus De Geer (Coleoptera: Dermestidae) has been recognized as a relevant component of the insect fauna associated with decomposing human and animal remains. Experiments were conducted to study the effect of fluoxetine on developing D. maculatus using two-drug administration models: a non-living animal model (pork muscle) and a living one (Sus scrofa L. pigs). We assessed the duration of immature stages and total life cycle, as well as morphological parameters (body length, cephalic width, and weight). The effect of fluoxetine was studied at an overdose concentration: In the non-living animal model the drug was mixed with macerated pork muscle (2000 mg/kg) and in the living animal model, pigs were given the drug orally (833 mg/kg). A control was used for each model. Daily observations were performed from the beginning to the end of the experiments. GC-MS was used for drug detection and quantification. There were no statistically significant differences in the duration of immature stages, life cycle, larval mortality, morphological parameters, or sex ratio, between treatment and control, regardless of the drug administration model. Given that fluoxetine had no detectable effect on the development of D. maculatus, detection of this drug in forensic situations would not compromise the accuracy of PMI estimations.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Update on Unipolar Nonpsychotic Depression

BACKGROUND

The Psychopharmacology Algorithm Project at the Harvard South Shore Program presents evidence-based recommendations considering efficacy, tolerability, safety, and cost. Two previous algorithms for unipolar nonpsychotic depression were published in 1993 and 1998. New studies over the last 20 years suggest that another update is needed.

METHODS

The references reviewed for the previous algorithms were reevaluated, and a new literature search was conducted to identify studies that would either support or alter the previous recommendations. Other guidelines and algorithms were consulted. We considered exceptions to the main algorithm, as for pregnant women and patients with anxious distress, mixed features, or common medical and psychiatric comorbidities.

SUMMARY

For inpatients with severe melancholic depression and acute safety concerns, electroconvulsive therapy (or ketamine if ECT refused or ineffective) may be the first-line treatment. In the absence of an urgent indication, we recommend trialing venlafaxine, mirtazapine, or a tricyclic antidepressant. These may be augmented if necessary with lithium or T3 (triiodothyronine). For inpatients with non-melancholic depression and most depressed outpatients, sertraline, escitalopram, and bupropion are reasonable first choices. If no response, the prescriber (in collaboration with the patient) has many choices for the second trial in this algorithm because there is no clear preference based on evidence, and there are many individual patient considerations to take into account. If no response to the second medication trial, the patient is considered to have a medication treatment-resistant depression. If the patient meets criteria for the atypical features specifier, a monoamine oxidase inhibitor could be considered. If not, reconsider (for the third trial) some of the same options suggested for the second trial. Some other choices can also considered at this stage. If the patient has comorbidities such as chronic pain, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, or posttraumatic stress disorder, the depression could be secondary; evidence-based treatments for those disorders would then be recommended.

A comprehensive analysis of attempted and fatal suicide cases involving frequently used psychotropic medications

OBJECTIVES

Self-poisoning is the most common suicide method in non-lethal suicide attempts and the third most frequent in fatal suicides. Psychoactive drugs are often used for intentional self-poisoning. While poisons centre data typically focus on survived suicide attempts and underrepresent fatal self-poisoning, medical examiner reports give insight into suicide deaths. To close this gap, we combined and compared data sets from both sources, assessing the mortality of psychotropic drugs used for self-poisoning.

METHODS

Anonymized cases of self-poisoning with suicidal intention from 2000 to 2010 were extracted from the national poisons centre case database and compared with cases of suicide documented in the project "Suicides, a national survey". All cases with single substance exposure to a psychoactive drug (antidepressants, mood stabilizers, antipsychotics, sedatives) were included in the analyses. Opioids, over-the-counter- and illicit- drugs were excluded from the analysis. A mortality index was calculated by the ratio of the number of suicides and the sum of all (lethal and non-lethal) suicide attempts.

RESULTS

Tricyclics had a higher mortality rate than other antidepressants. Among the sedatives, zolpidem was found to have a higher mortality index compared to benzodiazepines. Clozapine and levomepromazine were found to be the most lethal antipsychotics. Non-lethal suicide cases with single substance exposure (n = 4697) diminished as age increased, while the rate of suicide cases (n = 165) was higher in elderly subjects (>65 years of age, p < 0.001).

CONCLUSION

In summary, our findings confirm previous study results on the relative toxicity of distinct classes of psychotropic drugs. In this comprehensive analysis of a national cohort lorazepam had a lower mortality rate compared to other sedatives.

Substances Involved in Suicidal Poisonings in the United States

OBJECTIVE

This study investigated specific substances most commonly involved in suicidal poisonings, causing severe clinical effects, and leading to intensive treatments.

METHOD

Suicidal poisoning cases for individuals ≥13 years old were obtained from the National Poison Data System for 2011-2015. The most common products involved in single and multiple-product poisonings were identified. Single product cases were used to calculate substances causing the largest numbers of serious clinical effects and leading to intensive treatments.

RESULTS

More than half of reported cases involved only a single product (54.4%), but this frequency was higher at the extremes of age (66.7% in adolescents 13-19 years old and 70.5% in individuals ≥90 years old) and among pregnant women (65.8%). The top three substances involved in single-product poisonings were over-the-counter (OTC) medications, while alcohol and prescription sedatives were most common in multiple-product poisonings. One OTC medication, diphenhydramine, was a frequent cause of several serious clinical effects and intensive treatments.

CONCLUSIONS

Single product suicidal poisonings were more frequent with extremes of age and in pregnancy. OTC products were more frequently used in single product attempts. Products causing serious clinical effects can be targeted for suicide prevention efforts as well as education of health care providers.

Management of Trazodone Overdose with Severe Hypotension

Trazodone is a medication that possesses antidepressant, anxiolytic, and hypnotic properties. Its mechanism of action includes blockade of serotonin type 2 receptors, weak inhibition of serotonin reuptake, blockade of histamine 1 receptors, and blockade of alpha-1-adrenergic receptors. We present a case of intentional ingestion of an estimated 2500 mg of trazodone leading to persistent hypotension, requiring aggressive fluid resuscitation, pressor support, and intensive care unit admission. Complications associated with trazodone overdoses are significant and clinicians should be aware of the associated symptoms and necessary management plans necessary for such ingestions.

Construction of molecularly imprinted nanoparticles by employing ultrasound waves for selective determination of doxepin from human plasma samples: Modeling and optimization

In this work, molecularly imprinted nanoparticles (MINPs) were applied as selective adsorbent for ultrasound-assisted micro-solid-phase extraction (UAMSPE) of doxepin (DP) from human plasma samples, which was then cleaned up, pre-concentrated and subjected to HPLC. The MINPs were synthesized based on a non-covalent approach by precipitation polymerization utilizing methacrylic acid and styrene as functional monomers, DP as template, ethylene glycol dimethacrylate as cross-linker and 2,2-azobisisobutyronitrile (AIBN) as initiator. The obtained MINPs were characterized by Fourier transform-infrared and field emission scanning electron microscopy. Factors influencing the efficiency of UAMSPE such as sonication time, volume of eluent solvent and amount of sorbent were investigated using a central composite design and the optimal points were identified as 4 min of sonication time, 380 μL of eluent solvent and 30 mg of sorbent. Under optimized conditions, the proposed method has linear responses in the range of 0.2-2000 ng mL^-1 , with a satisfactory limit of detection of 0.04 ng mL^-1 and limit of quantification of 0.11 ng mL^-1 .

Toxicity of Bupropion Overdose Compared With Selective Serotonin Reuptake Inhibitors

OBJECTIVES

Adolescent depression and attempted and completed suicide are increasing in the United States. Because suicide is often impulsive, the means of self-harm are frequently items of convenience like medication. Authors of a recent study compared tricyclic antidepressant overdose to bupropion overdose. Fluoxetine and escitalopram are the only agents with Food and Drug Administration approval for pediatric depression, but off-label bupropion prescriptions are common. We sought to compare the effects of selective serotonin reuptake inhibitors (SSRIs) and bupropion in overdose.

METHODS

This was an analysis of the National Poison Data System from June 2013 through December 2017 for adolescent (ages 10-19) exposures to SSRIs or bupropion coded as "suspected suicide." Demographics, clinical effects, therapies, and medical outcome were analyzed.

RESULTS

There were 30 026 cases during the study period. Sertraline and fluoxetine accounted for nearly 60%, whereas bupropion was reported in 11.7%. Bupropion exposure was significantly associated with death (0.23% vs 0%; P < .001) or serious outcome (58.1% vs 19%; P < .001) as well as the 10 most common clinical effects, including seizures (27.0% vs 8.5%; P < .001) and hallucinations (28.6% vs 4.3%; P < .001). Bupropion exposure was significantly associated with the need for cardiopulmonary resuscitation (0.51% vs 0.01%; P < .001), intubation (4.9% vs 0.3%; P < .001), vasopressors (1.1% vs 0.2%; P < .001), and benzodiazepines (34.2% vs 5.5%; P < .001). There was a significant increase in all exposures and in proportion of serious outcomes over time.

CONCLUSIONS

Adolescents who attempt self-harm are at higher risk for serious morbidity and poor outcomes with bupropion than with SSRIs. These risks, and the patient's propensity for self-harm, should be evaluated when therapy with bupropion is considered.

Diet-Related Metabolic Perturbations of Gut Microbial Shikimate Pathway-Tryptamine-tRNA Aminoacylation-Protein Synthesis in Human Health and Disease

Human gut bacterial Na(+)-transporting NADH:ubiquinone reductase (NQR) sequence is associated with Alzheimer disease (AD). Here, Alzheimer disease-associated sequence (ADAS) is further characterized in cultured spore-forming Clostridium sp. Tryptophan and NQR substrate ubiquinone have common precursor chorismate in microbial shikimate pathway. Tryptophan-derived tryptamine presents in human diet and gut microbiome. Tryptamine inhibits tryptophanyl-tRNA synthetase (TrpRS) with consequent neurodegeneration in cell and animal models. Tryptophanyl-tRNA synthetase inhibition causes protein biosynthesis impairment similar to that revealed in AD. Tryptamine-induced TrpRS gene-dose reduction is associated with TrpRS protein deficiency and cell death. In animals, tryptamine treatment results in toxicity, weight gain, and prediabetes-related hypoglycemia. Sequence analysis of gut microbiome database reveals 89% to 100% ADAS nucleotide identity in American Indian (Cheyenne and Arapaho [C&A]) Oklahomans, of which ~93% being overweight or obese and 50% self-reporting type 2 diabetes (T2D). Alzheimer disease-associated sequence occurs in 10.8% of C&A vs 1.3% of healthy American population. This observation is of considerable interest because T2D links to AD and obesity. Alzheimer disease-associated sequence prevails in gut microbiome of colorectal cancer, which linked to AD. Metabolomics revealed that tryptamine, chorismate precursor quinate, and chorismate product 4-hydroxybenzoate (ubiquinone precursor) are significantly higher, while tryptophan-containing dipeptides are lower due to tRNA aminoacylation deficiency in C&A compared with non-native Oklahoman who showed no ADAS. Thus, gut microbial tryptamine overproduction correlates with ADAS occurrence. Antibiotic and diet additives induce ADAS and tryptamine. Mitogenic/cytotoxic tryptamine cause microbial and human cell death, gut dysbiosis, and consequent disruption of host-microbe homeostasis. Present analysis of 1246 participants from 17 human gut metagenomics studies revealed ADAS in cell death diseases.

Relative toxicity of analgesics commonly used for intentional self-poisoning: A study of case fatality based on fatal and non-fatal overdoses

BACKGROUND

Analgesics are used most frequently in fatal and non-fatal medicinal self-poisonings. Knowledge about their relative toxicity in overdose is important for clinicians and regulatory agencies.

METHODS

Using data for 2005-2012 we investigated case fatality (number of suicides relative to number of non-fatal self-poisonings) of paracetamol, aspirin, codeine, dihydrocodeine, tramadol, paracetamol with codeine (co-codamol), paracetamol with dihydrocodeine (co-dydramol), ibuprofen and co-proxamol (paracetamol plus dextropropoxyphene; withdrawn in the UK in 2008 due to high toxicity). Data on suicides obtained from the Office for National Statistics and on non-fatal self-poisonings from the Multicentre Study of Self-harm in England. Case fatality was estimated for each drug, using paracetamol as the reference category.

RESULTS

Compared to paracetamol and based on single drug deaths the case fatality index of dihydrocodeine was considerably elevated (odds ratio (OR) 12.81, 95% Confidence Interval (CI) 10.19-16.12). Case fatality indices for tramadol (OR 4.05, 95% CI 3.38-4.85) and codeine (OR 2.21, 95% CI 1.81-2.70) were also significantly higher than for paracetamol. The results when multiple drug deaths were included produced similar results. The relative toxicity of co-proxamol far exceeded that of the other analgesics.

LIMITATIONS

Data on fatal self-poisonings were based on national data, whereas those for non-fatal poisonings were based on local data.

CONCLUSIONS

Dihydrocodeine and tramadol are particularly toxic in overdose and codeine is also relatively toxic. They should be prescribed with caution, particularly to individuals at risk of self-harm.

Inhibition of the Voltage-Dependent K+ Current by the Tricyclic Antidepressant Desipramine in Rabbit Coronary Arterial Smooth Muscle Cells

We describe the effect of a tricyclic antidepressant drug desipramine on voltage-dependent K⁺ (Kv) currents in freshly isolated rabbit coronary arterial smooth muscle cells using a conventional whole-cell patch clamp technique. Application of desipramine rapidly decreased the Kv current amplitude in a concentration-dependent manner, with an IC₅₀ value of 5.91 ± 0.18 μM and a Hill coefficient of 0.61 ± 0.09. The steady-state inactivation curves of the Kv channels were not affected by desipramine. However, desipramine shifted the steady-state inactivation curves toward a more negative potential. Application of train pulses (1 or 2 Hz) slightly reduced the Kv current amplitude. Such reduction in the Kv current amplitude by train pulses increased in the presence of desipramine. Furthermore, the inactivation recovery time constant was also increased in the presence of desipramine, suggesting that desipramine-induced inhibition of the Kv current was use-dependent. Application of a Kv1.5 inhibitor (DPO-1) and/or a Kv2.1 inhibitor (guangxitoxin) did not change the inhibitory effect of desipramine on Kv currents. Based on these results, we concluded that desipramine directly inhibited the Kv channels in a dose- and state-dependent manner, but the effect was independent of norepinephrine/serotonin reuptake inhibition.

Sex differences in antidepressant efficacy

Sex differences have been observed across many psychiatric diseases, especially mood disorders. For major depression, the most prevalent psychiatric disorder, females show a roughly two-fold greater risk as compared to males. Depression is sexually dimorphic with males and females exhibiting differences in clinical presentation, course, and response to antidepressant treatment. In this review, we first discuss sex differences observed in depressed patients, as well as animal models that reveal potential underlying mechanisms. We then discuss antidepressant treatments including their proposed mechanism of action and sex differences observed in treatment response. We include possible mechanisms underlying these sex differences with particular focus on synaptic transmission.

Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning

BACKGROUND

Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour.

METHOD

Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012.

RESULTS

There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47).

CONCLUSIONS

There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.

Unintentional trazodone overdoses in children ≤6 years of age: data from poison center over a period of 16 years

CONTEXT

Trazodone is an atypical antidepressant with no established safety in children. Previous case reports showed no complications at doses 50-500 mg in children. Our study objective is to characterize the clinical effects, dose-related toxicity, and establish triage dose for acute trazodone ingestions in children ≤6 years of age.

METHODS

Cases with acute trazodone ingestions in children ≤6 years of age between 2000 and 2015 were retrospectively reviewed. Data were analyzed for dose (mg/kg), clinical effects, management site, treatment, and outcome. Cases with coingestions, unknown outcome, or unknown dose were excluded.

RESULTS

A total of 84 patients (mean age 26.7 months, 35 females, 49 males) were included. Of those, 52 (61.9%) had no clinical effects; 29 (34.5%) had minor effects (vomiting, dizziness, headache); and three (3.6%) had moderate effects (ataxia, slurred speech, priapism). No major effects or deaths were observed. Moderate effects were manifested at doses ≥6.9 mg/kg. Priapism occurred in a 2-year-old child at a dose of 6.9 mg/kg. Sixteen (19%) patients were managed at home and 68 (81%) patients were referred to a HCF. Among those referred to a HCF, three (4.4%) patients had moderate effects with ingested dose ≥6.9 mg/kg. However, 27 (39.7%) patients of those referred to a HCF had an ingested dose <6 mg/kg and none of them manifested symptoms beyond minor effects. All referred patients had uneventful recovery and no sequela.

CONCLUSIONS

Children should be referred for further evaluation in acute unintentional trazodone ingestions with doses ≥6 mg/kg.

Vortioxetine overdose in a suicidal attempt: A case report

RATIONALE

Vortioxetine is a new multimodal antidepressant approved by the Food and Drug Administration for the treatment of Major Depressive Disorder and recently introduced in Europe. While antidepressant properties of vortioxetine and its tolerability have been demonstrated by preclinical and clinical studies data on the safety of vortioxetine after overdose are still lacking.

PATIENT CONCERNS

A 50-year-old Caucasian man presenting a severe depressive episode that in a suicide attempt he took vortioxetine at 250 mg.

DIAGNOSES

Suicide attempt by vortioxetine in a patient affected by Major Depressive Disorder.

INTERVENTIONS

General evaluations and gastric lavage with 2 L of water plus 50 g of activated charcoal was performed. After 12 hours of clinical stability, the patient was discharged from the emergency department and considering the suicidal ideation he was admitted to the inpatients psychiatric department.

OUTCOMES

After vortioxetine overdose the patient displayed no clinical signs or symptoms resulting from the exposure suggesting a good safety in overdose.

LESSON

Overdose safety of different antidepressant drugs is a matter of great considering that overdose in individuals affected by Major Depressive Disorder frequently involves prescribed antidepressants. Previous studies showed wide variation in the relative toxicity of different antidepressant drugs with higher toxicity for tricyclic antidepressants, followed by venlafaxine bupropion and mirtazapine and lower for selective serotonin reuptake inhibitors. By now there is limited clinical trial experience regarding human overdose with vortioxetine and the maximum single dose tested was 75 mg in men associated with increased rates of nausea, dizziness, diarrhea, abdominal discomfort, generalized pruritus, somnolence, and flushing. Even if there is still limited available evidence and further investigation is needed to better understand the potential risk of vortioxetine overdose; from our case, it seems that vortioxetine overdose at 250 mg (12 times the common daily dose) showed no signs or symptoms resulting from the exposure suggesting a good safety in overdose.

Addressing the Side Effects of Contemporary Antidepressant Drugs: A Comprehensive Review

Randomized trials have shown that selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have better safety profiles than classical tricyclic antidepressants (TCAs). However, an increasing number of studies, including meta-analyses, naturalistic studies, and longer-term studies suggested that SSRIs and SNRIs are no less safe than TCAs. We focused on comparing the common side effects of TCAs with those of newer generation antidepressants including SSRIs, SNRIs, mirtazapine, and bupropion. The main purpose was to investigate safety profile differences among drug classes rather than the individual antidepressants, so studies containing comparison data on drug groups were prioritized. In terms of safety after overdose, the common belief on newer generation antidepressants having fewer side effects than TCAs appears to be true. TCAs were also associated with higher drop-out rates, lower tolerability, and higher cardiac side-effects. However, evidence regarding side effects including dry mouth, gastrointestinal side effects, hepatotoxicity, seizure, and weight has been inconsistent, some studies demonstrated the superiority of SSRIs and SNRIs over TCAs, while others found the opposite. Some other side effects such as sexual dysfunction, bleeding, and hyponatremia were more prominent with either SSRIs or SNRIs.

Antidepressant and antipsychotic medication errors reported to United States poison control centers

PURPOSE

To investigate unintentional therapeutic medication errors associated with antidepressant and antipsychotic medications in the United States and expand current knowledge on the types of errors commonly associated with these medications.

METHODS

A retrospective analysis of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications was conducted using data from the National Poison Data System.

RESULTS

From 2000 to 2012, poison control centers received 207 670 calls reporting unintentional therapeutic errors associated with antidepressant or antipsychotic medications that occurred outside of a health care facility, averaging 15 975 errors annually. The rate of antidepressant-related errors increased by 50.6% from 2000 to 2004, decreased by 6.5% from 2004 to 2006, and then increased 13.0% from 2006 to 2012. The rate of errors related to antipsychotic medications increased by 99.7% from 2000 to 2004 and then increased by 8.8% from 2004 to 2012. Overall, 70.1% of reported errors occurred among adults, and 59.3% were among females. The medications most frequently associated with errors were selective serotonin reuptake inhibitors (30.3%), atypical antipsychotics (24.1%), and other types of antidepressants (21.5%). Most medication errors took place when an individual inadvertently took or was given a medication twice (41.0%), inadvertently took someone else's medication (15.6%), or took the wrong medication (15.6%).

CONCLUSIONS

This study provides a comprehensive overview of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications. The frequency and rate of these errors increased significantly from 2000 to 2012. Given that use of these medications is increasing in the US, this study provides important information about the epidemiology of the associated medication errors.

Rapid Ascending Sensorimotor Paralysis, Hearing Loss, and Fatal Arrhythmia in a Multimorbid Patient due to an Accidental Overdose of Fluoxetine

BACKGROUND

Common side effects of selective serotonin reuptake inhibitors (SSRIs) include tachycardia, drowsiness, tremor, nausea, and vomiting. Although SSRIs have less toxic side effects compared to more traditional antidepressants, serious and life threatening cases of SSRI overdose have been reported. We describe a 24-year-old multimorbid female who presented to the emergency department with rapid onset ascending sensorimotor paralysis, complicated by respiratory and cardiac arrest, found to have fatal levels of fluoxetine by toxicological analysis, not taken in a suicidal act.

RESULTS

Autopsy was performed at the Los Angeles County Medical Examiner's Office of a female with no evidence of traumatic injury. Toxicological analysis revealed lethal levels of fluoxetine, toxic levels of diphenhydramine, and multiple other coingested substances at nontoxic levels. Neuropathological examination of the brain and spinal cord revealed no evidence of Guillain-Barre paralysis.

CONCLUSIONS

Lethal levels of fluoxetine and multiple potential drug-to-drug interactions in our patient likely contributed to her unique signs and symptoms. This is the first case reporting neurologic signs and symptoms consisting of rapid onset ascending sensorimotor paralysis, hearing loss, respiratory failure, cardiac arrest, and death in a patient with lethal levels of fluoxetine.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.

Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder

BACKGROUND

It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use.

METHODS

We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs).

RESULTS

Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01).

CONCLUSIONS

Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.

Proconvulsant effects of antidepressants - What is the current evidence?

Antidepressant drugs may have proconvulsant effects. Psychiatric comorbidity in epilepsy is common. Prescribers might be reluctant to initiate treatment with antidepressants in fear of seizure aggravation. The purpose of this review was to focus upon the current evidence for proconvulsant effects of antidepressants and possible clinical implications. Most antidepressants are regarded as safe and may be used in patients with epilepsy, such as the newer serotonin and/or noradrenaline reuptake inhibitors. Four older drugs should, however, be avoided or used with caution; amoxapine, bupropion, clomipramine and maprotiline. Proconvulsant effects are concentration-related. Optimization of drug treatment includes considerations of pharmacokinetic variability to avoid high serum concentrations of the most proconvulsant antidepressants. The risk of seizures is regarded as small and should, therefore, not hamper the pharmacological treatment of depression in people with epilepsy.

Crowdsourcing Twitter annotations to identify first-hand experiences of prescription drug use

Self-reported patient data has been shown to be a valuable knowledge source for post-market pharmacovigilance. In this paper we propose using the popular micro-blogging service Twitter to gather evidence about adverse drug reactions (ADRs) after firstly having identified micro-blog messages (also know as "tweets") that report first-hand experience. In order to achieve this goal we explore machine learning with data crowdsourced from laymen annotators. With the help of lay annotators recruited from CrowdFlower we manually annotated 1548 tweets containing keywords related to two kinds of drugs: SSRIs (eg. Paroxetine), and cognitive enhancers (eg. Ritalin). Our results show that inter-annotator agreement (Fleiss' kappa) for crowdsourcing ranks in moderate agreement with a pair of experienced annotators (Spearman's Rho=0.471). We utilized the gold standard annotations from CrowdFlower for automatically training a range of supervised machine learning models to recognize first-hand experience. F-Score values are reported for 6 of these techniques with the Bayesian Generalized Linear Model being the best (F-Score=0.64 and Informedness=0.43) when combined with a selected set of features obtained by using information gain criteria.

Clinical effects of exposure to DPP-4 inhibitors as reported to the National Poison Data System

DPP-4 inhibitors (sitagliptin, saxagliptin, and linagliptin) are approved for the treatment of diabetes. They are considered safe due to their hyperglycemia dependent mechanism of action. We examined all isolated exposures to DPP-4 inhibitors reported to the National Poison Database System since 2006 to determine if significant toxicity occurs after exposure with attention to pediatric and intentional overdoses. NPDS data regarding DPP-4 ingestions in all age groups between January 2006 and March 2013 was collected. Cases were reviewed, and the following inclusion criteria applied: (1) reported ingestion of a DPP-4 inhibitor and (2) known clinical outcome. Exclusion criteria included the following: (1) exposure to more than a single substance, (2) no known outcome, and (3) clinical outcome judged to be unrelated to the exposure. One thousand four hundred seventy-six cases were reviewed while 826 were excluded. Of 650 included cases, 562 developed no clinical effects. Mild effects were noted in 77. There were no deaths. Moderate/major effect cases were investigated: two medication-naive nondiabetic individuals with accidental exposures developed clinically significant hypoglycemia requiring treatment. One diabetic patient on a DPP-4 inhibitor developed prolonged hypoglycemia requiring admission and continuous exogenous dextrose. Of 650 included exposures to DPP-4 inhibitors, 639 (98.3%) had either no or minor clinical effects. Three resulted in clinically significant hypoglycemia requiring intervention. None of the moderate or major clinical outcomes were the result of intentional overdoses for the purpose of self-injury. No exploratory ingestions resulted in moderate or major effects. Based on this data, exposure to DPP-4 inhibitors may rarely result in clinically significant hypoglycemia.

Seizures after single-agent overdose with pharmaceutical drugs: analysis of cases reported to a poison center

CONTEXT

Seizures during intoxications with pharmaceuticals are a well-known complication. However, only a few studies report on drugs commonly involved and calculate the seizure potential of these drugs.

OBJECTIVES

To identify the pharmaceutical drugs most commonly associated with seizures after single-agent overdose, the seizure potential of these pharmaceuticals, the age-distribution of the cases with seizures and the ingested doses.

METHODS

A retrospective review of acute single-agent exposures to pharmaceuticals reported to the Swiss Toxicological Information Centre (STIC) between January 1997 and December 2010 was conducted. Exposures which resulted in at least one seizure were identified. The seizure potential of a pharmaceutical was calculated by dividing the number of cases with seizures by the number of all cases recorded with that pharmaceutical. Data were analyzed using descriptive statistics.

RESULTS

We identified 15,441 single-agent exposures. Seizures occurred in 313 cases. The most prevalent pharmaceuticals were mefenamic acid (51 of the 313 cases), citalopram (34), trimipramine (27), venlafaxine (23), tramadol (15), diphenhydramine (14), amitriptyline (12), carbamazepine (11), maprotiline (10), and quetiapine (10). Antidepressants were involved in 136 cases. Drugs with a high seizure potential were bupropion (31.6%, seizures in 6 of 19 cases, 95% CI: 15.4-50.0%), maprotiline (17.5%, 10/57, 95% CI: 9.8-29.4%), venlafaxine (13.7%, 23/168, 95% CI: 9.3-19.7%), citalopram (13.1%, 34/259, 95% CI: 9.5-17.8%), and mefenamic acid (10.9%, 51/470, 95% CI: 8.4-14.0%). In adolescents (15-19y/o) 23.9% (95% CI: 17.6-31.7%) of the cases involving mefenamic acid resulted in seizures, but only 5.7% (95% CI: 3.3-9.7%) in adults (≥ 20y/o; p < 0.001). For citalopram these numbers were 22.0% (95% CI: 12.8-35.2%) and 10.9% (95% CI: 7.1-16.4%), respectively (p = 0.058). The probability of seizures with mefenamic acid, citalopram, trimipramine, and venlafaxine increased as the ingested dose increased.

CONCLUSIONS

Antidepressants were frequently associated with seizures in overdose, but other pharmaceuticals, as mefenamic acid, were also associated with seizures in a considerable number of cases. Bupropion was the pharmaceutical with the highest seizure potential even if overdose with bupropion was uncommon in our sample. Adolescents might be more susceptible to seizures after mefenamic acid overdose than adults. "Part of this work is already published as a conference abstract for the XXXIV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 27-30 May 2014, Brussels, Belgium." Abstract 8, Clin Toxicol 2014;52(4):298.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Seizures during antidepressant treatment in psychiatric inpatients--results from the transnational pharmacovigilance project "Arzneimittelsicherheit in der Psychiatrie" (AMSP) 1993-2008

RATIONALE

There is little clinical data available about seizure rates in psychiatric inpatients, and there are no studies with reference data to the frequencies of antidepressant (AD) use for this important clinical population.

OBJECTIVE

This study investigates seizure rates during AD treatment in psychiatric inpatient settings, drawn from the transnational pharmacovigilance programme Arzneimittelsicherheit in der Psychiatrie (AMSP) in relation to the known frequencies of ADs used in the participating clinics. Comparisons are made to former publications and their limitations.

RESULTS

Seventy-seven cases were identified with grand mal seizures (GMS) during AD treatment between 1993 and 2008, with a total number of 142,090 inpatients under surveillance treated with ADs in the participating hospitals. The calculated overall rate of reported seizures of patients during AD treatment in this collective is 0.05 % for ADs imputed alone or in combination with other psychotropic drug groups and 0.02 % when only ADs were given and held responsible for GMS. The patients receiving tri- or tetracyclic ADs (TCAs) had a 2-fold risk to develop a seizure as compared to the overall average rate in this sample. In 11 cases, there was only one AD imputed--the majority of these cases (9/11) were TCA. Monotherapy with selective serotonin reuptake inhibitors (SSRI) or dual serotonin and noradrenaline reuptake inhibitors (SNRI) were never imputed alone in this sample.

CONCLUSIONS

The results of the study favour the assumption that SSRIs, noradrenergic and specific serotonergic antidepressants (NaSSA) and dual SNRI might be more appropriate than TCAs for the treatment of psychiatric patients with an enhanced seizure risk.

The value of drug and metabolite concentration in blood as a biomarker of psychopharmacological therapy

Desirable and undesirable effects of a drug are related to its concentration at various sites of actions. For many psychotropic drugs, it has been shown that drug concentration in brain correlates with concentration in blood. The latter is also an available estimate of clearance and bioavailability. Its monitoring enables identification of multiple factors that have an impact on clinical outcomes, especially uncertain compliance and pharmacokinetic peculiarities. For this review we analysed for antidepressants if drug concentration in blood can be used as biomarker for psychopharmacological treatment. Systematic review of the literature revealed for new and old antidepressant drugs that drug and metabolite concentrations in blood are measures of the pharmacokinetic phenotype and related differentially to occupancy of primary target structures, therapeutic effects and unwanted anticholinergic, cardiac and other side effects. Drug concentration in blood can therefore be used as biomarker in clinical practice to guide psychopharmacological treatment with established antidepressant drugs. Monitoring of drug concentration is suitable to improve efficacy and safety of the pharmacotherapy, especially in elderly patients who require complex pharmacological therapies.