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Dobravc Verbič M, Grabnar I, Brvar M. Association between Prescribing and Intoxication Rates for Selected Psychotropic Drugs: A Longitudinal Observational Study. Pharmaceuticals (Basel) 2024; 17:143. [PMID: 38276016 PMCID: PMC10818633 DOI: 10.3390/ph17010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Psychotropic prescription drugs are commonly involved in intoxication events. The study's aim was to determine a comparative risk for intoxication in relation to prescribing rates for individual drugs. This was a nationwide observational study in Slovenian adults between 2015 and 2021. Intoxication events with psychotropic drugs were collected from the National Register of intoxications. Dispensing data, expressed in defined daily doses, were provided by the Health Insurance Institute of Slovenia. Intoxication/prescribing ratio values were calculated. The correlation between trends in prescribing and intoxication rates was assessed using the Pearson correlation coefficient. In total, 2640 intoxication cases with psychotropic prescription drugs were registered. Anxiolytics and antipsychotics were the predominant groups. Midazolam, chlormethiazole, clonazepam, sulpiride, and quetiapine demonstrated the highest risk of intoxication, while all antidepressants had a risk several times lower. The best trend correlation was found for the prescribing period of 2 years before the intoxication events. An increase of 1,000,000 defined daily doses prescribed resulted in an increase of fifty intoxication events for antipsychotics, twenty events for antiepileptics, and five events for antidepressants. Intoxication/prescribing ratio calculation allowed for a quantitative comparison of the risk for intoxication in relation to the prescribing rates for psychotropic drugs, providing additional understanding of their toxicoepidemiology.
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Affiliation(s)
- Matej Dobravc Verbič
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
- The Department of Biopharmaceutics and Pharmacokinetics, Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Iztok Grabnar
- The Department of Biopharmaceutics and Pharmacokinetics, Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Miran Brvar
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
- Centre for Clinical Physiology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Nagashima K, Yasuno N, Watanabe M. Creating and evaluating the score to assess overdose: the OD score. BMC Emerg Med 2024; 24:5. [PMID: 38185623 PMCID: PMC10773033 DOI: 10.1186/s12873-023-00923-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND During disasters (including epidemics such as coronavirus disease 2019), the capacity of emergency departments is exceeded, thereby hindering the administration of appropriate lifesaving measures. Furthermore, the number of overdose patients increases because of the stress overload during emergency situation. The fact that overdose patients are forced to be transported to medical facilities that do not typically treat them is becoming worrisome. Moreover, there is no definitive score for overdose. This study aimed to create a patient-specific scoring system to assess overdose. METHODS This was a retrospective single-center study. The evidence-based OD score was evaluated on a scale of 0-15. Further, logistic analysis and receiver operating characteristic (ROC) curve analysis were performed to evaluate the score. RESULTS Overall, 262 patients (including 118 overdose patients) receiving care at the intensive care unit of Japan's Teikyo University Hospital in 2021 were targeted. Regarding the total OD score, ROC analysis revealed a cutoff of 8 (area under the curve [AUC]: 0.99, 95% confidence interval [CI]: 0.980-0.997, sensitivity: 0.95, specificity: 0.95, p < 0.05), which was considered to indicate an overdose. Of the items evaluated in the OD score, the scenario at the location of the patient's discovery (adjusted odds ratio [AOR]: 16.8, 95% CI: 5.0-255.9, p = 0.002) and recent experience of mental anxiety (AOR: 55.7, 95% CI: 2.8-5399.5, p = 0.03) significantly predicted an overdose in multivariable logistic regression analysis. External validation revealed that the OD score could also identify overdose in patients treated in a cohort from 2022 (average cutoff: 8.6, average AUC: 1.0, p < 0.0001). CONCLUSIONS The OD score could accurately assess overdose patients. Medical facilities that do not frequently address overdose patients will benefit from the use of this score.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Practical Pharmacy, Graduate School and Faculty of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8675, Japan.
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Nobuhiro Yasuno
- Laboratory of Hospital Pharmacy, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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Nagashima K, Hiruma K, Nakamura E, Watanabe M, Sekine Y. Identification of Factors Necessary for Gatekeeper of Overdose. Biol Pharm Bull 2024; 47:112-119. [PMID: 37967973 DOI: 10.1248/bpb.b23-00530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Overdose has become a global social problem. The Japanese government requires gatekeeper training to detect and prevent indicators of overdose and suicide. However, knowledge of necessary factors for the gatekeeper of overdose (patient intervention) is limited. This study aimed to investigate the characteristics of individuals who experienced intervening persons expected to overdose, and to identify the factors required of gatekeepers. A Google form was used to survey 298 pharmacists and registered sellers in Japan. We searched for factors by logistic analysis. Knowledge of prescription drugs used for overdose was higher among pharmacists than among registered sellers. Conversely, pharmacists and registered sellers had similar knowledge about OTC drugs. Overall multivariate logistic regression analysis revealed countermeasures against overdose at their workplace (odds ratio (OR): 4.01, 95% confidence interval (CI): 2.25-7.15, p < 0.01) and knowledge that overdose is on the rise (OR: 1.93, 95% CI: 1.04-3.69, p < 0.05) to be significantly associated with intervention experience as a gatekeeper. Countermeasures against overdose at their workplace (OR: 2.40, 95% CI: 1.10-5.25, p < 0.05) in pharmacists and years of work experience (OR: 1.13, 95% CI: 1.04-1.24, p < 0.05), countermeasure against overdose at their workplace (OR: 3.43, 95% CI: 1.18-10.0, p < 0.05), and willingness to participate in study sessions and workshops on overdose (OR: 3.50, 95% CI: 1.51-8.10, p < 0.05) in registered seller were significantly associated with intervention experience as a gatekeeper. These results are useful evidences for countermeasures and gatekeeper training for overdose at pharmacies and drugstores in the community.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Practical Pharmacy, Graduate School and Faculty of Pharmaceutical Sciences, Chiba University
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University
| | | | - Eri Nakamura
- Center for Promotion of Pharmaceutical Education & Research (Clinical Training Unit), Faculty of Pharma-Science, Teikyo University
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University
| | - Yuko Sekine
- Laboratory of Practical Pharmacy, Graduate School and Faculty of Pharmaceutical Sciences, Chiba University
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Kovacic V, Kvartuc L, Mikacic M, Jerkovic I, Begovic TI, Maras M, Nazlic J. Clinical and demographic features with outcome predictors of adult patients with acute intoxication admitted to a medical intensive care unit in the Mediterranean part of Croatia. Toxicol Res (Camb) 2023; 12:626-634. [PMID: 37663800 PMCID: PMC10470373 DOI: 10.1093/toxres/tfad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 09/05/2023] Open
Abstract
Background The objective of the study was to assess the demographics, clinical parameters, and outcome of acute intoxications among adult patients admitted to a medical intensive care unit in southern Croatia. Materials and Methods An observational retrospective study was conducted over a 1-year period. The subjects were patients admitted to the intensive care unit for acute poisoning. Results In all, 81 subjects (32.1% females) aged 43.16 ± 14.77 years were admitted to the intensive care unit because of poisoning (14.97% of the total annual intensive care unit admissions). Psychiatric disorders were previously established in 76.5% participants, and 69.1% of all acute intoxications were classified as suicidal. Non-suicidal subjects differed from suicidal subjects in age (37.36 ± 9.71 vs. 45.75 ± 15.93 years; P = 0.009), in pCO2 (6.38 ± 1.78 vs. 5.50 ± 1.26 kPa; P = 0.020), in length-of-stay in intensive care unit (median 1.00, interquartile range 1.00 vs. median 2.00, interquartile range 2.00 days; P = 0.022), and in length-of-stay in hospital (median 2.00, interquartile range 2.00 vs. median 10.50, interquartile range 15.25 days; P < 0.001). Three (3.7%) patients died. Pharmaceutical psychoactive drug intoxications were the most common poisoning cases; of these, diazepam was the most frequent (16.8%), followed by ethanol (9.0%) and alprazolam (7.8%). Benzodiazepines/hypnotics were the most common group (28.7%), followed by antipsychotics (13.2%). Intoxications with more than 1 poison accounted for the largest number of cases (67.9%). The number of toxins was significantly correlated with length-of-stay in the hospital (rho = -0.265; P = 0.008), systolic blood pressure (rho = -0.318; P = 0.002), and diastolic blood pressure (rho = -0.262; P = 0.009). The electrocardiogram was considered abnormal in 50.62% of the cases. Conclusion Acute intoxicants were most commonly caused by psychiatric pharmaceutical drugs. Multidrug exposure was a typical pattern of acute intoxication.
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Affiliation(s)
- Vedran Kovacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
| | - Lukas Kvartuc
- University of Split School of Medicine, 21000 Split, Croatia
| | - Marijana Mikacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
| | - Ivan Jerkovic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
| | - Tanja Ilic Begovic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
| | - Marina Maras
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
| | - Jurica Nazlic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, University Hospital of Split, 21000 Split, Croatia
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Nagashima K, Sumida M, Imanaka S, Kuwabara T, Kaneko I, Miyake Y, Yasuno N, Itagaki F, Watanabe M. Evaluation of factors related to overdose in patients with impaired consciousness who are transported by emergency medical services: an age-specific research. J Pharm Health Care Sci 2021; 7:34. [PMID: 34593039 PMCID: PMC8485428 DOI: 10.1186/s40780-021-00217-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/18/2021] [Indexed: 12/02/2022] Open
Abstract
Background Drug overdose accounts for most of the admissions to the emergency department. Prescription drugs, most of which are psychotropic medications, are often misused for drug overdose. The purpose of this study was to investigate the association between overdose in patients transported with disorders of consciousness and psychotropic medications administered prior to transport, so as to enable quick differentiation of drug overdose patients from patients with disorders of consciousness. Methods We evaluated 222 patients transported to the Advanced Critical Care Center of Teikyo University Hospital due to disorders of consciousness. The patients were categorized into two groups: overdose group (n = 128) and control group with other disorders of consciousness (n = 94). Logistic regression models were used to assess the association between disorders of consciousness due to drug overdose and psychotropic drugs prescribed before emergency transportation based on sex and age. Results According to multivariate logistic regression analysis, only female sex (odds ratio [OR] 4.54, 95% confidence interval [CI] 2.43–8.05, P < 0.0001) was associated with overall overdose. Results from the univariate logistic regression analysis showed that in the group of patients aged 40–50 years, female sex (OR 4.36, 95% CI; 1.54–12.4, P = 0.006) and the use of psychotropic drugs (OR 5.05, 95% CI; 1.75–14.6, P = 0.003), benzodiazepines (OR 4.64, 95% CI; 1.61–13.4, P < 0.05), antidepressants (OR 11.4, 95% CI; 2.35–55.8, P = 0.003), and anticonvulsants (OR 4.46, 95% CI; 1.11–17.9, P = 0.035) were associated with overdose. According to multivariate logistic regression analysis, female sex (OR 4.44, 95% CI; 1.37–14.3, P = 0.013) and antidepressants (OR 7.95, 95% CI; 1.21–52.1, P = 0.031) were associated with overdose patients aged 40–50 years. Conclusions As a reference in distinguishing overdose in women in their 40s and 50s who present with impaired consciousness, attention may need to be paid to the type of psychotropic drug used, especially antidepressants.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Megumi Sumida
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Shoichi Imanaka
- Department of Pharmacy, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Tatsuro Kuwabara
- Department of Pharmacy, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Ichiro Kaneko
- Department of Emergency Medicine, School of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Yasufumi Miyake
- Department of Emergency Medicine, School of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Nobuhiro Yasuno
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Fumio Itagaki
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
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Markin AV, Petrova NN. [Prevention of impulsive suicide with antidepressants in outpatients]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:113-115. [PMID: 34405666 DOI: 10.17116/jnevro2021121052113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A V Markin
- St. Petersburg State University, Russi, St. Petersburg State University, Russia
| | - N N Petrova
- ZAO «Pharmphirma Sotex», St. Petersburg, Russia
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Kumpula EK, Lambie B, Quigley P, Nada-Raja S, Norris P. Prescribers aware: a cross-sectional study from New Zealand emergency departments on the substances used in intentional self-poisoning and their sources. J Prim Health Care 2020; 12:235-243. [PMID: 32988445 DOI: 10.1071/hc20017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/23/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Intentional self-poisoning or self-harm through poisoning, is a common cause of presentations to emergency departments (EDs). National datasets do not allow identification of the substances most commonly used in hospital-treated intentional self-poisoning in New Zealand, nor do they capture sources of these substances. AIM To investigate the specific substances used in intentional self-poisoning and the sources from which they are obtained. METHODS In this cross-sectional study, information about the demographics and presentation particulars of intentional self-poisoning patients aged ≥16 years, presenting to three public EDs, as well as the substances they used in the self-poisoning event and the sources of these agents, were collected prospectively. RESULTS A total of 102 patients were recruited from the potentially eligible 1137 intentional self-poisoning patients presenting to the three EDs during the study period. Seventy per cent used their own prescription medications and 24% used medicines they purchased themselves. Paracetamol and ethanol were most commonly encountered substances. Patients presented a median of 1.9h after exposure (interquartile range 1.0-3.3h), 62% self-referred, 60% presented to the ED in the evening or at night and 66% were triaged into Australasian Triage Scale 3 (to be seen within 30min). Two-thirds were referred to emergency psychiatric services. DISCUSSION Collecting specific substance information, such as from this study, can assist in planning specific activities to prevent intentional self-poisoning. As most people used their prescribed medicines, the findings can inform and assist doctors in their prescribing practices when they manage patients at risk of self-poisoning.
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Affiliation(s)
- Eeva-Katri Kumpula
- School of Pharmacy, University of Otago, Dunedin, New Zealand; and Corresponding author.
| | - Bruce Lambie
- Department of Emergency Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Paul Quigley
- Department of Emergency Medicine, Wellington Regional Hospital, Wellington, New Zealand
| | - Shyamala Nada-Raja
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Pauline Norris
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Daly C, Griffin E, McMahon E, Corcoran P, Webb RT, Witt K, Ashcroft DM, Arensman E. Repeat Self-Harm Following Hospital-Presenting Intentional Drug Overdose among Young People-A National Registry Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176159. [PMID: 32854234 PMCID: PMC7504369 DOI: 10.3390/ijerph17176159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/09/2020] [Accepted: 08/10/2020] [Indexed: 11/20/2022]
Abstract
Background: The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Methods: Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10–24 years during 2009–2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. Results: During 2009–2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03–1.24), aged 10–17 years (HR = 1.29, 95% CI: 1.18–1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07–1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40–1.98) or antidepressants (HR = 1.36, 95% CI: 1.18–1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2–2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09–1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19–2.25). Conclusion: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.
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Affiliation(s)
- Caroline Daly
- National Suicide Research Foundation, Cork 021, Ireland; (E.G.); (E.M.); (P.C.); (E.A.)
- Correspondence: ; Tel.: +353-21-420-5551
| | - Eve Griffin
- National Suicide Research Foundation, Cork 021, Ireland; (E.G.); (E.M.); (P.C.); (E.A.)
- School of Public Health, University College Cork, Cork 021, Ireland
| | - Elaine McMahon
- National Suicide Research Foundation, Cork 021, Ireland; (E.G.); (E.M.); (P.C.); (E.A.)
- School of Public Health, University College Cork, Cork 021, Ireland
| | - Paul Corcoran
- National Suicide Research Foundation, Cork 021, Ireland; (E.G.); (E.M.); (P.C.); (E.A.)
- School of Public Health, University College Cork, Cork 021, Ireland
| | - Roger T. Webb
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester M13, UK; (R.T.W.); (D.M.A.)
- Division of Psychology & Mental Health, Centre for Mental Health and Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester M13, UK
| | - Katrina Witt
- Orygen, Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria 3052, Australia;
| | - Darren M. Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester M13, UK; (R.T.W.); (D.M.A.)
- Division of Pharmacy & Optometry, Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester M13, UK
| | - Ella Arensman
- National Suicide Research Foundation, Cork 021, Ireland; (E.G.); (E.M.); (P.C.); (E.A.)
- School of Public Health, University College Cork, Cork 021, Ireland
- Australian Institute for Suicide Research and Prevention, Griffith University, Queensland 4122, Australia
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Boggs JM, Lindrooth RC, Battaglia C, Beck A, Ritzwoller DP, Ahmedani BK, Rossom RC, Lynch FL, Lu CY, Waitzfelder BE, Owen-Smith AA, Simon GE, Anderson HD. Association between suicide death and concordance with benzodiazepine treatment guidelines for anxiety and sleep disorders. Gen Hosp Psychiatry 2020; 62:21-27. [PMID: 31765794 PMCID: PMC7001528 DOI: 10.1016/j.genhosppsych.2019.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/04/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Guidelines for management of anxiety and sleep disorders emphasize antidepressant medications and/or psychotherapy as first/second-line and benzodiazepines as third-line treatments. We evaluated the association between suicide death and concordance with benzodiazepine guidelines. METHODS Retrospective case-control study of patients with anxiety and/or sleep disorders from health systems across 8 U.S. states within the Mental Health Research Network. Suicide death cases were matched to controls on year and health system. Appropriate benzodiazepine prescribing defined as: no monotherapy, no long duration, and/or age < 65 years. The association between guideline concordance and suicide death was evaluated, adjusting for diagnostic and treatment covariates. RESULTS Sample included 6960 patients with anxiety disorders (2363 filled benzodiazepine) and 6215 with sleep disorders (1237 filled benzodiazepine). Benzodiazepine guideline concordance was associated with reduced odds for suicide in patients with anxiety disorders (OR = 0.611, 95% CI = 0.392-0.953, p = 0.03) and was driven by shorter duration of benzodiazepine use with concomitant psychotherapy or antidepressant medication. The association of benzodiazepine guideline concordance with suicide death did not meet statistical significance in the sleep disorder group (OR = 0.413, 95% CI = 0.154-1.11, p = 0.08). CONCLUSIONS We found reduced odds for suicide in those with anxiety disorders who filled benzodiazepines in short-moderate duration with concomitant psychotherapy or antidepressant treatment.
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Affiliation(s)
- Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus.
| | - Richard C Lindrooth
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Catherine Battaglia
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus; Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Aurora, CO, United States of America
| | - Arne Beck
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States of America; Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, United States of America; Behavioral Health Services, Henry Ford Health System, Detroit, MI, United States of America
| | - Rebecca C Rossom
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Frances L Lynch
- Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI, United States of America
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, United States of America
| | - Beth E Waitzfelder
- Kaiser Permanente Center for Health Research, Honolulu, HI, United States of America
| | - Ashli A Owen-Smith
- School of Public Health, Georgia State University, Atlanta, GA, United States of America; Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States of America
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Heather D Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO, United States of America
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Vancayseele N, Rotsaert I, Portzky G, van Heeringen K. Medication used in intentional drug overdose in Flanders 2008-2013. PLoS One 2019; 14:e0216317. [PMID: 31048918 PMCID: PMC6497282 DOI: 10.1371/journal.pone.0216317] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/19/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intentional drug overdose is the most common method of self-harm. As psychiatric disorders are very common in self-harm patients, the medication used to treat these disorders can become the means for the self-harm act. The present study aimed at investigating an association between the use of prescribed medication (analgesics and antipyretics, anti-epileptics, antipsychotics, antidepressants and psychostimulants) as a method of self-harm and prescription rates of this medication in Flanders. We investigated the possible effect of gender, alcohol use during the self-harm act and a history of self-harm. METHODS Data from the multicenter study of self-harm in Flanders between 2008 and 2013 were used. The significance of differences in percentages was calculated by GEE and the strength by odds ratios (OR). RESULTS There was an increase in the odds of using antidepressants (0.8%) and antipsychotics (2%) among females when the rate of prescription increases. Analgesics and antipyretics (39.3/1,000) and antidepressants (124.9/1,000) were the most commonly prescribed drugs among females. Antidepressants (63.9/1,000) and antipsychotics (26.5/1,000) were the most commonly prescribed drugs among males. Antidepressants and analgesics and antipyretics were the most frequently used medications for self-harm. Analgesics and antipyretics during the self-harm act were more common among first-timers, while repeaters more commonly overdosed using antipsychotics and antidepressants. CONCLUSION These findings suggest that the availability of medication via prescriptions plays an important role in the choice of the medication ingested during the self-harm act. Precautions are necessary when prescribing medication, including restrictions on the number of prescriptions and the return of unused medication to pharmacies after cessation of treatment. These issues should be a focus of attention in the education and training of physicians and pharmacists.
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Affiliation(s)
| | - Ine Rotsaert
- Unit for Suicide Research, Ghent University, Ghent, Belgium
- Flemish Centre of Expertise in Suicide Prevention, Ghent University, Ghent, Belgium
| | - Gwendolyn Portzky
- Unit for Suicide Research, Ghent University, Ghent, Belgium
- Flemish Centre of Expertise in Suicide Prevention, Ghent University, Ghent, Belgium
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11
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Daly C, Griffin E, Ashcroft DM, Webb RT, Perry IJ, Arensman E. Frequently used drug types and alcohol involvement in intentional drug overdoses in Ireland: a national registry study. Eur J Public Health 2019. [PMID: 29538652 DOI: 10.1093/eurpub/cky031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Intentional drug overdose (IDO) is the most common form of hospital-treated self-harm, yet no national study has systematically classified the range of drugs involved using a validated system. We aimed to determine the profile of patients engaging in overdose, to identify drugs frequently used and to quantify the contributions of multiple drug use and alcohol involvement. Methods Between 2012 and 2014, the National Self-Harm Registry, Ireland recorded 18 329 presentations of non-fatal IDO to Irish emergency departments. Information on demographic and overdose characteristics were obtained. Drugs were categorized using the Anatomical Therapeutic Chemical classification system. Results Analgesics (32.4%), antidepressants (21.9%), anxiolytics (21.2%) and hypnotics and sedatives (21.0%) were the most frequently used drugs types involved in overdose. Presentations involving analgesic and antidepressant medication were more common for females whereas males more often took illegal, anxiolytic and hypnotic and sedative drugs. Overdoses with drugs other than those which affect the nervous system were identified, including musculoskeletal drugs, taken in 12.0% of presentations. Paracetamol was the most frequently used drug, particularly among females (32.0%) and persons under 25 years (36.2%). Alcohol was most often present in overdoses involving anxiolytics and illegal drugs. Multiple drug use was a factor in almost half (47.1%) of presentations. Conclusions People who engage in IDO frequently take prescription only or sales restricted drugs, often involving alcohol and/or multiple drug use. These findings highlight the importance of addressing drug and alcohol misuse, potential inappropriate prescribing and the enforcement of legislation restricting specific drug sales.
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Affiliation(s)
- Caroline Daly
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland
| | - Eve Griffin
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland
| | - Darren M Ashcroft
- Division of Pharmacy & Optometry, Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Roger T Webb
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.,Division of Psychology & Mental Health, Centre for Mental Health and Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Ivan J Perry
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
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12
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Cully G, Corcoran P, Leahy D, Griffin E, Dillon C, Cassidy E, Shiely F, Arensman E. Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry. J Affect Disord 2019; 246:843-850. [PMID: 30795489 DOI: 10.1016/j.jad.2018.10.372] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/14/2018] [Accepted: 10/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Risk of self-harm repetition has consistently been shown to be higher following self-cutting compared to intentional drug overdose (IDO) and other self-harm methods. The utility of previous evidence is limited due to the large heterogeneous method categories studied. This study examined risk of hospital presented self-harm repetition according to specific characteristics of self-harm methods. METHODS Data on consecutive self-harm presentations to hospital emergency departments (2010-2016) were obtained from the National Self-Harm Registry Ireland. Associations between self-harm method and repetition were analysed using survival analyses. RESULTS Overall, 65,690 self-harm presentations were made involving 46,661 individuals. Self-harm methods associated with increased repetition risk included minor self-cutting, severe self-cutting, multiple drug IDOs involving psychotropic drugs and self-harm by blunt object. Minor self-cutting was the method associated with highest repetition risk (adjusted hazard ratio (AHR) 1.38, 95% CI 1.31-1.45). Risk of repetition was comparable following IDOs of four or more drugs involving psychotropic drugs (AHR = 1.29, 95% CI 1.20-1.39), severe self-cutting (AHR 1.25, 95% CI 1.16-1.34) and blunt object (AHR = 1.23, 95% CI 1.07-1.42). LIMITATIONS Information was not available on suicide or other causes of mortality. CONCLUSIONS Self-harm method and the associated risk of repetition should form a core part of biopsychosocial assessments and should inform follow-up care for self-harm patients. The observed differences in repetition associated with specific characteristics of IDO underline the importance of safety planning and monitoring prescribing for people who have engaged in IDO.
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Affiliation(s)
- G Cully
- School of Public Health, University College Cork, Cork, Ireland; National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland.
| | - P Corcoran
- School of Public Health, University College Cork, Cork, Ireland; National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland
| | - D Leahy
- School of Public Health, University College Cork, Cork, Ireland; National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland
| | - E Griffin
- National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland
| | - C Dillon
- National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland
| | - E Cassidy
- Liaison Psychiatry Service, Cork University Hospital, Cork, Ireland; Department of Psychiatry and Neurobehavioural Science, University College Cork, Cork, Ireland
| | - F Shiely
- School of Public Health, University College Cork, Cork, Ireland; HRB Clinical Research Facility, Mercy University Hospital, Cork, Ireland
| | - E Arensman
- School of Public Health, University College Cork, Cork, Ireland; National Suicide Research Foundation Ireland, 4.28 Western Gateway Building, Cork, Ireland
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13
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Ferrey AE, Geulayov G, Casey D, Wells C, Fuller A, Bankhead C, Ness J, Clements C, Gunnell D, Kapur N, Hawton K. Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning. BMC Psychiatry 2018; 18:399. [PMID: 30587176 PMCID: PMC6307121 DOI: 10.1186/s12888-018-1993-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 12/19/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Anne E. Ferrey
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK ,0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Galit Geulayov
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Deborah Casey
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Claudia Wells
- 0000 0001 2157 6840grid.426100.1Office for National Statistics, Newport, UK
| | - Alice Fuller
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jennifer Ness
- 0000 0004 0396 1667grid.418388.eCentre for Self-harm and Suicide Prevention Research, Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Caroline Clements
- 0000000121662407grid.5379.8Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - David Gunnell
- 0000 0004 1936 7603grid.5337.2School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Navneet Kapur
- 0000000121662407grid.5379.8Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - Keith Hawton
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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14
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Daly C, Griffin E, Ashcroft DM, Webb RT, Perry IJ, Arensman E. Intentional Drug Overdose Involving Pregabalin and Gabapentin: Findings from the National Self-Harm Registry Ireland, 2007-2015. Clin Drug Investig 2018; 38:373-380. [PMID: 29264838 DOI: 10.1007/s40261-017-0616-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Intentional drug overdose (IDO) is a significant public health problem. Concerns about the misuse of gabapentinoids, i.e. pregabalin and gabapentin, including their consumption in IDO have grown in recent years. This paper examines the trends in the prevalence of gabapentinoids taken in IDO, the profile of individuals taking them, and associated overdose characteristics. METHODS Presentations to emergency departments involving IDO, recorded by the National Self-Harm Registry Ireland between 1 January 2007 and 31 December 2015 were examined. Data items included patient demographics, drug names, total tablet quantity consumed and alcohol involvement. RESULTS Gabapentinoids were involved in 2115 (2.9%) of the 72,391 IDOs recorded. Presentations involving a gabapentinoid increased proportionally from 0.5% in 2007 to 5.5% in 2015. The majority of IDOs involving a gabapentinoid were made by females (59.9%), with over one-third (37.2%) involving alcohol. Compared with IDOs involving other drugs, presentations with a gabapentinoid were made by persons who were older (median 37 vs. 32 years) and involved a significantly greater median quantity of tablets (30 vs. 21, p ≤ 0.001), with over one-quarter (27.4%) of these involving the ingestion of 50 tablets or more. Admission to hospital was significantly more common following IDOs with a gabapentinoid compared with those without (49.4% vs. 41.4%, p ≤ 0.001). CONCLUSIONS This study identified the increasing use of gabapentinoids in IDO, describing the profile and overdose characteristics of presentations. It is important for clinicians to exercise vigilance while prescribing gabapentinoids, including being aware of other medications that their patients may have access to. Our findings support the need for routine monitoring for signs of misuse among those prescribed gabapentinoids.
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Affiliation(s)
- Caroline Daly
- National Suicide Research Foundation, University College Cork, Room 4.28, Fourth Floor, Western Gateway Building, Western Road, Cork, Ireland.
| | - Eve Griffin
- National Suicide Research Foundation, University College Cork, Room 4.28, Fourth Floor, Western Gateway Building, Western Road, Cork, Ireland
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Roger T Webb
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Ivan J Perry
- National Suicide Research Foundation, University College Cork, Room 4.28, Fourth Floor, Western Gateway Building, Western Road, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation, University College Cork, Room 4.28, Fourth Floor, Western Gateway Building, Western Road, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
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15
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Abstract
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.
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Affiliation(s)
| | - Aurora Rossetti
- Department of Medicine and Surgery, University of Milano Bicocca, Monza
| | | | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Monza
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16
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Hawkins M, Schaffer A, Sinyor M, Nishikawa Y, Herrmann N, Lanctôt KL, Styra R, Pompili M, Huffman J. Suicide deaths by intentional self-poisoning in people with cardiovascular disease. Gen Hosp Psychiatry 2018; 52:41-47. [PMID: 29621659 DOI: 10.1016/j.genhosppsych.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 03/13/2018] [Accepted: 03/21/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We aimed to characterize self-poisoning deaths in people with cardiovascular disease (CVD) and compare to other suicide decedent groups. METHODS Suicide deaths by self-poisoning in people with CVD (n = 151) were compared to suicide deaths by other methods in people with CVD (n = 260) and suicide deaths by self-poisoning in people without CVD (n = 509). Sub-analysis of the CVD self-poisoning group compared people with depression and without depression. Toxicology reports were compared between intentional self-poisoning groups. RESULTS A higher proportion of suicide deaths were due to self-poisoning in the CVD group compared to the non-CVD group. People with CVD were less likely to have any identified stressor (excluding medical stressor) prior to dying from self-poisoning compared to those without CVD. Female sex, past suicide attempts, living circumstances, and comorbid substance abuse were each significantly associated with self-poisoning as the method of suicide in people with CVD. Opioid, any antidepressants, benzodiazepines, and tricyclic antidepressants (TCAs) were commonly identified as lethal in people with CVD. Compared to people in the CVD self-poisoning without depression group, people in the CVD self-poisoning with depression group were more likely to have lethal levels of TCAs. CONCLUSIONS Our findings characterize suicide deaths in people with CVD, and identified notable differences based on method of death and presence of depression.
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Affiliation(s)
- Michael Hawkins
- Department of Psychiatry, University of Toronto, 27 King's College Circle, Toronto, Ontario M5S 1A1, Canada.
| | - Ayal Schaffer
- Mood & Anxiety Disorders Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada.
| | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
| | - Yasunori Nishikawa
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada; Mood & Anxiety Disorders Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nathan Herrmann
- Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
| | - Krista L Lanctôt
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.
| | - Rima Styra
- Department of Psychiatry, Division of Consultation/Liaison Psychiatry, University Health Network, 200 Elizabeth Street, Toronto M5G 2C4, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
| | - Maurizio Pompili
- Psychiatry Residency Training Program, Department of Neurosciences, Mental Health and Sensory Organs, Sant'Andrea Hospital, Sapienza University of Rome, Italy; Sant'Andrea Hospital, Sapienza University of Rome, Italy; Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Italy.
| | - Jeffrey Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA; Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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17
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Rasimas JJ, Smolcic EE, Sinclair CM. Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology. Psychiatry Res 2017; 255:304-313. [PMID: 28601000 DOI: 10.1016/j.psychres.2017.05.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 03/08/2017] [Accepted: 05/30/2017] [Indexed: 11/29/2022]
Abstract
This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted. Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care. These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.
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Affiliation(s)
- J J Rasimas
- PinnacleHealth Toxicology Center, Harrisburg, PA, USA; Emergency Medicine, Penn State College of Medicine, Hershey, PA, USA; Psychiatry, Penn State College of Medicine, Hershey, PA, USA.
| | - Erica E Smolcic
- Psychiatry, Penn State College of Medicine, Hershey, PA, USA; Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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18
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Exposure to psychotropic medications prior to overdose: a case-control study. Psychopharmacology (Berl) 2015; 232:3101-9. [PMID: 25963562 DOI: 10.1007/s00213-015-3952-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE Little is known about psychotropic medication prescriptions prior to drug overdose. OBJECTIVES We aimed to examine the possible associations between the risk of overdose and exposures to various psychotropic medications. METHODS We conducted a matched case-control study of 3 groups of patients aged 12-74 years, using a large-scale health insurance claims database in Japan (population 1.2 million). A total of 351 cases with drug poisoning were compared with two control groups without overdose: 1755 patients with any treatment (general controls) and those with depression (high-risk controls). Current, past, and nonusers were patients most recently exposed to psychotropic medications ≤ 90 days, 91-180 days, and ≥ 180 days before the index date. RESULTS Current sedative-hypnotic use was associated with an increased odds of overdose relative to general control nonusers (odds ratio [OR], 21.5; 95 % confidence interval [CI], 9.7-47.8) and high-risk control nonusers (OR, 2.6; 95 % CI, 1.9-3.5). In the comparison of cases and high-risk controls, the ORs for overdose were higher among excessive dosage users than among usual dosage users (OR, 4.3; 95 % CI, 3.0-6.1), among barbiturate users than among benzodiazepine/Z-drug only users (OR, 4.5; 95 % CI, 2.3-8.7), and among multiple provider episodes than among single provider episodes (OR, 4.4; 95 % CI, 1.7-11.0). Psychiatrists prescribed more than 77 % of potentially questionable prescriptions. CONCLUSIONS These results highlight the need for psychiatrists to monitor prescribed medications and balance the benefits and risks of pharmacological treatments.
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19
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Griffin E, Corcoran P, Cassidy L, O'Carroll A, Perry IJ, Bonner B. Characteristics of hospital-treated intentional drug overdose in Ireland and Northern Ireland. BMJ Open 2014; 4:e005557. [PMID: 25079938 PMCID: PMC4120413 DOI: 10.1136/bmjopen-2014-005557] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study compared the profile of intentional drug overdoses (IDOs) presenting to emergency departments in Ireland and in the Western Trust Area of Northern Ireland between 2007 and 2012. Specifically the study aimed to compare characteristics of the patients involved, to explore the factors associated with repeated IDO and to report the prescription rates of common drug types in the population. METHODS We utilised data from two comparable registries which monitor the incidence of hospital-treated self-harm, recording data from deliberate self-harm presentations involving an IDO to all hospital emergency departments for the period 1 January 2007 to 31 December 2012. RESULTS Between 2007 and 2012 the registries recorded 56 494 self-harm presentations involving an IDO. The study showed that hospital-treated IDO was almost twice as common in Northern Ireland than in Ireland (278 vs 156/100 000, respectively). CONCLUSIONS Despite the overall difference in the rates of IDO, the profile of such presentations was remarkably similar in both countries. Minor tranquillisers were the drugs most commonly involved in IDOs. National campaigns are required to address the availability and misuse of minor tranquillisers, both prescribed and non-prescribed.
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Affiliation(s)
- Eve Griffin
- National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Paul Corcoran
- National Suicide Research Foundation, University College Cork, Cork, Ireland
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | | | | | - Ivan J Perry
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
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20
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Gunnell D, Hawton K, Bennewith O, Cooper J, Simkin S, Donovan J, Evans J, Longson D, O'Connor S, Kapur N. A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England. PROGRAMME GRANTS FOR APPLIED RESEARCH 2013. [DOI: 10.3310/pgfar01010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
ObjectivesTo carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).MethodsThere were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.Key findings(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.ConclusionWithin the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.Study registrationA pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - K Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - O Bennewith
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Cooper
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - S Simkin
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - J Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Evans
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - D Longson
- Manchester Mental Health and Social Care Trust, Manchester, UK
| | - S O'Connor
- Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - N Kapur
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
- Manchester Mental Health and Social Care Trust, Manchester, UK
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Corcoran P, Heavey B, Griffin E, Perry IJ, Arensman E. Psychotropic medication involved in intentional drug overdose: implications for treatment. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/npy.13.23] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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How do methods of non-fatal self-harm relate to eventual suicide? J Affect Disord 2012; 136:526-33. [PMID: 22127391 DOI: 10.1016/j.jad.2011.10.036] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/24/2011] [Accepted: 10/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Methods used at an index episode of non-fatal self-harm may predict risk of future suicide. Little is known of suicide risk associated with most recent non-fatal method, and whether or not change in method is important. METHODS A prospective cohort of 30,202 patients from the Multicentre Study of Self-harm in England presenting to six hospitals with self-harm, 2000-2007, was followed up to 2010 using national death registers. Risks of suicide (by self-poisoning, self-injury, and all methods) associated with recent method(s) of non-fatal self-harm were estimated using Cox models. RESULTS Suicide occurred in 378 individuals. Cutting, hanging/asphyxiation, CO/other gas, traffic-related and other self-injury at the last episode of self-harm were associated with 1.8 to 5-fold increased risks (vs. self-poisoning) of subsequent suicide, particularly suicide involving self-injury. All methods of self-harm had similar risks of suicide by self-poisoning. One-third who died by suicide used the same method for their last self-harm and for suicide, including 41% who self-poisoned. No specific sequences of self-poisoning, cutting or other self-injury in the last two non-fatal episodes were associated with suicide in individuals with repeated self-harm. LIMITATIONS Data were for hospital presentations only, and lacked a suicide intent measure. CONCLUSIONS Method of self-harm may aid identification of individuals at high risk of suicide. Individuals using more dangerous methods (e.g. hanging, CO/other gas) should receive intensive follow-up. Method changes in repeated self-harm were not associated with suicide. Our findings reinforce national guidance that all patients presenting with self-harm, regardless of method, should receive a psychosocial assessment.
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Hawton K, Bergen H, Simkin S, Cooper J, Waters K, Gunnell D, Kapur N. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry 2010; 196:354-8. [PMID: 20435959 PMCID: PMC2862059 DOI: 10.1192/bjp.bp.109.070219] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important. AIMS To assess the relative toxicity of specific tricyclic antidepressants (TCAs), a serotonin and noradrenaline reuptake inhibitor (SNRI), a noradrenergic and specific serotonergic antidepressant (NaSSA), and selective serotonin reuptake inhibitors (SSRIs). METHOD Observational study of prescriptions (UK), poisoning deaths involving single antidepressants receiving coroners' verdicts of suicide or undetermined intent (England and Wales) and non-fatal self-poisoning episodes presenting to six general hospitals (in Oxford, Manchester and Derby) between 2000 and 2006. Calculation of fatal toxicity index based on ratio of rates of deaths to prescriptions, and case fatality based on ratio of rates of deaths to non-fatal self-poisonings. RESULTS Fatal toxicity and case fatality indices provided very similar results (rho for relative ranking of indices 0.99). Case fatality rate ratios showed greater toxicity for TCAs (13.8, 95% CI 13.0-14.7) than the SNRI venlafaxine (2.5, 95% CI 2.0-3.1) and the NaSSA mirtazapine (1.9, 95% CI 1.1-2.9), both of which had greater toxicity than the SSRIs (0.5, 95% CI 0.4-0.7). Within the TCAs, compared with amitriptyline both dosulepin (relative toxicity index 2.7) and doxepin (2.6) were more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs (1.1, 95% CI 0.8-1.4 v. 0.3, 95% CI 0.2-0.4). CONCLUSIONS There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, and to regulatory policy.
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Affiliation(s)
- Keith Hawton
- Centre for Suicide Research, University of Oxford, Department of Psychiatry, Warneford Hospital, Headington, Oxford OX3 7JX, UK.
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Jesse CR, Wilhelm EA, Bortolatto CF, Rocha JBT, Nogueira CW. Involvement of L-arginine-nitric oxide-cyclic guanosine monophosphate pathway in the antidepressant-like effect of bis selenide in the mouse tail suspension test. Eur J Pharmacol 2010; 635:135-41. [PMID: 20307533 DOI: 10.1016/j.ejphar.2010.03.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 02/20/2010] [Accepted: 03/04/2010] [Indexed: 11/28/2022]
Abstract
The present study investigated a possible antidepressant-like effect of bis selenide by using the forced swimming and the tail suspension tests. The involvement of the l-arginine-nitric oxide-cyclic guanosine monophosphate signaling pathway in the antidepressant-like action of bis selenide was investigated. Bis selenide, given by oral route at doses of 0.5-5mg/kg, decreased the immobility time in the forced swimming and tail suspension tests. Pretreatment with l-arginine (750mg/kg, intraperitoneal, i.p., a nitric oxide precursor), sildenafil (5mg/kg, i.p., a phosphodiesterase 5 inhibitor) or S-nitroso-N-acetyl-penicillamine (25microg/site, intracerebroventricular, i.c.v., a nitric oxide donor) reversed the reduction in the immobility time elicited by bis selenide (1mg/kg, p.o.) in the tail suspension test. Bis selenide (0.1mg/kg, p.o., a subeffective dose) produced a synergistic antidepressant-like effect with N(G)-nitro-L-arginine (0.3mg/kg, i.p., an inhibitor of nitric oxide synthase) or 7-nitroindazole (25mg/kg, i.p., a specific neuronal nitric oxide synthase inhibitor) in the tail suspension test. Pretreatment of animals with methylene blue (10mg/kg, i.p., an inhibitor of nitric oxide synthase and soluble guanylate cyclase) or 1H-[1,2,4] oxadiazolo [4,3-a]quinoxalin-1-one (30pmol, i.c.v., a specific inhibitor of soluble guanylate cyclase), at subeffective doses, caused a synergistic effect with bis selenide in the tail suspension test. Bis selenide (1mg/kg, p.o.), at an effective dose in the forced swimming and tail suspension tests, caused a significant decrease in the mouse cerebral nitrate/nitrite levels. The antidepressant-like effect of bis selenide in the tail suspension test is dependent on the inhibition of the L-arginine-nitric oxide-cyclic guanosine monophosphate pathway.
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Affiliation(s)
- Cristiano R Jesse
- Laboratório de Síntese, Reatividade e Avaliação Farmacológica e Toxicológica de Organocalcogênios, Centro de Ciências Naturais e Exatas, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
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