The utilization of antidepressants--a key issue in the prevention of suicide: an analysis of 5281 suicides in Sweden during the period 1992-1994

Veterans' satisfaction and perspectives on helpfulness of the Veterans Crisis Line

OBJECTIVE

Crisis hotlines are an important part of a public health approach to suicide prevention. The Veterans Crisis Line (VCL) provides hotline services to Veterans. There is a paucity of research concerning the effectiveness of the VCL. The current work describes efforts to establish groundwork for VCL effectiveness research.

METHODS

155 VCL users who were referred to a Veterans Affairs Medical Center Suicide Prevention Team completed interviews including open-ended and closed-ended questions. Outcomes are reported for suicidal participants, non-suicidal participants, and those who had emergency intervention. Thematic analysis was used for open-ended questions.

RESULTS

Eighty-seven percent of interviewees expressed satisfaction with the VCL, 81.9% reported that the VCL was helpful, and 72.9% said that the VCL helped keep them safe. Of those with suicidal thoughts, 82.6% said the contact helped stop them from killing themselves. Themes are described concerning user identified reasons for VCL contact, most and least helpful aspects of the contact, and suggestions for improvement.

DISCUSSION

This project demonstrates that this group of people who used the VCL overwhelmingly finds the service to be helpful and a barrier to suicide. Further, implications of user feedback for application to VCL operations and future research are discussed.

Touchscreen typing pattern analysis for remote detection of the depressive tendency

Depressive disorder (DD) is a mental illness affecting more than 300 million people worldwide, whereas social stigma and subtle, variant symptoms impede diagnosis. Psychomotor retardation is a common component of DD with a negative impact on motor function, usually reflected on patients’ routine activities, including, nowadays, their interaction with mobile devices. Therefore, such interactions constitute an enticing source of information towards unsupervised screening for DD symptoms in daily life. In this vein, this paper proposes a machine learning-based method for discriminating between subjects with depressive tendency and healthy controls, as denoted by self-reported Patient Health Questionnaire-9 (PHQ-9) compound scores, based on typing patterns captured in-the-wild. The latter consisted of keystroke timing sequences and typing metadata, passively collected during natural typing on touchscreen smartphones by 11/14 subjects with/without depressive tendency. Statistical features were extracted and tested in univariate and multivariate classification pipelines to reach a decision on subjects’ status. The best-performing pipeline achieved an AUC = 0.89 (0.72–1.00; 95% Confidence Interval) and 0.82/0.86 sensitivity/specificity, with the outputted probabilities significantly correlating (>0.60) with the respective PHQ-9 scores. This work adds to the findings of previous research associating typing patterns with psycho-motor impairment and contributes to the development of an unobtrusive, high-frequency monitoring of depressive tendency in everyday living.

The relationship between the prescription of pyschotropic drugs and suicide rates in adults in England and Wales

BACKGROUND

A few studies have demonstrated an inverse relationship between the general population and suicide rates and antidepressant prescribing rates. Correlations between general population suicide rates and prescribing rates of other psychotropic drugs have also been observed. There have not been any studies during the last decade.

METHODS

The relationship between adult suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. selective serotonin reuptake inhibitors) and for individual psychotropic drugs was examined over a 12-year period (1995-2006) was examined using Spearman's rank correlation. All data were ascertained from the archives of the Office for National Statistics.

RESULTS

There was an absence of significant correlations between adult suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological errors. Should the findings be accurate, then the following approaches require consideration to reduce suicide rates further: (i) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (ii) development of strategies to improve non-pharmacological measures, including improved mental health services provision for adults, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (iii) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

The relationship between the prescription of psychotropic drugs and suicide rates in older people in England and Wales

BACKGROUND

Several studies have reported an inverse correlation between general population and elderly suicide rates and antidepressant prescribing rates. Correlations between general population and elderly suicide rates and prescribing rates of other psychotropic drugs have also been reported. All studies of elderly suicide rates have used data over a decade old.

METHODS

The relationship between elderly suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. SSRIs), and for individual psychotropic drugs was examined over a 12-year period (1995-2006) using Spearman's rank correlation. All data were ascertained from the archives of the National Statistics Office.

RESULTS

There was an absence of significant correlations between elderly suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological flaws. However, if they are genuine, then the following approaches require consideration to further reduce suicide rates: (1) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (2) development of strategies to improve non-pharmacological measures, including improved mental health services provision for older people, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (3) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Antidepressant use and method of suicide in the United States: variation by age and sex, 1998-2007

This study examines the association between antidepressant use and suicide rates, by sex, age, and method of suicide, between 1998 and 2007 in the United States. Overall suicide rates for the young and elderly declined but rates for the middle-aged increased. All age groups experienced increases in antidepressant use. The elderly exhibited the largest increase in antidepressant usage and biggest declines in suicide rates. Firearm suicides for men and women declined but suicide by drug poisoning rose, particularly for women. For young males and elderly males and females, better treatment of severe depression may have contributed to declining suicide rates. However, rising rates of prescription drug use are associated with higher levels of suicide by drug poisoning.

Can we really prevent suicide?

Every year, suicide is among the top 20 leading causes of death globally for all ages. Unfortunately, suicide is difficult to prevent, in large part because the prevalence of risk factors is high among the general population. In this review, clinical and psychological risk factors are examined and methods for suicide prevention are discussed. Prevention strategies found to be effective in suicide prevention include means restriction, responsible media coverage, and general public education, as well identification methods such as screening, gatekeeper training, and primary care physician education. Although the treatment for preventing suicide is difficult, follow-up that includes pharmacotherapy, psychotherapy, or both may be useful. However, prevention methods cannot be restricted to the individual. Community, social, and policy interventions will also be essential.

Antidepressants medications and the relative risk of suicide attempt

This study was conducted on patients (n=1283) of different ages, 924 males and 359 female. These patients were attended to poison unit at emergency hospital, Mansoura University during the period from January 2002 to December 2009. The aim of this study was to characterize patients on antidepressants after self-poisoning with suicidal intent regarding age, sex, type of current antidepressant therapy, and type of substances ingested in order to commit suicide. During the study period, 175 Para suicide patients were found with current antidepressants therapy and presented with self-poisoning using their antidepressant therapy or other medications. A substantial difference between different types of antidepressants was found. Para suicide risks for selective serotonin reuptake inhibitor were significantly low than those of tricyclic antidepressants, so in suicide prevention, risks and benefits of an antidepressant should be taken into account when choosing treatment for depressive patients. At the same time, depressed patients should be under close psychiatric assessment in order to prevent such possible suicidal attempts.

The European Psychiatric Association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive.

DIAGNOSIS

An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.

TREATMENT

Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.

SAFETY

A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Seasonal effects on depression risk and suicidal symptoms in postpartum women

BACKGROUND

Postpartum depression (PPD) is the most common complication of childbirth. Suicide is a leading cause of maternal death in the first postpartum year. Depressed mothers often have suicidal ideation (SI). Depression and suicidality may vary across the seasons. Previous studies of seasonality and PPD were relatively small or encumbered by study design constraints. We examined the possible relationship between seasonality, depression, and SI in 9,339 new mothers.

METHODS

From 2006 to 2010, the investigators screened women within 4-6 weeks postpartum with the Edinburgh Postnatal Depression Scale (EPDS). We used spectral analysis to explore seasonal variation in risk for depression and suicidality.

RESULTS

The study team screened 9,339 new mothers, of whom 1,316 (14%) women had positive depression scores (EPDS≥10) which suggest PPD risk; 294 (3%) women had SI (item 10≥1). A positive EPDS was associated significantly with SI. PPD risk varied significantly across 12-months-risk was highest in December. We detected no seasonal variation in SI.

CONCLUSIONS

Effects of seasonal light variation may contribute to increased risk for depressive symptoms. Suicidality could be related to maternal depression but not seasonal variation.

Antidepressant medication prevents suicide in depression

OBJECTIVE

Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increasing use of antidepressants. To investigate on the individual level the hypothesis that antidepressant medication was a causal factor.

METHOD

Data on the toxicological detection of antidepressants in 18 922 suicides in Sweden 1992-2003 were linked to registers of psychiatric hospitalization as well as registers with sociodemographic data.

RESULTS

The probability for the toxicological detection of an antidepressant was lowest in the non-suicide controls, higher in suicides, and even higher in suicides that had been psychiatric in-patients but excluding those who had been in-patients for the treatment of depression.

CONCLUSION

The finding that in-patient care for depression did not increase the probability of the detection of antidepressants in suicides is difficult to explain other than by the assumption that a substantial number of depressed individuals were saved from suicide by postdischarge treatment with antidepressant medication.

Self-poisonings with tricyclic antidepressants and selective serotonin reuptake inhibitors in Tehran, Iran

In a prospective hospital-based cohort study, we addressed the question of severity and outcome of antidepressant poisonings in patients who attended the Loghman-Hakim Hospital Poison Center, the only national center in Tehran dedicated for detoxification. The aim of the study was to find out if tricyclic antidepressant (TCA) intoxications require more therapeutic efforts than selective serotonin reuptake inhibitor (SSRI) intoxications. The study was applied over a 7-week period (28 March-20 May 2006). From 3578 intoxications, 334 patients with antidepressant or lithium self-poisoning were identified (9.3% of all poisoning cases; 233 females, 101 males; median age 24 years, min 13, max 70). Compared to SSRI single-substance intoxications (n=17), TCA single-substance intoxications (n=73) were associated with: (1) a significantly lower level of consciousness (P=0.005); (2) a significantly higher admission frequency (80.8 vs. 35.3%; P<0.001); and (3) a higher intubation frequency (13.7 vs. 0%; P=ns). SSRI multiple-substance intoxications were associated with a significantly lower level of consciousness than SSRI single-substance intoxications (P=0.042), while there was no significant difference between TCA multiple- and single-substance intoxications. This study suggests that an overdose with SSRIs results in a more favourable clinical outcome than an overdose with TCAs.

A stubborn behaviour: The failure of antidepressants to reduce suicide rates

Over the past decades the rate of completed suicide has remained quite stable, that of suicide attempts even seems to have increased (to the extent it has been studied in defined regions). These are puzzling observations, since depression is the major suicide precursor and since antidepressants over the years have been increasingly used in the treatment of depression. These observations have not attracted sufficient attention, possibly because they do not accord with consensus opinions about depression treatment in psychiatry today. In this paper a number of possible explanations are discussed. They not only deserve but are definitely in need of systematic investigation.

Decrease in suicide among the individuals treated with antidepressants: a controlled study of antidepressants in suicide, Sweden 1995-2005

OBJECTIVE

Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increase in the use of antidepressants. Causality cannot, however, be inferred from such studies. The aim of this study was to test on the individual level the hypothesis that treatment with antidepressant medication has been a substantially contributing cause of the decrease in suicide.

METHOD

Time trends in the detection of antidepressants and five 'control medications' in the forensic toxicological screening of 16 937 suicides and 33 426 controls in Sweden 1995-2005.

RESULTS

The expected number of antidepressant-positive suicides in 2005 was 409 if the hypothesis was true and 603 if it was false. The observed number in 2005 was 420. The control medications were detected to the extent that was expected if not preventing suicide.

CONCLUSION

The observed trend in the number of suicides with antidepressants was well predicted by the hypothesis that the increased use of antidepressants has been a substantially contributing cause of the decrease in suicide.

Antidepressant use and suicide prevention: a prescription database study in the region Friuli Venezia Giulia, Italy

OBJECTIVE

To investigate the possible impact of the increased use of antidepressants on suicide rates in the Italian region of Friuli Venezia Giulia (FVG).

METHOD

Individual-based data on antidepressants in FVG from 1997 to 2006 were obtained from the regional prescription database, and linked to data on suicide for the same period obtained from the regional health information system. Age and sex were considered.

RESULTS

The number of users of antidepressants increased almost fivefold during the study period. Selective serotonin reuptake inhibitors accounted for 71% of the individual users in 2006. The number of defined daily doses (DDD) per patient increased almost sevenfold. In parallel, the suicide rate decreased by one-third in men as well as in women, and in subjects under and over the age of 60 years.

CONCLUSION

Suicide rates in FVG have declined in agreement with the hypothesis that the use of antidepressants may prevent suicide.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

Association of suicide and antidepressant prescription rates in Japan, 1999-2003

OBJECTIVE

We examined the relationship of increasing prescription volume of newer antidepressants, introduced in Japan in 1999, to national rates of suicide.

METHOD

The relationship between annual changes in rates of suicide (obtained from the Japanese Ministry of Health, Labor, and Welfare Vital Statistics Database) and prescription volume of the newer antidepressants paroxetine, fluvoxamine, and milnacipran (obtained from the database of IMS Japan K.K.), stratified by gender and age groups, was modeled statistically for the years 1999 through 2003. Effects of unemployment and alcohol consumption and the interaction of gender and age with antidepressant prescribing were assessed.

RESULTS

From 1999 through 2003 in Japan, total antidepressant prescriptions increased 57% among males and 50% among females. Approximately 80% of this increase involved the selective serotonin reuptake inhibitors (SSRIs). To reduce a limitation of ecological analysis, we compared annual change in prescription and suicide rates, which eliminates the effect of long-term (secular) linear trends. We found an inverse association between year-to-year changes in the suicide rate and prescription volume of newer antidepressants (fluvoxamine, paroxetine, and milnacipran) (beta = -1.34, p = .008) and SSRIs specifically (fluvoxamine, paroxetine) (beta = -1.41, p = .019). An increase of 1 defined daily dose of SSRI use/1000 population/day was associated with a 6% decrease in suicide rate. Exploratory analysis suggested a stronger association in males, who experienced a greater increase in antidepressant use. Changes in unemployment and alcohol consumption rates did not explain the association.

CONCLUSION

In Japan during 1999 through 2003, absent long-term linear trend effects, annual increases in prescribing of newer antidepressant medications, mainly SSRIs, were associated with annual decreases in suicide rates, particularly among males.

Do antidepressants reduce suicide rates?

Investigators from a number of countries have linked temporal declines in the rate of completed suicide in children and adults to the increasing utilization of selective serotonin reuptake inhibitor (SSRI) antidepressants. They suggest that the relationship is causal. We undertook a thorough literature search of the rates of completed suicide using data from 1980 onwards, from the World Health Organization, the US National Center for Health Statistics, and related studies, in order to ascertain if a broad array of epidemiological evidence would or would not support a consistent association between suicide completion and SSRI utilization. The major findings were: (1) within and between countries, suicide rates vary prominently by age group; (2) national differences are marked with respect to a temporal association between rates of completed suicide and SSRI utilization; (3) in nearly half of the countries of the world, the decline in the suicide rate preceded the onset of the use of SSRIs; (4) suicide rates have fluctuated dramatically over the last century; and (5) the association between declining rates of completed suicides and increased SSRI use in the USA between 1990 and 1999 was no longer present between 2000 and 2004. We conclude that available ecological evidence does not support an inverse temporal relationship between rates of completed suicide and SSRI utilization.

Continued antidepressant treatment and suicide in patients with depressive disorder

Antidepressant use in Denmark, as in many developed countries, has substantially increased during recent years, coinciding with a decreasing suicide rate. In a nationwide observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark from 1995 to 2000, we investigated the relation between continued treatment with antidepressants and suicide in a population of all patients discharged from hospital psychiatry with a diagnosis of depressive disorder. Patients discharged from hospital psychiatry with a diagnosis of depressive disorder had a highly increased rate of suicide. Those who continued treatment with antidepressants had a decreased rate of suicide compared with those who purchased antidepressants once (rate ratio: 0.31, 95% confidence interval: 0.26-0.36). Further, the rate of suicide decreased consistently with the number of prescriptions. On individualized data from a cohort of patients with a known history of depressive disorder, continued antidepressant treatment was associated with reduced risk of suicide.

Predicting and preventing suicide: do we know enough to do either?

In population studies, many risk factors are associated with suicide completion. Yet we cannot accurately predict whether any individual patient will die by suicide. Completers are a distinct population from attempters and do not necessarily present for treatment by mental health professionals. Research on suicide prevention has yielded some promising findings but has not shown that interventions produce definitive results. The strongest evidence for successful prevention derives from reducing access to means. A population-based strategy may be more effective than a high-risk strategy focusing on patients with suicidal ideas or attempts. Much more research is needed before developing effective suicide prevention programs.

Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a systematic review

The role of antidepressants in suicide prevention is a major public health question, given the high prevalence of both depression and depression-related suicidality. Therefore all means available should be utilised to clarify the influence of antidepressants on suicidality. This paper gives a comprehensive overview of the positive effects of antidepressants on suicidality. In the first section, principal methodological issues related to suicidology in general as well as to clinical and epidemiological studies that investigate the influence of antidepressants on suicidality are discussed. In the second section, the results of controlled clinical studies on the efficacy of antidepressants in suicidality are presented. The third section reports on the results of other types of studies, especially epidemiological studies. Altogether, there seems to be reasonable evidence from different research approaches that antidepressants are able to reduce suicidal ideation and also suicidal behaviour in depressive patients. While the evidence for the beneficial effect on suicidal ideation comes from randomised control group studies, some of which used a placebo arm, the evidence for the prophylactic effect on suicidal behaviour, especially suicide, was primarily obtained from well-designed epidemiological studies.

Do antidepressants prevent suicide?

As in many developed countries, the use of antidepressants in Denmark has been substantially increasing during recent years, coinciding with a decreasing suicide rate. We aimed to investigate the relationship between treatment with antidepressants and suicide on individualized data from a nationwide study comprising an observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark during the period 1995-99. A total of 438 625 patients who purchased at least one prescription of antidepressants and 1073 862 individuals from the general population were included in the study. Patients who continued treatment with selective serotonin reuptake inhibitors (SSRIs) (i.e. who purchased SSRIs twice or more) had a decreased rate of suicide compared with patients who purchased SSRIs once only [rate ratio (RR)=0.63; 95% confidence interval (CI)=0.56-0.71]. Furthermore, the rate of suicide decreased consistently with the number of prescriptions. Similarly, among patients treated with newer antidepressants other than SSRIs, the rate of suicide was decreased compared with the rate for patients who purchased other newer antidepressants once only (RR=0.70; 95% CI=0.52-0.94). Continued antidepressant treatment with SSRIs or other newer antidepressants is found to be associated with a reduced risk of suicide.

Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India

Patients' accounts complement psychiatric assessment of deliberate self-harm (DSH). In this study we examined psychiatric disorders, and sociocultural and cross-cultural features of DSH. SCID diagnostic interviews and a locally adapted EMIC interview were used to study 196 patients after DSH at a general hospital in Mumbai, India. Major depression was the most common diagnosis (38.8%), followed by substance use disorders (16.8%), but 44.4% of patients did not meet criteria for an enduring Axis-I disorder (no diagnosis, V-code, or adjustment disorder). Psychache arising from patient-identified sociocultural contexts and stressors complements, but does not necessarily fulfill, criteria for explanatory psychiatric disorders.

ACNP Task Force report on SSRIs and suicidal behavior in youth

This Task Force report by the American College of Neuropsychopharmacology evaluates the safety and efficacy of selective serotonin reuptake inhibitor (SSRIs) antidepressants for depressed youth under 18 years. The report was undertaken after regulatory agencies in the United States and United Kingdom raised concerns in 2003 about the possibility that treatment of depression in children and adolescents with SSRIs may increase the risk of suicidal thinking or suicide attempts.

Case report of a fatal intoxication by citalopram

Citalopram is an antidepressant drug within the group of the selective serotonin reuptake inhibitors (SSRI). It is widely prescribed both in Europe and in United States, and it has always been considered a "safe" drug as pure intoxication with lethal outcome is rare, and most cases of overdose, even with high doses of citalopram ingested, are reported to have an uneventful course. We report the case of a young woman found dead at home. She had been prescribed citalopram by her family doctor 3 weeks before her death for a depressive syndrome. Police found in her house 3 empty blister packages of 28 citalopram tablets (20 mg) and 2 bottles of citalopram oral solution (4%, 15 mL each). The autopsy findings were unremarkable. Nasal swabs, blood from femoral vein, urine, bile and tissue samples were collected for toxicologic investigation. Citalopram separation was performed by solid/liquid method, using Bond-Elute columns. The extracts were analyzed by GLC and GC/MS methods. The toxicologic analysis showed high levels of citalopram in all the examined fluids and tissue samples (blood concentration: 11.60 mg/L). No other drugs and alcohol were detected. Our data confirm that if no other drug is involved, fatal complications occur only after ingestion of very high doses. However, there is no predefined "toxic dose," and the conditions under which the overdose occurs can be very important. We report the exact concentrations of the citalopram in the organs, and wethink that this can be useful in the cases where the blood samples were not available (ie, carbonized or decomposed body).

Selective serotonin reuptake inhibitors in pediatric depression: is the balance between benefits and risks favorable?

Recent controversies surrounding the use of selective serotonin reuptake inhibitors (SSRIs) have highlighted the need to reassess potential benefits, as well as potential risks of this class of medications in the treatment of pediatric depression. The recent availability of data from meta-analyses of published and unpublished antidepressant trials, epidemiological studies, and the Treatment for Adolescents with Depression Study (TADS) has facilitated a reanalysis of this risk/benefit relationship. Despite reviewing similar data, various regulatory agencies have arrived at rather disparate conclusions regarding the data, resulting in continued controversy. Although all groups appear to agree that careful assessment, education regarding risks, and closer monitoring are essential for SSRIs, only the U.S. Food and Drug Administration (FDA) and the U.K. Medicine and Health Care Products Regulatory Agency maintain that an acceptable risk/benefit relationship exists for fluoxetine. The European Medicines Agency concluded that the SSRIs should not be used in the treatment of depression in children and adolescents. The authors of this review have taken into consideration many of these same data and offer a critical discussion of the pros and cons of SSRIs in pediatric depression. The authors have concluded that SSRIs -- in particular, fluoxetine -- do have a role in the treatment of pediatric depression.

The AGNP-TDM Expert Group Consensus Guidelines: focus on therapeutic monitoring of antidepressants

Therapeutic drug monitoring (TDM) of psychotropic drugs such as antidepressants has been widely introduced for optimization of pharmacotherapy in psychiatric patients. The interdisciplinary TDM group of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) has worked out consensus guidelines with the aim of providing psychiatrists and TDM laboratories with a tool to optimize the use of TDM. Five research-based levels of recommendation were defined with regard to routine monitoring of drug plasma concentrations: (i) strongly recommended; (ii) recommended; (iii) useful; (iv) probably useful; and (v) not recommended. In addition, a list of indications that justify the use of TDM is presented, eg, control of compliance, lack of clinical response or adverse effects at recommended doses, drug interactions, pharmacovigilance programs, presence of a genetic particularity concerning drug metabolism, and children, adolescents, and elderly patients. For some drugs, studies on therapeutic ranges are lacking, but target ranges for clinically relevant plasma concentrations are presented for most drugs, based on pharmacokinetic studies reported in the literature. For many antidepressants, a thorough analysis of the literature on studies dealing with the plasma concentration-clinical effectiveness relationship allowed inclusion of therapeutic ranges of plasma concentrations. In addition, recommendations are made with regard to the combination of pharmacogenetic (phenotyping or genotyping) tests with TDM. Finally, practical instructions are given for the laboratory practitioners and the treating physicians how to use TDM: preparation of TDM, drug analysis, reporting and interpretation of results, and adequate use of information for patient treatment TDM is a complex process that needs optimal interdisciplinary coordination of a procedure implicating patients, treating physicians, clinical pharmacologists, and clinical laboratory specialists. These consensus guidelines should be helpful for optimizing TDM of antidepressants.

Utah youth suicide study: psychological autopsy

We conducted a psychological autopsy study to further understand youth suicide in Utah. While traditional psychological autopsy studies primarily focus on the administration of psychometric measures to identify any underlying diagnosis of mental illness for the suicide decedent, we focused our interviews to identify which contacts in the decedent's life recognized risk factors for suicidal behavior, symptoms of mental illness, as well as barriers to mental health treatment for the decedent. Parents and friends recognized most symptoms universally, although friends better recognized symptoms of substance abuse than any other contact. The study results suggest that parents and friends are the most appropriate individuals for gatekeeper training and, in conjunction with other innovative screening programs, may be an effective strategy in reducing adolescent suicide.

Treatment of suicide attempters prior to hospital admission

OBJECTIVE

Numerous authors have reported serious shortcomings in the treatment of suicidal patients. This study examined the treatment suicide attempters admitted to a psychiatric hospital in Switzerland had received prior to the suicide attempt.

METHOD

Thirty-one patients were admitted to this hospital within a year, representing 36 suicide attempts, which corresponds to 6.5% of the annual admission number. Three of these patients were admitted twice, and one patient was admitted three times. Information on previous treatment was collected in personal interviews and included medication, and its dosage, at 1 month and 2 weeks prior to the suicide attempt, and whether the patient had received psychotherapy. In addition, details of the psychosocial event and the means of the suicide attempt were recorded.

RESULTS

Twenty-one patients had been prescribed psychotropic drugs in 24 events, but only in 17 events concerning 15 patients, antidepressants were prescribed prior to hospitalisation. Antipsychotics and benzodiazepines were prescribed in 6 and 21 events, respectively (including 8 events with hypnotics). None of the patients was treated with lithium. In 19 events, 16 patients had received psychotherapy prior to admission. In 32 events, psychotropic drugs were used for the suicide attempt.

CONCLUSION

The findings confirm the undertreatment of patients attempting suicide reported by other authors. In spite of the majority of patients being under psychiatric care, no adequate pharmacotherapy had been prescribed particularly for depressed patients.

Antidepressant drug use and suicide prevention

Depression has been identified as occurring in the majority of people who commit suicide. Effective antidepressant medications have been available for over half a century. It seems logical to conclude that treatment of depression with antidepressants would have a suicide preventive effect. This has been difficult to demonstrate due to the infrequency of suicide and methodological problems in prospectively testing the hypothesis. Pooled data from controlled clinical trials of antidepressants have not demonstrated a suicide preventive effect, but patient selection and the brief time of most trials limits the power of the data. Some reports from either long-term or very large databases have provided evidence that antidepressants prevent suicide. All but one study using aggregated data from naturalistic settings have shown inverse relationships between use of antidepressants and suicide rates in various populations. Definite conclusions cannot be drawn from naturalistic studies since unknown confounders cannot be excluded. The number of geographically widespread studies reporting positive results with varying methods leads us to conclude, however, that antidepressants do exert a suicide preventive effect.

Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides

OBJECTIVE

To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents.

METHOD

Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000.

RESULTS

There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs.

CONCLUSION

The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.

Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

OBJECTIVE

To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation.

METHOD

This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up.

RESULTS

BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home.

CONCLUSIONS

This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.

The impact of lithium long-term medication on suicidal behavior and mortality of bipolar patients

The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.

Antidepressants and suicidal behaviour in unipolar depression

OBJECTIVE

To compare the rates of suicidal behaviour during vs. after discontinuation of treatment with antidepressants, and to determine the comparative rates of suicidal behaviour for patients maintained on tricyclic (TCA) vs. selective serotonin reuptake inhibitor (SSRI) antidepressants.

METHOD

Charts were reviewed for 521 patients with major depressive disorder and/or dysthymic disorder. Periods of active treatment or discontinuation with SSRIs or TCAs were determined. Rates of completed suicide, suicide attempts, and hospitalization for suicidality were analyzed.

RESULTS

There was greater than a five-fold increase in risk for suicidal behaviour after discontinuation of antidepressant treatment (P < 0.0001). The rates of suicidal behavior during treatment with SSRIs or TCAs were similar.

CONCLUSION

Suicidal behaviour in unipolar depressed patients treated with antidepressants increases substantially after medication discontinuation. This effect occurred in both patients who were maintained on SSRIs and TCAs. The findings support a possible protective effect on suicidal behaviour for both SSRIs and TCAs.

Fatal intoxications in a Swedish forensic autopsy material during 1992-2002

Compilations of substances detected in fatal intoxications are important in order to observe changes in intoxication patterns, to monitor effects of preventive work and to discover new trends in drug usage. The aim of the present study was to describe the current pattern of substances detected in fatal intoxications in Sweden. Fatal intoxications investigated at the Department of Forensic Chemistry, Linköping, Sweden, during 1992-2002, were analysed. All suicides, uncertain cases and accidents where the cause of death were fatal intoxications (ICD-9: E950, E980 and E859) were included and substances detected in more than 50 fatal intoxications (in femoral blood) were listed. For each substance, a cut off value was set, above which concentrations were considered toxic. Fatal intoxications were detected by forensic-chemical analyses in 12% (6998/60,314) of the forensic autopsies during the study period. Among the suicides, an average of 3.8 substances were detected per case, the corresponding figure for uncertain cases and accidents were 3.5 and 4.1 substances, respectively. Ethanol was by far the most frequently detected substance, detected in 43% (3039) of the fatal intoxications, of which 32% (960) had toxic concentrations, followed by propoxyphene, detected in 27% (1863) of the fatal intoxications of which 74% (1370) had toxic concentrations. The number of cases where ethanol and propoxyphene were detected decreased during the study period. Moreover, other CNS-active drugs such as antidepressants, analgesics and anxiolytics were also frequently detected. The drugs with high proportions of cases with toxic concentrations detected were propoxyphene, amitriptyline, zolpidem, carisoprodol, alprazolam, thioridazine, methadone and ketobemidone. Selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCA) were detected in 12% (833) and 10% (665), respectively. A significantly (P <0.001) higher proportion of cases where TCA were detected had toxic concentrations when compared with cases where SSRI were detected (64% versus 31%).

Adolescent Suicide Myths in the United States

Abstract: In the United States, teen suicide rates tripled over several decades, but have declined slightly since the mid-1990s. Suicide, by its nature, is a complex problem. Many myths have developed about individuals who complete suicide, suicide risk factors, current prevention programs, and the treatment of at-risk youth. The purpose of this article is to address these myths, to separate fact from fiction, and offer recommendations for future suicide prevention programs. Myth #1: Suicide attempters and completers are similar. Myth #2: Current prevention programs work. Myth #3: Teenagers have the highest suicide rate. Myth #4: Suicide is caused by family and social stress. Myth #5: Suicide is not inherited genetically. Myth #6: Teen suicide represents treatment failure. Psychiatric illnesses are often viewed differently from other medical problems. Research should precede any public health effort, so that suicide prevention programs can be designed, implemented, and evaluated appropriately. Too often suicide prevention programs do not use evidence-based research or practice methodologies. More funding is warranted to continue evidence-based studies. We propose that suicide be studied like any medical illness, and that future prevention efforts are evidence-based, with appropriate outcome measures.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Death and dependence: current controversies over the selective serotonin reuptake inhibitors

Recent years have seen a considerable media interest in the adverse effects of the selective serotonin reuptake inhibitors (SSRIs). This has led to claims that these antidepressants may lead to suicide and homicide and that they cause dependence or even addiction. Such claims have caused great concerns to many patients and have confused doctors in both primary care and psychiatric practice. In this article I review the basis of these claims and show that many seem to emerge from the misinterpretation of evidence and the use of imprecise definitions. Although the SSRIs are not free of problems they compare very favourably with other antidepressants and other classes of psychotropic drugs. There is no evidence they are addictive in the formal sense of leading to a drug dependence syndrome. Some suggestions on the way these issues can be more precisely defined and studied in future are given.

The antisuicidal and mortality-reducing effect of lithium prophylaxis: consequences for guidelines in clinical psychiatry

The suicide-related mortality among patients with affective disorders is approximately 30 times higher, and overall mortality 2 to 3 times higher, than suicide-related mortality in the general population. Lithium has demonstrated possibly specific antisuicidal effects apart from its prophylactic efficacy: it significantly reduces the high excess mortality of patients with affective disorders. To date, suicide-prevention effects have not been shown for antidepressant or anticonvulsant long-term treatment. Clozapine appears to reduce the suicide rate in schizophrenia patients. Against this background, guidelines and algorithms for selecting an appropriate prophylactic strategy for affective disorders should consider the presence of suicidality in patient history. Appropriate lithium prophylaxis prevents approximately 250 suicides yearly in Germany, although lithium salts are infrequently prescribed within the National Health Scheme (specifically, to 0.06% of the population). Rational treatment strategies most likely would demand that prescription rates be about 10 times higher.

Suicidal behaviour in bipolar disorder: risk and prevention

Bipolar (manic-depressive) disorder is a common and severe illness. It is also potentially fatal as a result of accidents and increased mortality associated with comorbid substance use and medical illnesses, but its highest lethality results from suicide. Suicide rates, averaging 0.4% per year in men and women diagnosed with bipolar disorder, are >20-fold higher than in the general population. Suicidal acts often occur early in the illness course and in association with severe depressive and dysphoric-agitated mixed phases of illness, especially following repeated, severe depressions. Systematic consideration of risk and protective factors enhances assessment of potentially suicidal patients. Short-term interventions employed empirically to manage acute suicidality include close clinical supervision, rapid hospitalisation and use of electroconvulsive treatment. Several plausible therapeutic interventions have limited evidence of long-term effectiveness against mortality risks associated with any psychiatric disorder, including antidepressant, antimanic, antipsychotic and electroconvulsive, as well as psychosocial, treatments. However, in bipolar disorder and other major affective disorders, lithium maintenance treatment is a notable exception, with strong and consistent evidence that it reduces suicidal risk. The growing range of drugs being introduced to treat acute and long-term phases of bipolar disorder, including antiepileptic drugs, atypical antipsychotics and relatively safe, modern antidepressants, require research assessment for their ability to limit premature mortality from suicide and other causes. For now, however, more can be done to improve treatment in major affective illnesses by application of current knowledge in a systematic fashion, with close and sustained clinical follow-up of patients at risk, hopefully with a resulting reduction of mortality rates.

Assessment of Patients Who Attempt Suicide

Suicidal behavior is influenced in varying degrees by biological, personal, and social factors. Identifying 4 common reasons for suicidal acts (psychosis, major depression, philosophical reasons, and poor impulse control) can be very helpful in evaluating suicidal patients quickly and making decisions about how patients should be treated. Educating the general public and primary care physicians about these reasons while addressing biological, personal, and social factors that contribute to them can improve understanding of suicidal behavior and patient involvement in and adherence to the treatment process.

Utah youth suicide study, phase I: government agency contact before death

OBJECTIVE

To delineate the probability of contact between government agencies and youths who complete suicide, to investigate the nature of those contacts, and to identify new risk factors for suicide.

METHOD

A descriptive epidemiological analysis of data from multiple Utah government agencies on consecutive youth suicides (n = 151) between August 1, 1996, and June 6, 1999, aged 13-21 years. Data were collected from four government agencies: Office of the Medical Examiner, Juvenile Justice, Department of Human Services, and the Department of Education.

RESULTS

Utah descriptive data were similar to national statistics, with the majority of completers being male (89%) and firearms the most common method of suicide (58%). The data demonstrated an association between youth suicide and contact with Juvenile Justice. Sixty-three percent of youths who completed suicide in Utah had contact with Juvenile Justice, and there was a direct correlation between number of referrals and increased suicide risk. Suicide completers had multiple minor offenses over many years. A significant minority of school-age subjects could not be located within the school system. Few suicide completers had evidence of active psychiatric treatment.

CONCLUSIONS

Juvenile Justice is identified as a novel site for the screening and identification of youths at risk for suicide.

Age, period and cohort effects on suicide rates in Australia, 1919-1999

OBJECTIVE

To examine age, period and cohort effects on Australian suicide rates.

METHOD

Male suicide rates for successive 5-year periods between 1919 and 1998, and for 1999 were displayed graphically to examine interactions between age, period and cohort effects.

RESULTS

There has been a pronounced period effect on male suicide rates in all age groups over the last few decades, with lower rates in wartime and peak rates for most cohorts in the 1960s. Peak rates of all adult female 5-year age cohorts occurred in the 1960s or early 1970s.

CONCLUSION

Most so-called cohort effects appear to be associated with environmental changes that may not be a function of the cohort itself. While much attention has focused on the rising suicide rates in young males in Australia, local media and health authorities have given little emphasis to the high rates found in elderly males.

Unmet needs in the pharmacological management of depression

Newer antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs), selective noradrenaline reuptake inhibitors (NRIs) and drugs acting on both serotonin and noradrenaline, represent a clinically significant advance over the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors. Nevertheless, all current pharmacological treatments for depression fall somewhat short of the 'ideal', and unmet needs remain in the pharmacological management of depression. In general, current antidepressants differ little in terms of efficacy. However, in terms of tolerability, SSRIs appear to offer clear advantages over older therapies. For example, the proportion of patients who discontinue treatment because of adverse events and the risk of fatal toxicity both appear to be lower with SSRIs, compared with TCAs. Some adverse events, however, such as sexual dysfunction and nausea (typical serotonergic side effects), tend to be more frequent with SSRIs. Also, individual SSRIs appear to differ in the likelihood that they will be associated with these side effects. However, no clear advantage emerges for any one SSRI over another, and the current recommendation is that the anticipated side-effect profile should be tailored to the patient. Current pharmacoeconomic data do not appear to favour any antidepressant over another, with no cost benefits associated with prescribing TCAs instead of SSRIs.The refinement of current drugs arising from the introduction of their active enantiomers may translate into clinical benefit, bringing closer the 'ideal' antidepressant. Potential benefits of a single enantiomer versus the racemate in the management of depression include: a reduction in the total dose, while maintaining desired outcomes, as well as a possible greater efficacy, dose for dose,simpler assessment of dose-response relationships,a reduction in pharmacokinetic and pharmacodynamic variability between patients, anda reduction in any toxicity arising from the inactive stereoisomer. However, these benefits remain to be proved in clinical trials and naturalistic studies. Further refinement of the benefit:risk ratio of current 'gold standard' drugs may go some way to addressing the shortfalls in existing antidepressant therapy. Copyright 2001 John Wiley & Sons, Ltd.

Can better recognition and treatment of depression reduce suicide rates? A brief review

Depression, the major cause of suicide, is prevalent but an under-detected, underdiagnosed and, under-treated illness and it is particularly true for depressed suicide victims. However, several studies consistently show that successful treatment of depression not only relieves depressive symptoms, but also decreases and makes suicidality vanish. If the rate of treated depressions in the population increases gradually, at a given point it will appear in the decline of the suicide rates. Although absolute evidence is lacking at present, recent reports from some European countries strongly suggest that increasing utilisation of antidepressants is one of the most important contributing factors in the decrease in suicide rates.