Non-psychotropic medication and risk of suicide or attempted suicide: a systematic review

Involvement of propranolol in suicides: cross-sectional study using coroner-reported data

BACKGROUND

Propranolol is a beta-blocker medication indicated mostly for heart rhythm conditions and for physical symptoms of anxiety. Prescriptions for propranolol in the UK have increased since 2008. Recently, there have been concerns about the involvement of propranolol in intentional poisonings, but such deaths are not routinely reported. Therefore, use of coroner-reported and toxicology data enables unique investigation into the scale of involvement of propranolol in suicide.

AIMS

To describe the extent to which propranolol is involved in suicides, including patterns over time and characteristics of people whose suicide involved propranolol compared with other suicides.

METHOD

Data were derived from the National Programme on Substance Use Mortality (NPSUM). All suicides and deaths of undetermined intent between 2010 and 2021 in England, Wales and Northern Ireland were extracted, and a subset was identified where propranolol was involved in death.

RESULTS

There were 4473 suicides of which 297 (6.6%) involved propranolol, with the proportion involving propranolol nearly quadrupling during the study period (3.4% v. 12.3%). Compared with all other suicides, a greater proportion of propranolol suicides were in women (56.6% v. 37.1%) and in people with diagnoses of depression (39.1% v. 27.1%) and anxiety (22.2% v. 8.6%). When suicide involved propranolol, an antidepressant was detected at post-mortem in 81.8% of deaths, most commonly a selective serotonin reuptake inhibitor (SSRIs) (51.5%), and most often citalopram (24.6%).

CONCLUSIONS

A small number, but increasing proportion, of suicides reported to the NPSUM involve propranolol. Vigilance to the combined toxicity profile of medicines used alongside propranolol may be pertinent.

Supervised Relation Extraction Between Suicide-Related Entities and Drugs: Development and Usability Study of an Annotated PubMed Corpus

BACKGROUND

Drug-induced suicide has been debated as a crucial issue in both clinical and public health research. Published research articles contain valuable data on the drugs associated with suicidal adverse events. An automated process that extracts such information and rapidly detects drugs related to suicide risk is essential but has not been well established. Moreover, few data sets are available for training and validating classification models on drug-induced suicide.

OBJECTIVE

This study aimed to build a corpus of drug-suicide relations containing annotated entities for drugs, suicidal adverse events, and their relations. To confirm the effectiveness of the drug-suicide relation corpus, we evaluated the performance of a relation classification model using the corpus in conjunction with various embeddings.

METHODS

We collected the abstracts and titles of research articles associated with drugs and suicide from PubMed and manually annotated them along with their relations at the sentence level (adverse drug events, treatment, suicide means, or miscellaneous). To reduce the manual annotation effort, we preliminarily selected sentences with a pretrained zero-shot classifier or sentences containing only drug and suicide keywords. We trained a relation classification model using various Bidirectional Encoder Representations from Transformer embeddings with the proposed corpus. We then compared the performances of the model with different Bidirectional Encoder Representations from Transformer-based embeddings and selected the most suitable embedding for our corpus.

RESULTS

Our corpus comprised 11,894 sentences extracted from the titles and abstracts of the PubMed research articles. Each sentence was annotated with drug and suicide entities and the relationship between these 2 entities (adverse drug events, treatment, means, and miscellaneous). All of the tested relation classification models that were fine-tuned on the corpus accurately detected sentences of suicidal adverse events regardless of their pretrained type and data set properties.

CONCLUSIONS

To our knowledge, this is the first and most extensive corpus of drug-suicide relations.

Montelukast and Nightmares: Further Characterisation Using Data from VigiBase

INTRODUCTION

Montelukast is a medicine indicated for use in asthma. Psychiatric disorders including nightmares have not been described in clinical trials but during recent years have been included in the product information as having been reported post-marketing, without further description of the events. Previous descriptions in the scientific literature were based on limited numbers of reports or lacked detailed case information.

OBJECTIVE

The study aim was to further characterise post-marketing adverse drug reactions for nightmares, suspected to be induced by montelukast, to facilitate safer use of the medicine by providing additional information to patients and healthcare professionals.

METHODS

We clinically reviewed reports of nightmares with montelukast present in VigiBase, World Health Organization's global database of suspected adverse reactions to medicinal products, developed and maintained by the Uppsala Monitoring Centre, until 3 May, 2020.

RESULTS

There were 1118 reports of nightmares with montelukast in VigiBase, which provided valuable descriptions of the nightmares as well as information about the impact on the daily lives, with many cases describing a severe impact of the nightmares. About half of the reports were classified as serious. Two thirds concerned children, with the largest age group represented being children aged 5-10 years. In most cases, the nightmares disappeared upon discontinuation of the drug but for some patients it took a long time until the nightmares ceased.

CONCLUSIONS

The nature and potential severity of this adverse drug reaction, as described in these reports, present important knowledge for patients and healthcare providers that could help reduce drug-induced harm. This study highlights the value of post-marketing reports for further characterisation of known adverse drug reactions. The benefit-risk balance should be continuously monitored while patients are taking montelukast.

Multimodality Functional Magnetic Resonance Imaging Assisted Treatment of Primary Insomnia and Anxiety and Depression

Based on multimodal functional magnetic resonance imaging technology, explore the changes of local brain function in the whole brain range of patients with primary insomnia at rest, and conduct correlation analysis to explore the relationship between this locality and function and clinical features. Provide further imaging evidence for the exploration of the neural mechanism of primary insomnia. Using multimodal functional magnetic resonance imaging, self-rating anxiety scale, self-rating depression scale to assess the status anxiety factor and trait anxiety of STAI in patients with primary insomnia (88 cases) and normal sleepers (82 cases). Factors and total scores, depressive mental disorders and total scores were statistically significantly different from the normal sleep group. The study found that patients with primary insomnia under the multimodal functional magnetic resonance imaging assisted treatment have abnormal local functional activities in multiple brain regions such as emotions and sensorimotor regions. We explored the brain of patients with primary insomnia from the perspective of functional differentiation. Changes in nerve activity are conducive to further understanding the characteristics of nerve activity in primary insomnia.

The association of depression with use of prescription drugs in adults with noncommunicable diseases: Based on NHANES in 2005-2016

BACKGROUND

It is not clear how the noncommunicable diseases (NCDs) performed in the association of depression with use of prescription drugs.

METHODS

This cross-sectional study involved 20,836 participants with at least one NCDs who aged over 20 years old in the National Health and Nutrition Examination Survey (NHANES) from 2005-2016. Ordinal logistic regression under complex sampling was used to examine the association of depression with use of prescription drugs in patients with different categories of NCDs.

RESULT

Among patients with respiratory diseases (OR: 1.41, 95% CI: 1.13-1.76), genitourinary diseases (OR: 1.59, 95% CI: 1.28-1.98), and cardiovascular diseases (OR: 1.43, 95% CI: 1.27-1.60), the risk of depression was higher among those who used prescription drugs than those who did not. The results showed that the association of depression with use of prescription drugs was significantly stronger, especially in patients with genitourinary diseases ≥65 years of age (OR: 1.91, 95% CI: 1.01-3.61). Trend analysis showed that the categories of prescription drugs used and the risk of depression was significantly statistically different (P for trend <0.001).

LIMITATIONS

Self-reported prevalence of depression may differ from actual prevalence of depression. The categories of NCDs studied in this article are limited and the association between specific drugs and depression is not analyzed.

CONCLUSIONS

In patients with NCDs, use of prescription drugs increased the risk of depression, and this risk increased significantly, especially in patients with genitourinary diseases who aged over 65 years. The risk of depression was increasing with the categories of prescription drugs used.

Prescription Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Depression among Adults with Inflammatory Chronic Conditions in the United States

The association of prescription NSAIDs to presence of depression among adults with inflammatory chronic conditions in adults with and without depression and seeking care in routine clinical practice remains unknown. We examined the association of prescription NSAIDs to depression among adults with inflammatory chronic conditions in a nationally representative sample of the US non-institutionalized civilian population. We used a retrospective cross-sectional design. Data on 10,713 adults with inflammatory chronic conditions were derived from 2015 Medical Expenditure Panel Survey (MEPS). The dependent variable was the presence or absence of depression and the key independent variable was prescription NSAIDs use. Logistic regression models were used to examine the adjusted associations of prescription NSAIDs to depression. In these regressions, other independent variables (biological, sociocultural, socio-economic, access to healthcare services, medical conditions and treatment factors, behavioural, and environmental factors) that may affect the relationship of prescription NSAIDs to depression were also included. All analyses accounted for the complex survey design of MEPS. Overall, 18.2% reported depression. Almost 21% used prescription NSAIDs. In the unadjusted model, prescription NSAIDs use had higher odds of depression (OR = 1.59;95%CI = [1.40, 1.82]) as compared to those without NSAIDs. In the fully-adjusted logistic regression model, with controls for other independent variables, adults using prescription NSAIDs had no significant association with depression (AOR = 0.97;95%CI = [0.84, 1.13]) compared to those without NSAIDs. In this first real-world study of all adults (with and without depression) in the US, we did not observe a statistically significant association of prescription NSAIDs to the presence of depression.

Effects of chronic physical disease and systemic inflammation on suicide risk in patients with depression: a hospital-based case-control study

BACKGROUND

Few studies have examined the concurrent effects of physical disease and systemic inflammation on suicide risk in patients with depression. The authors investigated the independent contributions of chronic physical disease and systemic inflammation as indexed by C-reactive protein (CRP), on risk of suicide attempt.

METHODS

In this case-control study, 1468 cases of suicide attempters and 14 373 controls, both aged 18-65 years with a diagnosis of depression during 2011-2015, were identified from the hospital-wide database. Regression models were implemented to identify separate effects of physical diseases and systemic inflammation indexed by CRP, on risk of suicide attempt.

RESULTS

Compared with having no physical disease, having one, two, and three or more physical diseases was associated with a 3.6-, 6.4-, and 14.9-fold increase in odds of making a suicide attempt, respectively, after adjusting for age, sex, and race/ethnicity. In a sub-sample of cases and controls with available CRP values, patients with high CRP (>3 mg/L) had 1.9 times the odds of suicide attempt compared with patients with low CRP (<1 mg/L). This association was no longer significant when controlling for the effect of physical disease.

CONCLUSIONS

The presence of physical disease is an important risk factor for suicide attempt among patients with depression. Systemic inflammation is likewise associated with increased risk for suicide attempt, however, this association appears to be accounted for by the presence of physical disease among patients receiving care in a medical center setting. Healthcare providers should consider the risk of suicide attempt in depressed patients burdened with multiple comorbidities.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

Assessment of suicidal behavior in dermatology (Review)

Many diseases that affect physical health can also affect mental health. Many of these diseases are studied in terms of quality of life, depression and suicidal behavior. Dermatological disorders, although having a strong impact on the individual's life, are less studied with regard to suicidal behavior. There is a need to approach several dermatological diseases from the perspective of suicidal behavior in order to intervene early with specific treatment or to prevent suicide. Psoriasis, acne, melanoma, atopic dermatitis and urticaria are scarcely studied from the point of view of suicidal behavior. In addition to these diseases, there are others that require attention in terms of suicidal behavior, such as vitiligo or oculocutaneous albinism, most probably due to a small number of people suffering from these diseases, research is almost non-existent in these cases. We want to draw attention to the importance of early detection of suicidal behavior in dermatological practice and to highlight the need for several studies on this subject.

Access to means of lethal overdose among psychiatric patients with co-morbid physical health problems: Analysis of national suicide case series data from the United Kingdom

BACKGROUND

Many physical health problems are associated with elevated suicide risk whilst also providing access to means of overdose. We aimed to investigate whether psychiatric patients with physical co-morbidities who die by suicide were more likely than those without co-morbidities to self-poison with non-psychotropic medications.

METHODS

We analysed data on 14,648 psychiatric patients who died by suicide in England & Wales during 2004-2015, as recorded by the National Confidential Inquiry into Suicide and Safety in Mental Health. Using logistic regression models adjusted for age, gender, ethnicity, and primary drug dependence/misuse we compared patients diagnosed with physical co-morbidities versus those without to assess whether a greater proportion of the former had died by overdose, and medication prescribed to treat such disorders (e.g. opioids, insulin).

RESULTS

24% (n = 3525) were recorded as having physical co-morbidity. A greater proportion of these individuals died by self-poisoning than those without physical co-morbidity (37% vs. 20%, p < .001; adjusted OR 2.47; 95% CI 2.26-2.70), and they were more likely to have used medications for a physical health disorder in overdose (50% vs. 34%; adjusted OR 2.10; 95% CI 1.80-2.46), particularly opioids (30% vs. 22%; p < .001), paracetamol/opioid compounds (11% vs. 7%, p < .001) and insulin (4% vs. 1%, p < .001).

LIMITATIONS

Use of survey data may have resulted in under-reporting of physical health problems and/or overdose medications.

CONCLUSIONS

Overdose, rather than hanging, is the leading cause of suicide among psychiatric patients with physical co-morbidities, particularly using non-psychotropic medications. There is potential for means restriction in preventing suicide among these patients.

Use of prescription medication prior to suicide in Norway

BACKGROUND

The use of psychotropic medications in relation to mental disorders is considered central to preventing suicide. However, few studies have addressed prescription patterns at different time points within the last year prior to suicide and compared these with those of the general population.

METHODS

We use data covering the period from 2010 to 2011 from the Norwegian Cause of Death Registry and the Norwegian Prescription Database to examine dispensing patterns of prescription medication within 12 months and within 30 days of suicide. Our data includes all registered suicides in Norway among individuals aged 15 years and older in 2011 (n = 594), 434 men and 160 women. Dispensing of prescription medication in the general population (n ≈ 4 million) are used for comparison.

RESULTS

Dispensing of any prescription medication were high and varied from 95.6% for females and 83.2% for males within 12 months of suicide, to 64.4% for females and 47.2% for males within 30 days of suicide, respectively. The percentages with dispensed prescription medication increased with age. A similar sex and age pattern was observed for the dispensing of psychotropic medications. Within the last 30 days, close to one in two were dispensed psychotropic medications. The dispensing of antidepressants, hypnotics and sedatives was more common than the dispensing of other categories of psychotropics. The percentages with dispensed prescription medication among the population controls were considerably lower, in particular the dispensing of psychotropics.

CONCLUSION

Dispensing of prescription medications, including psychotropic medications, is common prior to suicide. The percentage with dispensed prescription medication increases with age and are higher for females than for males.

Risk factors for self-harm in people with epilepsy

OBJECTIVE

To estimate the risk of self-harm in people with epilepsy and identify factors which influence this risk.

METHODS

We identified people with incident epilepsy in the Clinical Practice Research Datalink, linked to hospitalization and mortality data, in England (01/01/1998-03/31/2014). In Phase 1, we estimated risk of self-harm among people with epilepsy, versus those without, in a matched cohort study using a stratified Cox proportional hazards model. In Phase 2, we delineated a nested case-control study from the incident epilepsy cohort. People who had self-harmed (cases) were matched with up to 20 controls. From conditional logistic regression models, we estimated relative risk of self-harm associated with mental and physical illness comorbidity, contact with healthcare services and antiepileptic drug (AED) use.

RESULTS

Phase 1 included 11,690 people with epilepsy and 215,569 individuals without. We observed an adjusted hazard ratio of 5.31 (95% CI 4.08-6.89) for self-harm in the first year following epilepsy diagnosis and 3.31 (95% CI 2.85-3.84) in subsequent years. In Phase 2, there were 273 cases and 3790 controls. Elevated self-harm risk was associated with mental illness (OR 4.08, 95% CI 3.06-5.42), multiple general practitioner consultations, treatment with two AEDs versus monotherapy (OR 1.84, 95% CI 1.33-2.55) and AED treatment augmentation (OR 2.12, 95% CI 1.38-3.26).

CONCLUSION

People with epilepsy have elevated self-harm risk, especially in the first year following diagnosis. Clinicians should adequately monitor these individuals and be especially vigilant to self-harm risk in people with epilepsy and comorbid mental illness, frequent healthcare service contact, those taking multiple AEDs and during treatment augmentation.

Availability and sufficiency of phenobarbital, an essential medication, in Bhutan: a survey of global and neuropsychiatric relevance

Objective

We aimed to provide a reliable evidence-based conclusion around manufacturing, import, availability and sufficiency of one essential medication, phenobarbital (PB) through our example location (Bhutan). The relevant details about manufacturing, import, annual quantity, dose strength were obtained.

Results

There was no local manufacturing of PB and all other anti-seizure medications. A total of 1068 vials of PB 200 mg/mL inj and 489,350 tablets of PB30 mg (i.e. 14.6 kilos) was estimated to annually become available. Of this, 5.3 k (36.3%) was present at the basic health units (BHUs). The PB was absent at 26 (14.7%) BHUs. There was no availability of PB syrup. Treating supposed target of 50.0% of the 20.0% of the prevalent case-load (N = 4523) require 18.1 kilo of PB annually. To conclude, having or not the local manufacturing may or may not be a limitation. There is a need to overcome challenges of inappropriate dose strength, absent pediatric formulation, indirect cost, and low selling price of PB. The possible therapeutic participation of PB in managing disease conditions (like epilepsy) remains limited despite favorable safety and efficacy profile. Strengthening the availability of essential medications is essential to reduce the treatment gap and public health burden of treatable disease conditions.

Prevalence of Prescription Medications With Depression as a Potential Adverse Effect Among Adults in the United States

IMPORTANCE

Prescription medications are increasingly used among adults in the United States and many have a potential for causing depression.

OBJECTIVES

To characterize use of prescription medications with depression as a potential adverse effect and to assess associations between their use and concurrent depression.

DESIGN, SETTING, AND PARTICIPANTS

Five 2-year cycles (2005-2006 through 2013-2014) of the National Health and Nutrition Examination Survey, representative cross-sectional surveys of US adults aged 18 years or older, were analyzed for use of medications with depression as a potential adverse effect. Multivariable logistic regression examined associations between use of these medications and concurrent depression. Analyses were performed among adults overall, excluding antidepressant users, and among adults treated with antidepressants and with hypertension.

EXPOSURES

Prescription medications with depression as a potential adverse effect (listed in Micromedex).

MAIN OUTCOMES AND MEASURES

Prevalence of any use and concurrent use of medications with a potential to cause depression and prevalence of depression (PHQ-9 score ≥10).

RESULTS

The study included 26 192 adults (mean age, 46.2 years [95% CI, 45.6-46.7]; women, 51.1%) and 7.6% (95% CI, 7.1%-8.2%) reported depression. The overall estimated prevalence of use of medications with depression as an adverse effect was 37.2%, increasing from 35.0% (95% CI, 32.2%-37.9%) in the cycle years 2005 and 2006 to 38.4% (95% CI, 36.5%-40.3%) in 2013 and 2014 (P for trend = .03). An estimated 6.9% (95% CI, 6.2%-7.6%) reported use of 3 or more concurrent medications with a potential for depression as an adverse effect in 2005 and 2006 and 9.5% (95% CI, 8.4%-10.7%) reported such use in 2013 and 2014 (P for trend = .001). In adjusted analyses excluding users of antidepressants, the number of medications used with depression as possible adverse effects was associated with increased prevalence of concurrent depression. The estimated prevalence of depression was 15% for those reporting use of 3 or more medications with depression as an adverse effect vs 4.7% for those not using such medications (difference, 10.7% [95% CI, 7.2%-14.1%]). These patterns persisted in analyses restricted to adults treated with antidepressants, among hypertensive adults, and after excluding users of any psychotropic medication.

CONCLUSIONS AND RELEVANCE

In this cross-sectional survey study, use of prescription medications that have depression as a potential adverse effect was common. Use of multiple medications was associated with greater likelihood of concurrent depression.

Alexithymia and Suicide Risk in Psychiatric Disorders: A Mini-Review

It is well known that alexithymic individuals may show significantly higher levels of anxiety, depression, and psychological suffering than non-alexithymics. There is an increasing evidence that alexithymia may be considered a risk factor for suicide, even simply increasing the risk of development of depressive symptoms or per se. Therefore, the purpose of this narrative mini-review was to elucidate a possible relationship between alexithymia and suicide risk. The majority of reviewed studies pointed out a relationship between alexithymia and an increased suicide risk. In several studies, this relationship was mediated by depressive symptoms. In conclusion, the importance of alexithymia screening in everyday clinical practice and the evaluation of clinical correlates of alexithymic traits should be integral parts of all disease management programs and, especially, of suicide prevention plans and interventions. However, limitations of studies are discussed and must be considered.

Comparative risk of self-harm hospitalization amongst depressive disorder patients using different antidepressants: a population-based cohort study in Taiwan

BACKGROUND

The aim of the study was to evaluate the comparative risk of self-harm associated with the use of different antidepressants.

METHOD

A cohort study was conducted using data from Taiwan's National Health Insurance Research Database from 2001 to 2012. A total of 751 606 new antidepressant users with depressive disorders were included. The study outcome was hospitalization due to self-harm (International Classification of Diseases, Ninth Revision, Clinical Modification codes: E950-E958 and E980-E988). Cox proportional hazards models with stratification of the propensity score deciles were used to estimate the hazard ratios of self-harm hospitalization during the first year following the initiation of antidepressant treatment.

RESULTS

There were 1038 hospitalization episodes due to self-harm that occurred during the follow-up of 149 796 person-years, with an overall incidence rate of 6.9 [95% confidence interval (CI) 6.5-7.4] per 1000. Compared with fluoxetine, the risk of self-harm hospitalization was higher for maprotiline [adjusted hazard ratio (aHR) = 3.00, 95% CI 1.40-6.45], milnacipran (aHR = 2.34, 95% CI 1.24-4.43) and mirtazapine (aHR = 1.40, 95% CI 1.06-1.86), lower for bupropion (aHR = 0.51, 95% CI 0.30-0.86), and similar level of risk was found for other selective serotonin reuptake inhibitors (citalopram, escitalopram, fluvoxamine, paroxetine and sertraline).

CONCLUSIONS

The risk of self-harm may vary across different antidepressant drugs. It would be of importance to conduct further research to investigate the influence of antidepressant use on self-harm behaviors.