Suicide attempts associated with akathisia

Risk factors for suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders: An analysis using the Japanese Adverse Drug Event Report database

The present study attempted to identify risk factors for suicidality and hostility/aggression in patients with bipolar disorders. Data on 3521 patients were extracted from the Japanese Adverse Drug Event Report (JADER) database. There were 134 reports regarding suicidal behavior/ideation, and 129 patients were judged to have it. Standardized Medical Dictionary for Regulatory Activities queries indicated that 248 adverse drug events pertained to hostility/aggression, and 218 patients were considered to show hostility/aggression. A multiple logistic regression analysis revealed the association of the risk for suicidal behavior/ideation with bipolar II disorder [adjusted odds ratio (aOR): 4.55, 95% confidence interval (CI): 1.90-10.9], male sex (aOR: 1.23, 95% CI: 1.02-1.48), age <50 years (aOR: 1.75, 95% CI: 1.43-2.15), the administration of aripiprazole (aOR: 1.27, 95% CI: 1.00-1.60), and akathisia (aOR: 3.05, 95% CI: 1.80-5.18), while lithium carbonate decreased its odds (aOR: 0.664, 95% CI: 0.537-0.821). The risk of hostility/aggression was associated with male sex (aOR: 1.22, 95% CI: 1.06-1.40), lithium carbonate (aOR: 0.823, 95% CI: 0.710-0.953), and carbamazepine (aOR: 0.693, 95% CI: 0.500-0.961). No association between suicidal behavior/ideation and hostility/aggression was recognized. The present study proposes factors related with suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders using the JADER database. Lithium carbonate appeared to decrease the risks of suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders, and akathisia may be associated with the former risk. Further studies are required to evaluate the identified signals.

Akathisia Among Patients Undergoing Antipsychotic Therapy: Prevalence, Associated Factors, and Psychiatric Impact

OBJECTIVES

The prevalence of akathisia is variably reported in the literature and its psychiatric impact is little studied. The aim of this study was to establish the prevalence, the associated factors, and the psychiatric impact of akathisia among patients undergoing antipsychotic treatment.

METHODS

A cross-sectional descriptive study was carried out at the Department of Psychiatry A, at Razi Hospital, in Tunis. It included patients with psychosis, undergoing antipsychotic treatment, from June 2016 to February 2017. Akathisia was diagnosed according to the Barnes Akathisia Scale.

RESULTS

The prevalence of akathisia was 19.5% (n = 24, schizophrenia/schizoaffective disorder, n = 20; bipolar disorder, n = 4). The delay between the diagnosis of the disease and the onset of akathisia was 7.1 ± 8.8 years. Among the sample of patients with akathisia, 20/24 were on monotherapy of which 14 on conventional antipsychotics and six on atypical antipsychotics. Patients with akathisia were on atypical (8/24), low-potency conventional (4/24), or high-potency conventional (17/24) antipsychotics. The average dose of antipsychotics in chlorpromazine equivalent was 2294.5 ± 3037.7 mg. After adjusting for confounders, the only factor significantly positively associated with the diagnosis of akathisia was the dose of antipsychotics prescribed (P = 0.01). The following psychiatric manifestations were reported by patients with akathisia: dysphoria/irritability (16/23), anxiety (18/24), sadness (15/24), suicidal thoughts (11/24), heteroaggressivity (8/23), sleep disturbances (16/24), and suicidal attempts (9/24).

CONCLUSIONS

Despite the high psychiatric and social burden of akathisia, it remains largely underdiagnosed and undertreated, because in part of its subjective component.

Aripiprazole IM depot as an option for the treatment of bipolar disorder

Introduction: Long-acting injectable (LAI) antipsychotic drugs are developed to reduce daily intake need and to overcome treatment non-adherence. Aripiprazole IM depot refers to two long-acting aripiprazole formulations, once monthly monohydrate (AOM) and aripiprazole lauroxil. AOM has been approved for schizophrenia since 2012 and for bipolar disorder since 2017. Aripiprazole lauroxil is approved for schizophrenia, not for bipolar disorder.Areas covered: To assess the effect of AOM in bipolar disorder, the authors searched PubMed and ClinicalTrials.gov for randomized trials using AOM in patients with bipolar disorder. Included were four studies covering efficacy, functioning, quality of life, and safety/tolerability. Studies lasted 12 months.Expert opinion: AOM reduced symptoms of patients with bipolar disorder and a manic episode, increased functioning and quality of life, and protected from recurrence of manic episodes. It proved to be safe/tolerable, with only akathisia occurring in ≥10% of cases and more frequently than with placebo. However, there were only 143 patients receiving AOM in the considered studies. Included studies were backed in their conclusions by other literature, but they come from 2017-2018. No studies are expected or planned in the near future. Aripiprazole lauroxil has not applied for approval in bipolar disorder and there is no sign it will.

The Relationship Between Antipsychotic-Induced Akathisia and Suicidal Behaviour: A Systematic Review

OBJECTIVE

We aim to systematically review evidence for a relationship between antipsychotic-induced akathisia and suicidal behaviour, in order to guide further clinical decision making in this area.

METHODS

Several electronic databases (Embase, Medline, Cochrane and PsychINFO) were systemically searched for articles published up to February 2021, using search terms related to akathisia, antipsychotics and suicidal behaviour. Two reviewers independently evaluated all the relevant studies using predetermined criteria and assessed the risk of bias for each included study. The systematic review was conducted in line with PRISMA methodology and reporting.

RESULTS

Following de-duplication, screening and application of exclusion criteria, four eligible studies were identified. All of the available studies were in English and included adult patients. Nevertheless, there was significant variability regarding methodology and overall quality was deemed low due to small sample sizes. There was insufficient data to perform statistical analyses of the results. Of the four studies, two found a weak correlation between antipsychotic-related akathisia and suicidal behaviour, a finding that was not supported by the remaining two studies.

CONCLUSION

The search yielded very few studies for inclusion. On the basis of the existing evidence, akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication. However, proactive screening for emerging suicidal behaviour in this vulnerable patient group is advisable. Our findings highlight the pressing need for further research in this area.

Diagnosis and Treatment of Depression in Patients with Schizophrenia

Depression is the third most common illness among patients with schizophrenia which negatively affects the course of the disease and significantly contributes to the mortality rate, due to increased suicide. Depression, along with negative symptoms and cognitive deficits, is one of the main factors that significantly decreases the quality of life and the disease prognosis in patients with schizophrenia. In addition, depression increases the frequency of exacerbations and readmissions, decreases the quality and duration of remissions and is associated with more frequent substance abuse and an increased economic burden. Data on the prevalence of depression among patients with schizophrenia are contradictory and are associated with a low detection rate of depression in such patients, a lack of clear diagnostic criteria and difficulties in differentiation between extrapyramidal and negative symptoms. The average prevalence of depression that meets the diagnostic criteria of major depressive episodes in patients with schizophrenia is 25% at a specific point, and 60% over the course of a lifetime; the frequency of subsyndromal depression is much higher. It is essential to distinguish between primary (axial syndrome) and secondary depressive symptoms (extrapyramidal symptoms, psychogenic or nosogenic reactions, social factors, etc.) to determine treatment strategies. The published data relating to randomized clinical trials for the development of evidence-based guidelines are limited. Current recommendations are based mainly on the results of small-scale trials and reviews. Certain atypical antipsychotics (quetiapine, lurasidone, amisulpride, aripiprazole, olanzapine, clozapine) are superior to typical antipsychotics in the reduction of depressive symptoms. Clozapine is effective in the management of patients at risk from suicide. The additional prescription of antidepressants, transcranial magnetic stimulation and electroconvulsive therapy are not always effective and are only possible following the management of acute psychosis in cases when antipsychotic monotherapy proved to be ineffective.

[Suicidality in schizophrenic psychosis: a current overview]

BACKGROUND

Suicidality in schizophrenic psychosis is an important topic but stands in clinical everyday work behind the perception of suicide especially in affective disorders. Schizophrenic psychosis is recognized as an independent risk factor for suicide attempts and suicides, whereas it poses particular challenges to the clinical professional due to the frequent unpredictability, abruptness and brutality of the methods used. For this reason, the suicide of a psychotic patient often leaves the professional and non-professional environment disturbed.

AIMS

An overview of the existing relevant literature on suicide in psychosis is given. Explanations on the psychodynamics, indications on pharmacotherapy and psychotherapy and considerations on prevention round off this article and provide an up to date overview of this topic for clinicians.

MATERIAL AND METHODS

A search was carried out in PubMed and Google scholar using the terms "suicide", "suicidality", "schizophrenia", "suicide AND schizophrenia", "suicide AND psychosis", "suicidality AND schizophrenia", "suicidality AND psychosis", "suicidality AND psychosis AND prevention", "suicide AND psychosis AND prevention", "suicidality AND schizophrenia AND prevention", "suicide AND schizophrenia AND prevention".

CONCLUSION

Clinicians must have knowledge of the specific risk factors for suicide in psychotic patients, the characteristics of suicide in terms of design and temporal connection with treatment. The exploration and assessment of suicidality is often more difficult in psychotic patients than in affective or personality disorder patients, as there are often impulsive suicide attempts that can be explained by (suddenly occurring) psychotic symptoms and are therefore difficult or even impossible to foresee.

Comparative Tolerability of Dopamine D2/3 Receptor Partial Agonists for Schizophrenia

Aripiprazole, brexpiprazole and cariprazine differ from all other second-generation antipsychotics due to partial agonism at the dopamine D2 and D3 receptors. In contrast to aripiprazole, brexpiprazole has lower intrinsic dopamine D2 activity and higher affinity for the serotonin 5-HT1A and 5-HT2A receptors, while cariprazine has the highest affinity for the dopamine D3 receptor, and the longest half-life. The main adverse effect of dopamine receptor partial agonists (DRPAs) is akathisia of low-to-moderate severity, which occurs in a small proportion of patients, usually in the first few weeks of treatment. While definitive conclusions concerning differences between the DRPAs require head-to-head comparison studies, on the available evidence, akathisia is probably least likely to occur with brexpiprazole and most likely with cariprazine; the risk of akathisia with aripiprazole lies in between. Weight-gain risk is low with aripiprazole and cariprazine, but moderate with brexpiprazole. Risk of sedation is low with DRPAs, as is risk of insomnia and nausea. Partial dopamine agonism leads to a low risk for hyperprolactinaemia (and probably a low risk of sexual dysfunction). Prolactin concentrations fall in some patients (particularly those with elevated levels prior to initiating the drugs). Rates of discontinuation due to adverse effects in pivotal studies were low, and on the whole, DRPAs are well tolerated. Aripiprazole has been implicated in pathological gambling and other impulse control behaviours, likely due to partial dopamine agonist activity (there have been no reports with brexpiprazole and cariprazine). The risks for diabetes and tardive dyskinesia with DRPAs are unknown, but are likely to be low. On the basis of tolerability, DRPAs should be considered as first-line treatment options, particularly in patients with early schizophrenia.

Response and remission of subjective well-being in patients suffering from schizophrenia spectrum disorders

Background

Purpose of this study was to assess subjective well-being in schizophrenia inpatients and to find variables predictive for response and remission of subjective well-being.

Method

The subjective well-being under neuroleptic treatment scale (SWN-K) was used in 232 schizophrenia patients within a naturalistic multicenter trial. Early response was defined as a SWN-K total score improvement of 20% and by at least 10 points within the first 2 treatment weeks, response as an improvement in SWN-K total score of at least 20% and by at least 10 points from admission to discharge and remission in subjective well-being as a total score of more or equal to 80 points at discharge. Logistic regression and CART analyses were used to determine valid predictors of subjective well-being outcome.

Results

Twenty-nine percent of the patients were detected to be SWN-K early responders, 40% fulfilled criteria for response in subjective well-being and 66% fulfilled criteria for remission concerning subjective well-being. Among the investigated predictors, SWN-K early improvement and the educational status were significantly associated with SWN-K response. The SWN-K total score at baseline showed a significant negative predictive value for response. Baseline SWN-K total score, PANSS global subscore, and side effects as well as the educational status were found to be significantly predictive for remission.

Conclusions

Depressive symptoms should be radically treated and side effects closely monitored to improve the patient's subjective well-being. The important influence of subjective well-being on overall treatment outcome could be underlined.

Isolated vocal akathisia-Does it exist?

An 81 years old Jewish-Iranian lady, with a psychiatric history of postpartum depression in her twenties and a previous hospitalization due to a depressive episode accompanied by suicidal thoughts and a history of hearing loss and COPD, was hospitalized in the psychogeriatric department of our Mental Health Center due to repetitive incoherent sounds she was uttering for the past month, which increased in intensity and caused suicidal thoughts.

The symptom of depression in schizophrenia and its management

Depression is a frequently occurring symptom in schizophrenia. While today it is often underrecognised and under-treated, historically such symptoms were the focus of much attention. Affective symptoms were used by Kraepelin as an important criterion with which to separate dementia praecox from manic–depressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of the illness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction to acute psychotic episodes and Bleuler considered depression to be one of the core symptoms of schizophrenia.

[Psychopharmaceuticals for treatment of suicidal patients and for suicide prevention]

Suicidality represents a frequent phenomenon in affective and psychotic disorders but the treatment of acute and chronic suicidality is still a controversial issue. Especially the efficacy of antidepressant and neuroleptic drugs for prevention of suicide continues to be debated. There is a lack of evidence due to limitations of methodological studies and ethical concerns are a major issue. Considering methodological problems in the conducted studies the often insufficiently valued differentiation between suicidal thoughts and actual suicidal behavior has to be emphasized. With the exception of lithium and clozapine suicide-preventing effects of antidepressants and neuroleptics could not yet be demonstrated. Regarding new antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) even the possible new onset of suicidal thoughts and ideations as an adverse effect needs to be stressed. Considering the frequent occurrence of suicidality the currently available evidence is undoubtedly insufficient. The improvement of study concepts and especially a more differentiated consideration of the vague term "suicidality" seems to be essential. An underrepresentation of the evidence-based therapeutic options with lithium and clozapine in the treatment of suicidal patients needs to be avoided.

Suicide risk and antipsychotic side effects in schizophrenia: nested case-control study

OBJECTIVE

This study explores suicide risk in schizophrenia in relation to side effects from antipsychotic medication.

METHODS

Among patients with a first clinical discharge diagnosis of schizophrenia or schizoaffective disorder in Stockholm County between 1984 and 2000 (n = 4000), those who died by suicide within 5 years from diagnosis were defined as cases (n = 84; 54% male). For each case, one individually matched control was identified from the same population. Information on antipsychotic side effects, including extrapyramidal symptoms (EPS) and akathisia, as well as prescriptions of anticholinergic medication, was retrieved from clinical records in a blinded fashion. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of the association between suicide and side effects as well as anticholinergic medication were estimated using conditional logistic regression.

RESULTS

A lower suicide risk was found in patients with a history of EPS (aOR 0.33, 95% CI 0.12-0.94). There was no statistically significant association between akathisia or anticholinergic medication use and the suicide risk.

CONCLUSIONS

A lower suicide risk identified among patients with EPS could potentially reflect higher antipsychotic adherence, exposure to higher dosage, or polypharmacy among these patients. Copyright © 2016 John Wiley & Sons, Ltd.

Mirtazapine for antipsychotic-induced acute akathisia: a systematic review and meta-analysis of randomized placebo-controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized placebo-controlled trials of mirtazapine for the treatment of antipsychotic-induced acute akathisia (AIAA).

METHODS

Studies were identified using online searches of PUBMED/MEDLINE and Cochrane database (CENTRAL), along with websites recording trial information such as www.clinicaltrials.gov, www.controlled-trials.com, and www.clinicalstudyresults.org. The study eligibility criteria were randomized, double-blind clinical trials comparing mirtazapine with placebo for AIAA with standardized rating for akathisia as outcome measure. The methodological quality of included trials was assessed using the Jadad Scale. Separate meta-analyses were undertaken for each outcome (response rate and complete remission) and treatment effects were expressed as Mantel-Haenszel risk ratio (RR). Fixed-effect meta-analysis was performed as heterogeneity was not significant. Number need to treat (NNT) as a measure of relative treatment effectiveness was calculated.

RESULTS

A systematic review of the literature revealed six studies that had assessed mirtazapine for the treatment of AIAA. Of these, two studies (n = 86) met the review inclusion criteria and were included in the final analysis. A meta-analysis was performed to see the effect size of response rate and complete remission. For response rate, RR was 6.67 [95% confidence interval (CI) 2.14-20.78], favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.001, NNT 4, 95% CI 2.6-8.6). For complete remission, RR was 6.20 (95% CI 1.74-22.08), favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.005, NNT 5, 95% CI 2.9-11.6).

CONCLUSIONS

Although limited to only two studies and small sample, existing data support the efficacy of mirtazapine for the treatment of AIAA, with one in four patients showing partial response and one in five patients showing complete remission.

Recognition and treatment of neuropsychiatric disturbances in Parkinson's disease

The non-motor symptoms of Parkinson's disease (PD) have been attracting increasing attention due to their ubiquitous nature and their often devastating effects on the quality of life. Behavioral problems in PD include dementia, depression, apathy, fatigue, anxiety, psychosis, akathisia, personality change, sleep disorders and impulse control disorders. Some of these are intrinsic to the neuropathology while others occur as an interplay between pathology, psychology and pharmacology. While few data exist for guiding therapy, enough is known to guide therapy in a rational manner.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation

These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.

Commonly used gastrointestinal drugs

This chapter reviews the spectrum and mechanisms of neurologic adverse effects of commonly used gastrointestinal drugs including antiemetics, promotility drugs, laxatives, antimotility drugs, and drugs for acid-related disorders. The commonly used gastrointestinal drugs as a group are considered safe and are widely used. A range of neurologic complications are reported following use of various gastrointestinal drugs. Acute neurotoxicities, including transient akathisias, oculogyric crisis, delirium, seizures, and strokes, can develop after use of certain gastrointestinal medications, while disabling and pervasive tardive syndromes are described following long-term and often unsupervised use of phenothiazines, metoclopramide, and other drugs. In rare instances, some of the antiemetics can precipitate life-threatening extrapyramidal reactions, neuroleptic malignant syndrome, or serotonin syndrome. In contrast, concerns about the cardiovascular toxicity of drugs such as cisapride and tegaserod have been grave enough to lead to their withdrawal from many world markets. Awareness and recognition of the neurotoxicity of gastrointestinal drugs is essential to help weigh the benefit of their use against possible adverse effects, even if uncommon. Furthermore, as far as possible, drugs such as metoclopramide and others that can lead to tardive dyskinesias should be used for as short time as possible, with close clinical monitoring and patient education.

Clinical determinants of life satisfaction in chronic schizophrenia: data from the CATIE study

OBJECTIVE

Quality of life is seen as an important outcome variable for patients with schizophrenia. However, the precise definition of this construct varies and has often been used to define health-related domains. The present study sought to focus on global life satisfaction as a key subjective domain and determine its relationship with clinical variables.

METHOD

The study sample included 1437 patients with chronic schizophrenia who participated in the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) study. Patients were evaluated with a comprehensive battery of assessments capturing symptoms, cognition and medication side effects, among other variables. Life satisfaction was evaluated with a global self-report item.

RESULTS

Greater depressive symptoms were the most robust indicator of worse life satisfaction. Lower life satisfaction was also associated with poorer psychosocial functioning, greater symptoms of anxiety, apathy and more negative attitudes toward medication. Taken together, these variables explained 20% of the variance in life satisfaction scores. Positive symptoms and other medication side effects also negatively influenced life satisfaction scores.

CONCLUSIONS

These results affirm that clinical variables have an adverse effect on the overall subjective well-being of patients with schizophrenia. The relatively small amount of variance explained, though, argues for a better understanding of those other variables that contribute to life satisfaction.

Akathisia: a life-threatening side effect of a common medication

The authors describe the case of a 38-year-old man with a history of schizoaffective disorder, who attempted suicide following the recent starting of a neuroleptic agent that resulted in the development of intolerable akathisia. He survived the attempt, and following changes in his medications the akathisia resolved with no further suicidal ideation.

Suicide attempts in veterans with bipolar disorder during treatment with lithium, divalproex, and atypical antipsychotics

Suicide attempt rates were assessed in 1306 subjects in this 6 year retrospective study of Bipolar disorder. Participants were Veterans from 5 different Veterans Administration Hospitals who met criteria for bipolar type 1 or 2 and who had at least one prescription for lithium or divalproex or both during the study period. This study focused on the impact of atypical antipsychotics on the suicide attempt rate when used in addition to or in place of lithium or divalproex. Medication exposure was calculated using computerized pharmacy records. Suicide attempts were established through chart review including emergency room records, inpatient records, and outpatient records. There were a total of 117 suicide attempts and 2 suicide completions during the study period. Most attempts (59%) occurred when patients were on no medications. Nearly 90% of subjects spent an average of 45 months during the 6 year period on none of the aforementioned medications. The lowest percentage of suicide attempts (15%) occurred while on lithium, 21% while on divalproex and 24% while on atypical antipsychotics. When total months of exposure were taken into account, the lowest attempt rate occurred on lithium plus divalproex (6.3 attempts per 10,000 months of exposure), followed by divalproex alone (7.0 attempts/10,000 months of exposure), and lithium alone (7.7 attempts per 10,000 months of exposure). Patients on atypical antipsychotics alone had an attempt rate of 26.1 attempts per 10,000 months of exposure. In this study, lithium and divalproex provided protection against suicide attempts. Results need to be replicated in future prospective studies and clearly strategies for improving medication compliance among veterans are warranted.

Persistent akathisia masquerading as agitated depression after use of ziprasidone in the treatment of bipolar depression

There has been increasing recognition that the second-generation antipsychotic drugs can produce extrapyramidal side effects. This case reports the development of severe akathisia in a patient being treated with ziprasidone for bipolar depression. The case illustrates that this symptom can be easily mistaken for worsening agitated depression. Akathisia may produce considerable distress and elevate suicide risk. Such symptoms may persist for weeks and be refractory to discontinuation of the offending agent or to pharmacological interventions commonly used to mitigate this reaction.

Akathisia and suicidal ideation in first-episode schizophrenia

Patients with first-episode schizophrenia (FES) are known to be notably sensitive for developing extrapyramidal adverse effects, but the relation of akathisia and suicidal ideation has rarely been studied. The current report is an ongoing analysis of an 8-week double-blind randomized controlled multicenter trial in 289 FES, comparing risperidone and haloperidol. Assessments were conducted weekly and included the Hillside Akathisia Scale and 21-item Hamilton Depression Rating Scale ratings. Suicidal ideation was significantly associated with clinician observed akathisia, depressed mood, younger age, and use of propranolol. The allocated treatment, anxiety, and nervousness had no influence. The present findings suggest a promoting effect of akathisia on suicidal ideation can not be ruled out in patients with FES.

Suicidality and antidepressants in the elderly

Suicide has reached epidemic proportions in the elderly, particularly in non-Hispanic white men. Unfortunately, the risk is underappreciated in this population. Known risk correlates for suicide in this population fall into three interrelated categories. Sociologic factors include such considerations as living alone and having few social interactions. Physical health factors include having more medical comorbidity and being a current smoker. The mental health risk factors include the presence of mood and anxiety disorders with a focus on the greater severity of symptoms, especially hypersomnia, hopelessness, and a history of suicide attempts. Suicide is a spectrum comprising ideation, intent, and plan. Clinical depression is never a normal part of aging and warrants aggressive treatment. Recent warnings linking antidepressants and suicide may have special relevance in the elderly. Based on preliminary studies with antipsychotic drugs, a subgroup of patients who experience akathisia may be particularly vulnerable to suicide. Upon initiation of antidepressants, it is recommended that adults be seen in follow-up three times within the first 12 weeks of treatment; if medically indicated, the first contact should be during the first week.

Predictors of switching antipsychotic medications in the treatment of schizophrenia

BACKGROUND

To identify patient characteristics and early changes in patients' clinical status that best predict subsequent switching of antipsychotic agents in the long-term treatment of schizophrenia.

METHODS

This post-hoc analysis used data from a one-year randomized, open-label, multisite study of antipsychotics in the treatment of schizophrenia. The study protocol permitted switching of antipsychotics when clinically warranted after the first eight weeks. Baseline patient characteristics were assessed using standard psychiatric measures and reviews of medical records. The prediction model included baseline sociodemographics, comorbid psychiatric and non-psychiatric conditions, body weight, clinical and functional variables, as well as change scores on standard efficacy and tolerability measures during the first two weeks of treatment. Cox proportional hazards modeling was used to identify the best predictors of switching from the initially assigned antipsychotic medication.

RESULTS

About one-third of patients (29.5%, 191/648) switched antipsychotics before the end of the one-year study. There were six variables identified as the best predictors of switching: lack of antipsychotic use in the prior year, pre-existing depression, female gender, lack of substance use disorder, worsening of akathisia (as measured by the Barnes Akathisia Scale), and worsening of symptoms of depression/anxiety (subscale score on the Positive and Negative Syndrome Scale) during the first two weeks of antipsychotic therapy.

CONCLUSIONS

Switching antipsychotics appears to be prevalent in the naturalistic treatment of schizophrenia and can be predicted by a small and distinct set of variables. Interestingly, worsening of anxiety and depressive symptoms and of akathisia following two weeks of treatment were among the more robust predictors of subsequent switching of antipsychotics.

Education initiative improves the evidence-based use of metoclopramide following morphine administration in the emergency department

OBJECTIVE

We aimed to evaluate a multifaceted education initiative designed to reduce the prophylactic use of metoclopramide.

METHODS

This was a pre- and post-intervention trial undertaken in a single ED. All ED doctors and nurses were targeted. The intervention comprised a specifically designed, 19-slide 'e-learning module', accessible via the ED intranet, supplemented by in-service training and a range of reminder techniques (posters, emails and drug room flyers). The primary end-point was the proportion of patients administered metoclopramide prophylactically with their initial morphine dose. Data were collected on random samples of patients who received morphine, using explicit medical chart review.

RESULTS

Both pre- and post-intervention periods were of 3 month duration. The charts of 146 cases were reviewed in each period. In the post-intervention period: * The proportion of patients administered metoclopramide prophylactically decreased from 22.6% to 4.1% (difference 18.5% [95% CI 10.3-26.7], P < 0.001) * The proportion of patients administered metoclopramide appropriately (for known morphine sensitivity, established nausea and rescue anti-emesis) rose marginally from 28.8% to 32.9% (difference 4.1% [95% CI -7.2-15.4], P = 0.53) * There was a 12.7% decrease in the number of ampoules of metoclopramide issued to the ED without a concurrent rise in the issue of other anti-emetic drugs

CONCLUSION

The education initiative resulted in a significant improvement in the evidence-based use of metoclopramide.

CSF 5-HIAA, attempted suicide and suicide risk in schizophrenia spectrum psychosis

INTRODUCTION

There is evidence for a relationship between low levels of 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid (CSF) and suicidal behavior in mood disorder. A relationship between CSF homovanillic acid (HVA) and suicidal behavior has not been completely established. Studies done in patients with schizophrenia spectrum psychosis suffer from small numbers, short periods of follow-up and the results are contradictory. The objective of this study was to investigate the relationship between levels of CSF 5-HIAA, CSF HVA and suicidal behavior in patients with schizophrenia spectrum psychosis.

METHOD

Three hundred eighty five patients with schizophrenia spectrum psychosis admitted to the Karolinska University Hospital between 1973 and 1987 were lumbar punctured in standardized manner. Patients were followed until 2006 for a median of 26 years. Information about prior suicide attempt was retrieved from medical records and causes of death were obtained from the Causes of Death Register at the National Board of Health and Welfare.

RESULTS

At the end of the follow-up 26 patients (6.8%) had died by suicide. Male gender (OR=3.5) and attempted suicide (OR=12.4) were risk factor for suicide when combined. There were no significant correlations between levels of CSF 5-HIAA, CSF HVA, HVA/5-HIAA ratio and attempted, violent or non-violent suicide.

CONCLUSION

Male schizophrenia spectrum psychosis patients with prior suicide attempt are at high risk for suicide. No correlation between CSF monoamine metabolites levels and suicidal behavior was found. Suicidal behavior in schizophrenia spectrum psychosis may not, in contrast to mood disorders, be predicted by levels of CSF 5-HIAA and HVA.

Risk factors for deliberate self-harm and completed suicide in young Chinese people with schizophrenia

OBJECTIVES

Suicide is best conceptualized as a risk rather than all-or-none behaviour. In the literature the majority of suicide studies have adopted a cross-sectional case-control design. Longitudinal design should be used in order to account for the time dimension of variables. The aim of the present study was therefore to identify risk factors and calculate hazard ratios for suicidal behaviour in young Chinese people suffering from schizophrenia.

METHODS

Using a retrospective cohort design, 234 subjects with schizophrenia in the Early Assessment Service for Young People with Psychosis service were recruited and data retrieved from case notes and discharge summaries. Cox proportional hazard modelling was used to analyse potential risk factors.

RESULTS

Traditional risk factors were confirmed to be applicable to the present subjects. Continuing medication was a protective factor while hallucination was a risk factor for suicide.

CONCLUSION

The limitations of the present study were due to its retrospective design, reliance on past records, and the large Type II error. A prospective cohort study design is recommended for future research in this area.

Behavioral risk assessment of the guarded suicidal patient

Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time-limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist in the early identification of the guarded suicidal patient, thus avoiding total reliance on the patient's reporting.

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE

The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital.

METHOD

Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed.

RESULTS

Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay.

CONCLUSION

The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.

Role of mirtazapine in the treatment of antipsychotic-induced akathisia

OBJECTIVE

To evaluate the role of mirtazapine in the treatment of antipsychotic-induced akathisia.

DATA SOURCES

MEDLINE (1966-February 2008) and PsycINFO (1967-February 2008) were searched using the terms akathisia and mirtazapine. A bibliographic search was conducted as well.

STUDY SELECTION AND DATA EXTRACTION

All English-language articles identified from the search were evaluated. All primary literature was included in the review.

DATA SYNTHESIS

Antipsychotic-induced akathisia can be difficult to manage and may respond to mirtazapine based on its antagonist activity at the serotonin 5-HT(2A)/5-HT(2C) receptors. Three case reports (N = 9 pts.), 1 placebo-controlled trial (N = 26), and 1 placebo- and propranolol-controlled study (N = 90) that evaluated mirtazapine for antipsychotic-induced akathisia have been published. Mirtazapine demonstrated a response rate of 53.8% compared with a 7.7% response rate for placebo, based on at least a 2-point reduction on the Barnes Akathisia Scale (global subscale; p = 0.004). Using the same criterion, mirtazapine and propranolol demonstrated efficacy based on response rates of 43.3% and 30.0% compared with placebo (6.7%; p = 0.0051). Mirtazapine was better tolerated than propranolol. In both studies, drowsiness was the most common adverse event associated with mirtazapine.

CONCLUSIONS

Mirtazapine may be considered a treatment option for antipsychotic-induced akathisia. It may be especially useful for patients with contraindications or intolerability to beta-blockers and for those with comorbid depression or negative symptoms. Additional studies should be conducted to provide further evidence of mirtazapine's effectiveness in treating akathisia.

Neuroleptic-induced movement disorders in a naturalistic schizophrenia population: diagnostic value of actometric movement patterns

Background

Neuroleptic-induced movement disorders (NIMDs) have overlapping co-morbidity. Earlier studies have described typical clinical movement patterns for individual NIMDs. This study aimed to identify specific movement patterns for each individual NIMD using actometry.

Methods

A naturalistic population of 99 schizophrenia inpatients using conventional antipsychotics and clozapine was evaluated. Subjects with NIMDs were categorized using the criteria for NIMD found in the Diagnostic and Statistical Manual for Mental Disorders – Fourth Edition (DSM-IV).

Two blinded raters evaluated the actometric-controlled rest activity data for activity periods, rhythmical activity, frequencies, and highest acceleration peaks. A simple subjective question was formulated to test patient-based evaluation of NIMD.

Results

The patterns of neuroleptic-induced akathisia (NIA) and pseudoakathisia (PsA) were identifiable in actometry with excellent inter-rater reliability. The answers to the subjective question about troubles with movements distinguished NIA patients from other patients rather well. Also actometry had rather good screening performances in distinguishing akathisia from other NIMD. Actometry was not able to reliably detect patterns of neuroleptic-induced parkinsonism and tardive dyskinesia.

Conclusion

The present study showed that pooled NIA and PsA patients had a different pattern in lower limb descriptive actometry than other patients in a non-selected sample. Careful questioning of patients is a useful method of diagnosing NIA in a clinical setting.

Midazolam vs. diphenhydramine for the treatment of metoclopramide-induced akathisia: a randomized controlled trial

OBJECTIVES

To compare the effects of midazolam, which is a fast and short-acting benzodiazepine, and diphenhydramine, which is a widely used anticholinergic agent, in clinical practice for the treatment of metoclopramide-induced akathisia.

METHODS

All adults older than 17 years given metoclopramide for nausea and vomiting or for headache and who had akathisia were eligible for this clinical, randomized, double-blind trial. Patients were randomized to receive diphenhydramine or midazolam. Subjective, objective, and total akathisia scores and modified Ramsay Sedation Scale scores were recorded. Repeated-measures analysis of variance was used to compare the efficacy and side effects of the medications.

RESULTS

Forty-one (73.3%) of the 56 enrolled patients were women. The mean (+/-SD) age was 39.9 (+/-15.7) years in the diphenhydramine group and 40.9 (+/-16.2) years in the midazolam group. Mean subjective, objective, and total akathisia scores in the first 5 minutes declined considerably in the midazolam group compared with the diphenhydramine group (p < 0.001). However, the mean Ramsay Sedation Scale score in the first 15 minutes increased significantly in the midazolam group compared with the diphenhydramine group (p < 0.001).

CONCLUSIONS

Midazolam can correct the symptoms of metoclopramide-induced akathisia faster than diphenhydramine, but it causes more sedation.

Melancholia agitata and mixed depression

OBJECTIVE

The diagnostic entity of major depressive episode includes both simple and agitated or mixed depression. Mixed depression is characterized by a full depressive episode with several symptoms of excitatory nature. Mixed depressions worsen if treated with antidepressants.

METHOD

We have reviewed the clinical charts of the 2141 patients treated at the Centro Lucio Bini of Rome from January 1999 to June 2006. These patients were diagnosed according to DSM-IV criteria. Research diagnostic criteria were applied for agitated depression with motor agitation and Author's diagnostic criteria for agitated depression without motor agitation.

RESULTS

One thousand and twenty-six patients had a depressive episode as index episode. Three hundred and forty six (33%) were mixed depressive states. One hundred and thirty eight (44%) of them were spontaneous; in 173 cases, the onset of the mixed depression was associated with antidepressants.

CONCLUSION

Psychic and motor agitation are considered equally important for the definition of agitated depression. Treating agitated depression with antidepressants worsens the clinical picture. The use of Electroconvulsive Therapy (ECT), neuroleptics and anticonvulsants are recommended. The term Melancholia Agitata is proposed for agitated (mixed) depression.

Transcultural differences in suicide attempters: analysis on a high-risk population of patients with schizophrenia or schizoaffective disorder

The aim of the study was to investigate transcultural differences between schizophrenia spectrum disorder patients who did or did not attempt suicide. DSM-IV schizophrenia (N=609) or schizoaffective disorder (N=371) patients who participated in the multicentre International Suicide Prevention Trial (InterSePT) were studied. Patients were sub-divided into 5 groups according to the different geographical regions of recruitment: North America (NA), Europe (EUR), East Europe (EEUR), South Africa (SAf), and South America (SA). The main lifetime clinical variables were compared, within each group, between attempters and non-attempters. The presence of comorbid substance abuse disorder and smoking was associated with suicide attempts in all the geographical groups considered (NA: chi(1)(2)=7.575, p<0.01 and chi(1)(2)=69.549, p<0.0001; EUR: chi(1)(2)=55.068, p<0.0001, and chi(1)(2)=48.431, p<0.0001; EEUR: chi(1)(2)=164.628, p<0.000, and chi(1)(2)=5.127, p<0.01; SA: chi(1)(2)=30.204, p<0.0001 and chi(1)(2)=11.710, p=0.001) except for SAf. For the other clinical variables various differences were found across the different groups. Variables related to suicide behavior were similar across the five groups investigated, with differences only in the age at the first suicide attempt (earlier in the NA sample) and the number of lifetime suicide attempts (higher in the NA sample). Results from this study show that, while some suicide-related clinical characteristics in schizophrenia patients are consistent worldwide suggesting the influence of stable biological traits, other variables may vary across different geographical areas suggesting environmental influences.

On the relationship of atypical and low-dose conventional antipsychotics with akathisia in a clinical patient population

Metabolic side-effects of atypical antipsychotics have led to concern about their relative safety compared with low doses of conventional neuroleptics. Akathisia is an often misdiagnosed side-effect, which leads to non-compliance and sometimes even exacerbation of psychosis or suicidal behaviour. In fact, little is known about the differences between antipsychotic drugs in clinical practice, since only as few as 20% of patients may be eligible for studies comparing antipsychotic medications with each other. The aim of this study was to find out if the use of conventional antipsychotics is associated with an increased risk of akathisia (compared with atypical antipsychotics) even when low doses of conventional antipsychotics are used. The Barnes Akathisia Rating Scale was used to evaluate akathisia in 100 outpatients on antipsychotic medication. Conventional antipsychotics were associated with an increased risk of akathisia compared with atypical antipsychotics, although the chlorpromazine equivalent doses of conventional antipsychotics were lower than those of the atypicals. An additional akathisia-provoking effect of SSRIs could not be ruled out. The results suggest favouring atypical antipsychotic medication in patients who may easily develop akathisia.

Placebo-level incidence of extrapyramidal symptoms (EPS) with quetiapine in controlled studies of patients with bipolar mania

OBJECTIVES

To evaluate extrapyramidal symptoms (EPS), including akathisia, with quetiapine in patients with bipolar mania.

METHODS

Data were analyzed from four similarly designed, randomized, double-blind, 3- to 12-week studies. Two studies evaluated quetiapine monotherapy (up to 800 mg/day) (n = 209) versus placebo (n = 198), with lithium or haloperidol monotherapy as respective active controls. Two studies evaluated quetiapine (up to 800 mg/day) in combination with a mood stabilizer (lithium or divalproex, QTP + Li/DVP) (n = 196) compared to placebo and mood stabilizer (PBO + Li/DVP) (n = 203). Extrapyramidal symptoms were evaluated using the Simpson-Angus Scale (SAS), the Barnes Akathisia Rating Scale (BARS), adverse event reports and anticholinergic drug usage.

RESULTS

The incidence of EPS-related adverse events, including akathisia, was no different with quetiapine monotherapy (12.9%) than with placebo (13.1%). Similarly, EPS-related adverse events with QTP + Li/DVP (21.4%) were no different than with PBO + Li/DVP (19.2%). Adverse events related to EPS occurred in 59.6% of patients treated with haloperidol (n = 99) monotherapy, whereas 26.5% of patients treated with lithium (n = 98) monotherapy experienced adverse events related to EPS. The incidence of akathisia was low and similar with quetiapine monotherapy (3.3%) and placebo (6.1%), and with QTP + Li/DVP (3.6%) and PBO + Li/DVP (4.9%). Lithium was associated with a significantly higher incidence (p < 0.05) of tremor (18.4%) than quetiapine (5.6%); cerebellar tremor, which is a known adverse effect of lithium, may have contributed to the elevated rate of tremor in patients receiving lithium therapy. Haloperidol induced a significantly higher incidence (p < 0.001) of akathisia (33.3% versus 5.9%), tremor (30.3% versus 7.8%), and extrapyramidal syndrome (35.4% versus 5.9%) than quetiapine. No significant differences were observed between quetiapine and placebo on SAS and BARS scores. Anticholinergic use was low and similar with quetiapine or placebo.

CONCLUSIONS

In bipolar mania, the incidence of EPS, including akathisia, with quetiapine therapy is similar to that with placebo.

Adolescent violence screening in the ED

Youth violence is widely recognized as a major public health problem. Adolescent suicidality (ideation, behavior, or both) is disturbingly common in the United States, and homicide remains one of the leading causes of death for young people aged 10 to 24 years. Assessing youth suicidality and homicidality in the emergency department (ED) is a complex and challenging task. Evidence about the value of available ED risk assessments is not encouraging. Attempts to develop models that predict violence have in part been unsuccessful from the fact that ideation is common and the value of depression is hard to determine. The current study presents an empirically based assessment (adolescent and child urgent threat evaluation) and algorithm (violence ideation and suicidality treatment algorithm) evaluating the impact of ideation and nonideation states on attempt among clinical samples, such as serotonin reuptake inhibitor akathisia and acute adjustment disorders. The authors suggest important time-related factors and easy-to-administer procedures when assessing near-future youth violence. A validated suicide-homicide final common pathway model is discussed.

Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide

Metoclopramide, the only drug approved by the FDA for treatment of diabetic gastroparesis, but used off-label for a variety of other gastrointestinal indications, has many potentially troublesome adverse neurologic effects, particularly movement disorders. In this article, we comprehensively review the indications and side effects of metoclopramide, and describe some common pitfalls and strategies to minimize the medicolegal risks to the prescribing physician. Metoclopramide accounts for nearly a third of all drug-induced movement disorders, a common reason for a malpractice suit. The entire spectrum of drug-induced movement disorders, ranging from subtle to life-threatening, can ensue from its use; akathisia and dystonia are generally seen early in the course of metoclopramide-induced movement disorders, whereas tardive dyskinesia and parkinsonism seem to be more prevalent in chronic users. Female sex, age and diabetes are the major risk factors for metoclopramide-induced movement disorders. It is therefore incumbent on gastroenterologists and other prescribing physicians to become familiar with the adverse neurologic effects associated with the use of metoclopramide, and to take appropriate preventive and defensive measures.

Lifetime suicide rates in treated schizophrenia: 1875-1924 and 1994-1998 cohorts compared

BACKGROUND

Recent interest in suicide rates in schizophrenia has been considerable.

AIMS

To establish the lifetime suicide rate from the pre-chlorpromazine era and to compare this with recent lifetime suicide rates for schizophrenia.

METHOD

We have compared suicide and suicide attempt rates for 741 admissions for schizophrenia and 1303 admissions for psychoses to the North Wales Asylum between 1875 and 1924, with first admissions for psychosis in NorthWest Wales between 1994 and 1998.

RESULTS

The suicide rate in schizophrenia between 1875 and 1924 was 20 per 100 000 hospital years, a lifetime rate of less than 0.5%. The suicide rate for all psychoses was 16 per 100 000 hospital years. Current rates of suicide for schizophrenia and other psychoses appear 20-fold higher.

CONCLUSIONS

These findings point to an increase in suicide rates for patients with schizophrenia.

Rate of metoclopramide infusion affects the severity and incidence of akathisia

OBJECTIVE

To investigate the effect of the rate of metoclopramide infusion on akathisia incidence, severity, onset of symptoms, and duration in patients with headache, and/or nausea/vomiting in the emergency department (ED) setting.

METHODS

Prospective, double blind, randomised clinical study comparing two rates of intravenous infusion of metoclopramide over a period of six months at a tertiary university hospital ED.

RESULTS

A total of 300 patients presented to the ED met the inclusion criteria: 151 (50.3%) with nausea/vomiting, 108 (36%) with headache, and 41 (13.7%) with headache and nausea/vomiting. Of these, 154 patients (51.3%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 minutes plus placebo (SIG group) and 146 patients were given 10 mg metoclopramide intravenous bolus infusion over two minutes plus placebo (BIG group). Nine of the 154 patients in the SIG group (5.8%) had akathisia compared with 36/146 patients (24.7%) in the BIG group (p < 0.001, OR 5.273, 95% CI 2.43 to 11.403). Severe akathisia were observed in 13/45 (28.8%). The incidence of severe akathisia was significantly higher in the BIG group (30.5%; 11/36) than in the SIG group (22.2%; 2/9), p = 0.009. Metoclopramide successfully relieved the presenting symptom(s) of 137/146 (90.8%) and 139/154 (90.2%) patients in the BIG and SIG groups, respectively.

CONCLUSIONS

This study suggests that slowing the rate of infusion of metoclopramide is an effective strategy for reducing the incidence of akathisia in patients with headache, and/or nausea/vomiting in ED.

A case-control study of 92 cases of in-patient suicides

BACKGROUND

A significant number of patients committed suicide while receiving in-patient treatment in psychiatric hospitals. Most previous studies on psychiatric in-patient suicides were conducted in the West. This study aimed to describe the characteristics and identify risk factors of suicides occurring during psychiatric in-patient care in Hong Kong.

METHOD

The case record data of suicide cases (Coroner's verdicts of suicides and undetermined deaths) from all public psychiatric hospitals in the entire region within a 3 years' period (N=93) were compared with matched controls.

RESULTS

In-patient suicide rate was 269/100,000 admissions. Majority had schizophrenia. Suicide usually occurred after the first month of admission, during leave, and by jump from heights. There were little case-control differences in treatment received. Multiple conditional logistic regression found 5 risk factors: previous history of deliberate self-harm (OR=4.60, 95% CI=1.57-13.5); admitted because of suicidal behaviour (OR=3.92, 95% CI=1.3-11.9); depressive symptoms at time of suicide (OR=8.53, 95% CI=1.4-52); away without leave at anytime during index admission (OR=17, 95% CI=1.76-163); and extrapyramidal side effects/akathisia at time of suicide (OR=10.8, 95% CI=1.75-66.7).

LIMITATIONS

Retrospective case record review depended on non-standardized and variable quality of case notes entry. Matching for hospitals in this study would make the comparison between hospitals impossible. Although this is the second largest case-control study of psychiatric in-patient suicide, the estimated power suggested subtle risk factors would be missed.

CONCLUSION

Majority of in-patient suicides occurred at a time of perceived low risk. A high sensitivity to the risk of suicide and vigorous treatment of depressive symptoms were indicated. The care processes during the index admission could bear strong influences on the risk of in-patient suicides.

Schizophrenia and suicide: systematic review of risk factors

BACKGROUND

Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important.

AIMS

To identify risk factors for suicide in schizophrenia.

METHOD

The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts.

RESULTS

Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71).

CONCLUSIONS

Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.

Pharmacotherapy of suicidal behavior in bipolar disorder

Patients with Bipolar Disorder (BD) are at particularly high risk for both attempted and completed suicides. The period of highest risk for completed suicide is during the 2 years following discharge from a hospitalization. To date, pharmacological studies of suicidal behavior in BD have been quite limited. While strong evidence has been found regarding the anti-suicidal effects of lithium, evidence for such properties in other commonly prescribed medications for BD, including anticonvulsants, SSRIs and anti-psychotics, has been largely unexplored. Considering the high risk of suicidal acts in patients with BD, further research on the pharmacotherapy of suicidal behavior is crucial.