Definition and Management of Suicidality in Psychiatric Patients
Jan A. Fawcett, MD (Chair)
University of New Mexico School of Medicine, Albuquerque
Ross J. Baldessarini, MD
Harvard Medical School and McLean Hospital, Belmont, Mass
William H. Coryell, MD
Carver College of Medicine, University of Iowa, Iowa City
Morton M. Silverman, MD
University of Chicago, Chicago, Ill
Dan J. Stein, MD, FRCPC
University of Cape Town, Cape Town, South Africa, and Mt. Sinai School of Medicine, New York, NY
The FDA warnings1–3 about the increased risk of suicidality when taking psychotropic medications have generated concern about prescribing them for psychiatric illnesses. On November 24, 2008, Jan A. Fawcett, MD, assembled a group of experts to address the topic of suicidality in patients taking antidepressants or antiepileptics. The experts were Ross J. Baldessarini, MD; William H. Coryell, MD; Morton M. Silverman, MD; and Dan J. Stein, MD, FRCPC. This J Clin Psychlopedia activity presents highlights from their discussion.
To begin, the faculty agreed that suicidality is a broad term with little clinical value; however, it has been widely used since the FDA warnings were released. Drs. Silverman and Baldessarini explained that the word does not allow clinicians to make needed distinctions between patients who are acutely suicidal versus those who are chronically suicidal or patients who think about suicide versus those who attempt suicide (AV 1). Further, stated Dr. Stein, the idea that suicidality is one-dimensional is problematic; a single term does not equate to a single dimension of behavior.
Deliberate self-harm, which is commonly used in the European literature, was also identified by the experts as a term with little clinical significance; it refers to self-harm both with and without suicidal intent, which is often difficult to ascertain with confidence. The terms nonsuicidal self-injury and parasuicide have been suggested for referring to self-injury without suicidal intent, but they are also problematic.
Suicidal Ideation and Attempts During Psychotropic Treatment
The FDA data1–3 suggested a slightly greater risk of suicidal thinking and behavior in the early stages of psychotropic treatment, continued Dr. Silverman; however, with antidepressants, the risk was only increased in juveniles and young adults (under the age of 25 years). Although no suicides occurred during the pediatric antidepressant trials reviewed by the FDA, 4 completed suicides were observed in the antiepileptic drug trials. However, added Dr. Baldessarini, some researchers4 – 6 have questioned the validity of the FDA analyses on suicide and antidepressants and believe that the findings may have an unsound statistical basis. Moreover, the reported effects of some anticonvulsants apply only to patients with epilepsy and not to those with psychiatric illnesses.
Managing Suicide Risk During Depression Treatment
In the long-term, antidepressant therapy may prevent suicide,7,8 and denying treatment could increase the risk of suicide. Thus, Dr. Coryell advised that clinicians provide treatment when necessary and monitor patients closely
Dr. Stein recommended making treatment decisions with individual patient situations and suicidal risk factors in mind. In addition, clinicians need to know how to proceed after discovering that a patient is suicidal; therefore, Drs. Baldessarini and Silverman emphasized the importance of using suicide risk assessments and suicide risk management procedures, even though precise prediction of suicidal acts and their timing is not possible with available methods.
Discussing Medication Risks With Patients
Drs. Baldessarini and Stein advised that clinicians be honest with patients about the potential for adverse effects, such as agitation and possible increased risk of suicidal thinking, and encourage communication if they feel worse when taking antidepressants. Suicidal thinking and akathisia can usually be relieved by adding propranolol9 or benzodiazepines10 to manage agitation due to antidepressant use, explained Dr. Fawcett.
Dr. Coryell also urged clinicians to tell patients that the medication may not work immediately. In addition to informing patients about the various risks, clinicians should tell significant others, because the patient may not be in the best position to monitor his or her own behavior or to report problems, especially when extremely depressed.
Preventing Suicide With Depression Treatment
Certain treatments have been proven to reduce suicidal behaviors, including CBT,11 dialectical-behavioral therapy,11 clozapine (in patients with schizophrenia),12 and lithium (in patients with bipolar disorder and possibly in patients with MDD).13 Also, 1 study14 found that suicide attempts were significantly reduced among high school students who were given suicide intervention information (P < .05).
Dr. Baldessarini remarked that clozapine has not been conclusively proven to prevent death, only to reduce suicidal or suicide-related behaviors. Further, many controlled trials15 have shown that antidepressants reduce suicidal thinking more than placebo, but data supporting their efficacy for reducing rates of acting on suicidal thoughts are less conclusive. In response, Dr. Fawcett cited 2 studies16,17 that found depression treatments to be efficacious for decreasing the risk of suicide and preventing completed suicides. The faculty agreed that, the longer that medications are taken, the more effective they seem to be at reducing the risk of suicide (AV 3).
Suicide Risk Factors
The group recommended that clinicians vigilantly look for certain risk factors for suicide, including anxiety and other states of negative arousal18; mania; the presence of comorbid psychiatric illnesses19; psychosis20; past suicidal behavior21; and perceived loss, such as divorce or job loss. Common acute risk factors that were identified included prior suicide attempts or plans, living alone, male sex, and hopelessness.21
Drs. Silverman and Fawcett stressed the importance of understanding and discussing the patient’s past suicidal behavior to prevent future attempts (AV 4). As a final point, Dr. Coryell warned that many completed suicides occur shortly after the crisis that brings the person to clinical attention,21 so this should be a period of maximum surveillance.
When to Assess Suicidal Risk
The group agreed that clinicians should always examine suicidal risk during initial assessments, but, after that, suicidal assessments are imperative only when the acute risk level increases, such as when the patient has experienced an accumulation of losses or is experiencing a perceived crisis, when clinical presentation continuously or suddenly worsens despite treatment, and when symptoms of mania, agitation, anger, or insomnia increase.
Having patients sign “no-suicide” contracts was not considered to be clinically useful. In fact, Drs. Coryell and Fawcett thought that these contracts may be more harmful than helpful in preventing suicide, because they have not clearly demonstrated a preventive effect and may falsely reassure the clinician (AV 5).
Hospitalization for Suicidal Patients
Hospitalization should be discussed with the patient and family whenever increased suicidal risk is suspected, even if he or she is not technically committable. Clinicians need to know how the patient feels about being hospitalized (willing or resistant). If the patient is resistant to the idea, Dr. Coryell suggested enlisting family members to vigilantly monitor him or her. However, Drs. Baldessarini and Fawcett cautioned that the clinician must remain available and inform family members when the suicide risk is high so that their vigilance does not lapse. Also, clinicians should at least briefly document what was done to assess and manage risks.
For Clinical Use
- Long-term treatment for patients with unipolar or bipolar depression reduces the risk of suicide; thus, provide treatment and closely monitor patients, especially younger or new patients, particularly during the initial weeks of treatment
- Suicidal assessments should be conducted at any point in treatment when the patient’s risk level appears to increase
- Remember that, while not all suicides can be prevented, by using current tools and techniques, the likelihood of your patients’ dying by suicide can be decreased
clozapine (Clozaril, FazaClo, and others), lithium (Lithobid, Eskalith, and others), propranolol (Innopran, Inderal, and others)
CBT = cognitive-behavioral therapy
FDA = US Food and Drug Administration
MDD = major depressive disorder
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- FDA Public Health Advisory. Worsening depression and suicidality in patients being treated with antidepressant medications. March 22, 2004. Available at www.fda.gov/cder/drug/antidepressants/AntidepressanstPHA.htm. Accessed Feb 1, 2009.
- FDA News. FDA proposes new warnings about suicidal thinking, behavior in young adults who take antidepressant medications. May 2, 2007. Available at www.fda.gov/bbs/topics/NEWS/2008/NEW01624.html. Accessed Feb 1, 2009.
- FDA News. FDA alerts health care providers to risk of suicidal thoughts and behavior with antiepileptic medications. Jan 31, 2008. Available at www.fda.gov/bbs/topics/NEWS/2008/NEW01786.html. Accessed Feb 1, 2009.
- Klein DF. The flawed basis for FDA post-marketing safety decisions: the example of antidepressants and children. Neuropsychopharmacology. 2006;31(4):689–699.
- Kaizar EE, Greenhouse JB, Seltman H, et al. Do antidepressants cause suicidality in children? a Bayesian meta-analysis. Clin Trials. 2006;3(2):73–90.
- Gibbons RD, Segawa E, Karabatsos G, et al. Mixed-effects Poisson regression analysis of adverse event reports: the relationship between antidepressants and suicide. Stat Med. 2008;27(11):1814–1833.
- Søndergård L, Kvist K, Andersen PK, et al. Do antidepressants prevent suicide? Int Clin Psychopharmacol. 2006;21(4):211–218.
- Grunebaum MF, Ellis SP, Li S, et al. Antidepressants and suicide risk in the United States, 1985–1999. J Clin Psychiatry. 2004;65(11):1456–1462.
- Rothschild AJ, Locke CA. Reexposure to fluoxetine after serious suicide attempts by three patients: the role of akathisia. J Clin Psychiatry. 1991;52(12):491–493.
- Barak Y, Olmer A, Aizenberg D. Antidepressants reduce the risk of suicide among elderly depressed patients. Neuropsychopharmacology. 2006;31(1):178–181.
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- Hennen J, Baldessarini RJ. Suicidal risk during treatment with clozapine: a meta-analysis. Schizophr Res. 2005;73(2–3):139–145.
- Baldessarini RJ, Tondo L, Davis P, et al. Decreased risk of suicides and suicide attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord. 2006;8(5 pt 2):625–639.
- Aseltine RH Jr, James A, Schilling EA, et al. Evaluating the SOS suicide prevention program: a replication and extension. BMC Public Health. 2007;7:161.
- Möller HJ. Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a systematic review. Eur Arch Psychiatry Clin Neurosci. 2006;256(6):329–343.
- Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006;163(1):41–47.
- Angst J, Angst F, Gerber-Werder R, et al. Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years' follow-up. Arch Suicide Res. 2005;9(3):279–300.
- Hall RC, Platt DE, Hall RC. Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts: evaluation of suicide risk in a time of managed care. Psychosomatics. 1999;40(1):18–27.
- Nock MK, Kessler RC. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J Abnorm Psychol. 2006;115(3):616–623.
- Schaffer A, Flint AJ, Smith E, et al. Correlates of suicidality among patients with psychotic depression. Suicide Life Threat Behav. 2008;38(4):403–414.
- Coryell W, Young EA. Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry. 2005;66(4):412–417.