Psychopharmacology for Suicide Prevention

Therapeutic research on suicide was virtually unknown a decade ago, but recently a great deal of clinically important information has emerged. A landmark event was approval by the US FDA of antisuicidal effects of clozapine in schizophrenia patients in 2003. Interest in effects of psychotropic drug treatments on suicidal behavior was strongly stimulated by recent regulatory warnings of increased risk of suicidal thoughts or behaviors in juveniles and young adults treated with modern antidepressants. This chapter reviews recent research findings pertaining to effects of psychoactive drugs on suicide risk. Antipsychotics other than clozapine are not known to reduce suicidal risk. Lithium has compelling evidence of long-term effectiveness in reducing risks of suicide and attempts by as much as 80% among patients with bipolar disorders, a mix of major affective disorders, and possibly also recurrent major depressive disorder. Its effects may be superior to those of some mood-stabilizing anticonvulsants. Several ecological studies, especially in the US and Nordic countries, find inverse associations between prescriptions for modern antidepressants and temporal or regional variance in suicide rates. However, suicide rates decreased in the same countries even before introduction of modern antidepressants, and other factors may be involved. Notably, lower regional suicide rates are associated with indices of greater access to clinical care. Many large cohort and case-control studies have found reduced suicidal risk with long-term antidepressant treatment; a minority found increased risk, which may be confounded by association of antidepressant treatment with more severe illness and selection of relatively nontoxic modern antidepressants for patients at increased suicidal risk. In many randomized, controlled trials in adults, antidepressants show reductions in suicidal ideation, along with other depressive symptoms, but without consistent effects on rates of suicidal acts. The FDA finds evidence of increased risk of suicidal thoughts and perhaps of attempts in juvenile and young adult patients treated with modern antidepressants vs. a placebo. It has long been recognized that some depressed patients experience increased agitation soon after exposure to antidepressants, and such reactions may increase suicidal risk. These effects usually can be anticipated and minimized by timely clinical interventions. The findings of beneficial effects of antidepressant treatment on suicidal ideation but not behavior, and of reduced risk of suicidal behaviors by lithium and clozapine, suggest differential pharmacologic effects on particular components of “suicidality,” in that reduction of anger, aggression and impulsivity evidently can limit progression from suicidal ideation to acts. Effective suicide prevention requires focused assessment and supervision, especially early in clinical management of patients with major mood disorders, with appropriate pharmacological and psychosocial interventions.

Keywords: Psychopharmacology, suicide, prevention, mood disorders, schizophrenia.