What is the Relationship Between Antidepressants and Suicide Risk?

Introduction

The relationship between antidepressant use and suicide risk is a subject of medical research and has faced varying levels of debate.

This problem was thought to be serious enough to warrant intervention by the US Food and Drug Administration (FDA) to label greater likelihood of suicide as a risk of using antidepressants. Some studies have shown that the use of certain antidepressants correlate with an increased risk of suicide in some patients relative to other antidepressants. However, these conclusions have faced considerable scrutiny and disagreement: A multinational European study indicated that antidepressants decrease risk of suicide at the population level, and other reviews of antidepressant use claim that there is not enough data to indicate antidepressant use increases risk of suicide.

Youth/Young Adults

People under the age of 25 with depression antidepressants could increase the risk of suicidal thoughts and behaviour. In 2004, the FDA along with the Neuro-Psychopharmacologic Advisory Committee and the Anti-Infective Drugs Advisory Committee, concluded that there was a causal link between newer antidepressants and paediatric suicidality. Federal health officials unveiled proposed changes to the labels on antidepressant drugs in December 2006 to warn people of this danger.

A 2016 review of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) which looked at four outcomes – death, suicidality, aggressive behaviour, and agitation – found that while the data was insufficient to draw strong conclusions, adults taking these drugs did not appear to be at increased risk for any of the four outcomes, but that for children, the risks of suicidality and for aggression doubled. The authors expressed frustration with incomplete reporting and lack of access to data, and with some aspects of the clinical trial designs.

Warnings

The FDA requires “black box warnings” on all SSRIs, which state that they double suicidal ideation rates (from 2 in 1,000 to 4 in 1,000) in children and adolescents. It remains controversial whether increased risk of suicide is due to the medication (a paradoxical effect) or part of the depression itself (i.e. the antidepressant enables those who are severely depressed – who ordinarily would be paralysed by their depression – to become more alert and act out suicidal urges before being fully recovered from their depressive episode). The increased risk for suicidality and suicidal behaviour among adults under 25 approaches that seen in children and adolescents. Young patients should be closely monitored for signs of suicidal ideation or behaviours, especially in the first eight weeks of therapy. Sertraline, tricyclic agents and venlafaxine were found to increase the risk of attempted suicide in severely depressed adolescents on Medicaid.

Increased Risk for Quitting Medication

A 2009 study showed increased risk of suicide after initiation, titration, and discontinuation of medication. A study of 159,810 users of either amitriptyline, fluoxetine, paroxetine or dothiepin found that the risk of suicidal behaviour is increased in the first month after starting antidepressants, especially during the first 1 to 9 days.

Prevalence

On 06 September 2007, the US Centres for Disease Control and Prevention reported that the suicide rate in American adolescents, (especially girls, 10 to 24 years old), increased 8% (2003 to 2004), the largest jump in 15 years, to 4,599 suicides in Americans ages 10 to 24 in 2004, from 4,232 in 2003, giving a suicide rate of 7.32 per 100,000 people that age. The rate previously dropped to 6.78 per 100,000 in 2003 from 9.48 per 100,000 in 1990. Jon Jureidini, a critic of this study, says that the US “2004 suicide figures were compared simplistically with the previous year, rather than examining the change in trends over several years”. It has been noted that the pitfalls of such attempts to infer a trend using just two data points (years 2003 and 2004) are further demonstrated by the fact that, according to the new epidemiological data, the suicide rate in 2005 in children and adolescents actually declined despite the continuing decrease of SSRI prescriptions. “It is risky to draw conclusions from limited ecologic analyses of isolated year-to-year fluctuations in antidepressant prescriptions and suicides.

One promising epidemiological approach involves examining the associations between trends in psychotropic medication use and suicide over time across a large number of small geographic regions. Until the results of more detailed analyses are known, prudence dictates deferring judgment concerning the public health effects of the FDA warnings.” Subsequent follow-up studies have supported the hypothesis that antidepressant drugs reduce suicide risk.

Suicide Risk

In those under the age of 25 antidepressants appear to increase the risk of suicidal thoughts and behaviours. In the United States they contain a black box warning regarding this concern.

A 2016 review found a decreased suicidal events in older adults.

What are the Factors Associated with Suicide in Chinese Adults?

Research Paper Title

Factors associated with suicide risk among Chinese adults: A prospective cohort study of 0.5 million individuals.

Background

Suicide is a leading cause of death in China and accounts for about one-sixth of all suicides worldwide. The objective of this study was to examine the recent distribution of suicide and risk factors for death by suicide. Identifying underlying risk factors could benefit development of evidence-based prevention and intervention programmes.

Methods

The researchers conducted a prospective study, the China Kadoorie Biobank, of 512,715 individuals (41% men, mean age 52 years) from 10 (5 urban, 5 rural) areas which are diverse across China in geographic locations, social economic developmental stages, and prevalence of disease patterns. After the baseline measurements of risk factors during 2004 to 2008, participants were followed up for suicide outcomes including suicide and possible suicide deaths. Risk factors, such as sociodemographic factors and physical and mental health status, were assessed by semi-structured interviews and self-report questionnaires.

Suicide and possible suicide deaths were identified through linkage to the local death registries using ICD-10 codes. The researchers conducted Cox regression to calculate hazard ratios (HRs) for suicide and for possible suicide in sensitivity analyses.

Results

During an average follow-up period of 9.9 years, 520 (101 per 100,000) people died from suicide (51.3% male), and 79.8% of them lived in rural areas. Sociodemographic factors associated with increased suicide risk were male gender (adjusted hazard ratios [aHR] = 1.6 [95% CI 1.4 to 2.0], p < 0.001), older age (1.3 [1.2 to 1.5] by each 10-yr increase, p < 0.001), rural residence (2.6 [2.1 to 3.3], p < 0.001), and single status (1.7 [1.4 to 2.2], p < 0.001). Increased hazards were found for family-related stressful life events (aHR = 1.8 [1.2 to 1.9], p < 0.001) and for major physical illnesses (1.5 [1.3 to 1.9], p < 0.001). There were strong associations of suicide with a history of lifetime mental disorders (aHR = 9.6 [5.9 to 15.6], p < 0.001) and lifetime schizophrenia-spectrum disorders (11.0 [7.1 to 17.0], p < 0.001). Links between suicide risk and depressive disorders (aHR = 2.6 [1.4 to 4.8], p = 0.002) and generalized anxiety disorders (2.6 [1.0 to 7.1], p = 0.056) in the last 12 months, and sleep disorders (1.4 [1.2 to 1.7], p < 0.001) in the past month were also found.

All HRs were adjusted for sociodemographic factors including gender, age, residence, single status, education, and income. The associations with possible suicide deaths were mostly similar to those with suicide deaths, although there was no clear link between possible suicide deaths and psychiatric factors such as depression and generalised anxiety disorders. A limitation of the study is that there is likely underreporting of mental disorders due to the use of self-report information for some diagnostic categories.

Conclusions

In this study, the researchers observed that a range of sociodemographic, lifestyle, stressful life events, physical, and mental health factors were associated with suicide in China. High-risk groups identified were elderly men in rural settings and individuals with mental disorders. These findings could form the basis of targeted approaches to reduce suicide mortality in China.

Reference

Yu, R., Chen, Y., Li, L., Chen, J., Guo, Y., Bian, Z., Lv., Yu, C., Xie., Huang, D., Chen, Z. & Fazel, S. (2021) Factors associated with suicide risk among Chinese adults: A prospective cohort study of 0.5 million individuals. PLoS Med. doi: 10.1371/journal.pmed.1003545. eCollection 2021 Mar.

New Insights on Suicide Care from a Nursing Perspective

Research Paper Title

Suicide care from the nursing perspective: A meta-synthesis of qualitative studies.

Background

To explore nurses’ experiences of suicide care and to identify and synthesize the most suitable interventions for the care of people with suicidal behaviour from a nursing perspective. A qualitative meta-synthesis.

Methods

Comprehensive search of five electronic databases for qualitative studies published between January 2015 and June 2019.

The PRISMA statement was used for reporting the different phases of the literature search and the Critical Appraisal Skills Programme (CASP) qualitative research checklist was used as an appraisal framework. Data synthesis was conducted using Sandelowski and Barroso’s method.

Results

Seventeen articles met the inclusion criteria. The data analysis revealed 13 subcategories from which four main categories emerged: ‘Understanding suicidal behaviour as a consequence of suffering’, ‘Nurses’ personal distress in suicide care’, ‘The presence of the nurse as the axis of suicide care’ and, ‘Improving nurses’ relational competences for a better therapeutic environment’.

Conclusions

Further training of nurses on the therapeutic relationship, particularly in non-mental health care work settings, and monitoring of the emotional impact on nurses in relation to suicide is required to promote more effective prevention and care.

Impact

This review provides new insights on how suicide is interpreted, the associated emotions, the way suicide is approached and proposals for improving clinical practice from the point of view of nurses. The results demonstrate that the nurse-patient relationship, ongoing assessment, and the promotion of a sense of security and hope are critical in nursing care for patients who exhibit suicidal behaviour. Consequently, to promote an effective nursing care of suicide, nurses should be provided with further training on the therapeutic relationship. Thus, health institutions do not only provide the time and space to conduct an adequate therapeutic relationship, but also, through their managers, they should supervise and address the emotional impact that is generated in nurses caring for patients who exhibit suicidal behaviour.

Reference

Clua-Garcia, R., Casanova-Garrigos, G. & Moreno-Poyato, A.R. (2021) Suicide care from the nursing perspective: A meta-synthesis of qualitative studies. Journal of Advanced Nursing. doi: 10.1111/jan.14789. Online ahead of print.

Interoceptive Impairment & Non-Suicidal Self-Injury

Research Paper Title

A multi-measure examination of interoception in people with recent nonsuicidal self-injury.

Background

Self-injurious behaviors (SIB) are highly dangerous, yet prediction remains weak. Novel SIB correlates must be identified, such as impaired interoception. This study examined whether two forms of interoceptive processing (accuracy and sensibility) for multiple sensations (general, cardiac, and pain) differed between people with and without recent nonsuicidal self-injury (NSSI).

Methods

Participants were adults with recent (n = 48) NSSI and with no history of SIBs (n = 55). Interoceptive sensibility was assessed with self-reports. Interoceptive accuracy for cardiac sensations was assessed using the heartbeat tracking task. Interoceptive accuracy for pain was assessed with a novel metric that mirrored the heartbeat tracking test.

Results

Participants with recent NSSI reported significantly lower interoceptive sensibility for general sensations relative to people without SIBs. Groups did not differ on interoceptive sensibility for cardiac sensations or pain. Groups also did not differ on interoceptive accuracy for cardiac sensations. The NSSI group exhibited significantly lower interoceptive accuracy for pain compared with the No SIB group.

Conclusions

Interoceptive impairment in people with NSSI may vary by interoceptive domain and sensation type. Diminished interoceptive accuracy for sensations relevant to the pathophysiology of self-injury may be a novel SIB correlate.

Reference

Forrest, L.N. & Smith, A.R. (2021) A multi-measure examination of interoception in people with recent nonsuicidal self-injury. Suicide & Life-Threatening Behaviour. doi: 10.1111/sltb.12732. Online ahead of print.

What are the Correlates of Suicidal Ideation & Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration?

Research Paper Title

Correlates of Suicidal Ideation and Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration.

Background

The current study sought to explore suicidal concomitants, both demographic and psychological, among former military personal.

Methods

The sample included 645 veterans who are at increased risk for suicide but have not yet pursued Veterans Health Administration (VHA) services.

Results

Descriptive statistics revealed that these veterans are primarily young Caucasian males who served in the US Army.

In terms of psychological characteristics, the current sample reported clinically significant levels of depression, post-traumatic stress, and insomnia.

Furthermore, respondents acknowledged use of various substances and high levels of perceived burdensomeness and thwarted belongingness.

Conclusions

The demographic and psychological makeup of the researchers sample was somewhat similar to that of VHA-connected veterans except that their sample was slightly more educated and reported less physical pain.

Reference

Raines, A.M., Allan, N.P., Franklin, C.L., Huet, A. Constans, J.I. & Stecker, T. (2020) Correlates of Suicidal Ideation and Behaviors Among Former Military Personnel Not Enrolled in the Veterans Health Administration. Archives of Suicide Research. 24(4), pp.517-533. doi: 10.1080/13811118.2019.1660286. Epub 2019 Dec 2.

Book: Reasons to Stay Alive

Book Title:

Reasons to Stay Alive.

Author(s): Matt Haig.

Year: 2015.

Edition: First (1st).

Publisher: Canongate Books Ltd.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

Aged 24, Matt Haig’s world caved in. He could see no way to go on living. This is the true story of how he came through crisis, triumphed over an illness that almost destroyed him and learned to live again.

A moving, funny and joyous exploration of how to live better, love better and feel more alive, Reasons to Stay Alive is more than a memoir. It is a book about making the most of your time on earth.

“I wrote this book because the oldest clich├ęs remain the truest. Time heals. The bottom of the valley never provides the clearest view. The tunnel does have light at the end of it, even if we haven’t been able to see it . . . Words, just sometimes, really can set you free.”

Book: Suicide Prevention Handbook

Book Title:

Suicide Prevention Handbook: A Mental Health Guide For Saving Lives.

Author(s): Ben Oakley.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

The book includes our detailed four-step guide for suicide prevention:

  • Warning Signs include social signs, personal signs and planning signs.
  • Risk Factors include isolation and social inequality, violence or abuse, self-harm and mental health disorders.
  • Intervention includes social intervention, personal intervention including exactly what to say to start a mental health conversation and how to seek help.
  • Coping Strategies include distraction, grounding and relaxation.

With real-world examples and concrete ways of how to help yourself or another.

Many mental health advocates and organisations recommend you talk about mental health but they don’t tell you how to get the conversation started. This book provides you with Conversation Starters, Direct Questions, Indirect Questions, Example Lists, Guidance and ways to move a conversation from negative emotions to positive ones.

Along with the extensive four-step suicide prevention handbook, there is a guide to writing your own suicide prevention life plan with tips on creating priorities, goals, action plans and how to write it.

You’ll also find a list of UK mental health organisations, what not to say, myths debunked and a series of essays about the misconception of man.

Supreme Movement is a mental health awareness social enterprise in the United Kingdom whose mission is to raise awareness of mental health issues, specifically suicide and self-harm among males.

Ben Oakley is an established non-fiction author, researcher, mental health advocate and founder of Supreme Movement.

Book: Cognitive Behavioural Therapy for Depression

Book Title:

Cognitive Behavioral Therapy for Depression: Retrain your Brain from Wrong Behaviors, Irrational Beliefs and Negative Ways of Thinking. Open Yourself to Life, Happiness and the Freedom of Change.

Author(s): John Rich.

Year: 2019.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Hardcover and Kindle.

Synopsis:

Depression is said to affect more than 300 million people globally, from all age categories. This particular mental disorder is incredibly common, and yet incredibly challenging for people to face, overcome, and heal from. Depression is considered to be a serious and even life-threatening condition as it can progress into more advanced stages that lead to thoughts surrounding self-harm and suicidal ideation.

Learning how to face, navigate, overcome, and heal from depression is important in your ability to protect yourself from the painful symptoms that depression can present in your life. If you have been looking for natural, healthy ways to overcome depression, cognitive behavioural therapy may be exactly what you are looking for.

Cognitive Behavioural Therapy (CBT) is a form of psychotherapy that is used to intentionally rewire the way your brain works through the power of specific thought processes and skills that are instilled within the individual that is healing from depression. As you learn how to navigate depression with CBT skills in tow, you will begin to realise how capable you are of overcoming this painful, dreadful, and often traumatising mental disorder that you might be facing in your life right now.

For some people, CBT is the only therapy that they need to support them in healing from depression. For others, CBT works in conjunction with lifestyle changes and even antidepressants to support a holistic form of therapy that helps the patient heal from depression in the immediate present while also being able to overcome episodes in the future.

The book seeks to shine a light on the power of CBT and how this particular psychotherapy can support you in having a healthier life, free of the struggles of depression. The goal is for you to learn to overcome depression in a way that supports you with increasing your mental strength, mental stamina, and emotional intelligence, while also improving your natural emotional resistance.

Some of what you will learn in Cognitive Behavioural Therapy for Depression includes:

  • What CBT is and how it works.
  • Who founded CBT and how.
  • What depression is and the specific symptoms to look for.
  • How you can use self-awareness to overcome depression.
  • How CBT works to heal depression.
  • How CBT supports mental and emotional strength and resiliency.
  • The exact steps for executing CBT in your own life.
  • How to monitor your CBT to make sure it is actually working.
  • How to use CBT to instantly boost your mood.
  • How to use CBT to boost your mood in the long term.
  • Natural methods for overcoming and healing depression.
  • And more!.

If you are ready to relieve yourself from the grasp of depression and heal yourself and your life, grab your copy of Cognitive Behavioural Therapy for Depression today to get started!

Book: Critical Suicidology

Book Title:

Critical Suicidology: Transforming Suicide Research and Prevention for the 21st Century.

Author(s): Jennifer White, Ian Marsh, Michael J. Kral, and Jonathan Morris (Editors).

Year: 2015.

Edition: First (1st).

Publisher: UBC Press.

Type(s): Paperback and EPUB.

Synopsis:

This book is a must-read for practitioners, policy makers, and researchers working in mental health services, psychology, counselling, social work, psychiatry, medicine, philosophy, sociology, suicidology, feminism, anthropology, critical disability studies, and cultural studies.

Do Older Adults with Parent(s) Alive Experience Higher Psychological Pain and Suicidal Ideation?

Research Paper Title

Do Older Adults with Parent(s) Alive Experience Higher Psychological Pain and Suicidal Ideation? A Cross-Sectional Study in China.

Background

Elderly mental health promotion is an important task in the current “Healthy China Action”.

This study aims to:

  1. Clarify the psychological pain and suicidal ideation of the Chinese elderly with different parental states;
  2. Examine the associated factors of psychological pain and suicidal ideation; and
  3. Examine the relationship between psychological pain and suicidal ideation.

Methods

A sample of 4622 adults aged 60 years and older were included in this study, from the China’s Health-related Quality of Life Survey for Older Adults 2018.

Results

Participants with both parents alive demonstrated the heaviest psychological pain, and those with one parent alive observed significantly lowest psychological pain and suicidal ideation.

Participants who were single, divorced, or widowed, live in rural areas, had higher education level, had lower family income, suffered from two or more chronic diseases, and had no self-care ability were more likely to experience psychological pain and suicidal ideation.

In addition, higher psychological pain was significantly associated with the occurrence of suicidal ideation.

Conclusions

In China, much more attention should be paid to the mental health condition of the elderly, especially for those with both parents alive.

Moreover, the associated factors above should be considered to develop targeted health interventions.

Reference

Yang, Y., Wang, S., Hu, B., HAo, J., Hu, R., Zhou, Y. & Mao, Zongfu. (2020) Do Older Adults with Parent(s) Alive Experience Higher Psychological Pain and Suicidal Ideation? A Cross-Sectional Study in China. International Journal of Environmental Research and Public Health. 17(17), pp.E6399. doi: 10.3390/ijerph17176399.