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.

10 Mental Health Stats

Good mental health is related to mental and psychological well-being. The World Health Organisation’s (WHO’s) work to improve the mental health of individuals and society at large includes the promotion of mental well-being, the prevention of mental disorders, the protection of human rights and the care of people affected by mental disorders.

  1. Mental, neurological and substance use disorders make up 10% of the global burden of disease and 30% of non-fatal disease burden.
  2. Around 1 in 5 of the world’s children and adolescents have a mental disorder.
  3. Depression is one of the leading causes of disability, affecting 264 million people.
  4. About half of mental disorders begin before the age of 14.
  5. Almost 800,000 people die by suicide every year; 1 person dies from suicide every 40 seconds.
    • Suicide is the second leading cause of death in individuals aged 15-29 years.
  6. Around 1 in 9 people in settings affected by conflict have a moderate or severe mental disorder.
  7. People with severe mental disorders die 10 to 20 years earlier than the general population.
  8. Rates of mental health workers vary from below 2 per 100,000 population in low-income countries to over 70 per 100,000 in high-income countries.
  9. Less than half of the 139 countries that have mental health policies and plans report having these aligned with human rights conventions.
  10. The global economy loses about US$ 1 trillion per year in productivity due to depression and anxiety.

Reference

World Health Organisation. (2019) Mental Health. Available from World Wide Web: https://www.who.int/news-room/facts-in-pictures/detail/mental-health. [Accessed: 17 May, 2021].

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.

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 clichés 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: 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.

Book: Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel

Book Title:

Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel.

Author(s): Patrick Dobson.

Year: 2020.

Edition: First (1st).

Publisher: Skyhorse Publishing.

Type(s): Hardcover and Kindle.

Synopsis:

A deeply moving account of one man’s return to the German town where he first pursued a career in winemaking, and his attempt to reckon with the mental illness, alcoholism, and enduring relationships that defined the most formative chapter of his life.

After an attempted suicide by hanging – with his son in the next room – author Patrick Dobson checks into a mental hospital, clueless, reeling from bone-crushing depression and tortuous, racing thoughts. A long overdue diagnosis of manic depression offers relief but brings his confused and eventful past into question.

To make sense of his suicide attempt and deal with his past, he returns to Germany where, three decades earlier, he arrived as twenty-two-year-old – lost, drunk, and in the throes of untreated mental illness – in search of a new life and with dreams of becoming a winemaker. The sublime Mosel vineyards and the ancient city of Trier changed his life forever.

Ferment charts his days in Trier’s vineyards and cellars, and the enduring friendships that would define his life. A winemaker and his wife become like parents to him. In their son, he finds a brother, whose death years later sends Dobson into a suicidal tailspin. His friends, once apprentices like himself, become leaders in their fields: an art historian and church-restoration expert, an art- and architectural-glass craftsman, a painter and photographer, and a theologian/journalist. The relationships he builds with them become hallmarks of a life well-lived.

In Ferment, Dobson reconnects with the people who stood by him through his dissolution and eventual recovery. In these relationships, he seeks who he was and how his time in Germany changed him. He peers into his memory to understand how manic depression and alcoholism affected who he was then and how his time in Germany made him who he’s become.

World Suicide Prevention Day

Introduction

World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organisation (WHO) and the World Federation for Mental Health (WFMH) to host World Suicide Prevention Day.

In 2011 an estimated 40 countries held awareness events to mark the occasion. According to WHO’s Mental health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 10% of lower-middle income countries, and almost a third of upper-middle and high-income countries had.

On its first event in 2003, the 1999 WHO’s global suicide prevention initiative is mentioned with regards to the main strategy for its implementation, requiring:

  1. “The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.”
  2. “The strengthening of countries’s capabilities to develop and evaluate national policies and plans for suicide prevention.”

As of recent WHO releases, challenges represented by social stigma, the taboo to openly discuss suicide, and low availability of data are still to date obstacles leading to poor data quality for both suicide and suicide attempts: “given the sensitivity of suicide – and the illegality of suicidal behaviour in some countries – it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.”

Background

An estimated one million people per year die by suicide or about one person in 10,000 (1.4% of all deaths), or “a death every 40 seconds or about 3,000 every day”. As of 2004 the number of people who die by suicide is expected to reach 1.5 million per year by 2020.

On average, three male suicides are reported for every female one, consistently across different age groups and in almost every country in the world. “Conversely, rates of suicide attempts tend to be 2-3 times higher in women than in men, although the gender gap has narrowed in recent years.” More people die from suicide than from murder and war; it is the 13th leading cause of death worldwide. According to the WHO there are twenty people who have a suicide attempt for every one that is fatal, at a rate approximately one every three seconds. Suicide is the “most common cause of death for people aged 15 – 24.”

According to the WHO, suicide accounts for nearly half of all violent deaths in the world. Brian Mishara, IASP president, noted that, “more people kill themselves than die in all wars, terrorist acts and interpersonal violence combined.” As of 2008, the WHO refers the widest number of suicides occur in the age group 15 – 29, while the lowest in the 80+ although representing as well the one with the highest rate (per 100,000) of all age groups, with 27.8 suicides and 60.1 for females and males respectively. In 2015 the reported global age-standardised rate is 10.7 per 100,000.

Social norms play a significant role in the development of suicidal behaviours. Late 19th century’s sociological studies recorded first ever observations on suicide: with statistics of the time at hand, sociologists mentioned the effects of industrialisation as in relations between new urbanised communities and vulnerability to self-destructive behaviour, suggesting social pressures have effects on suicide. Today, differences in suicidal behaviour among different countries can be significant.

Themes

  • 2003 – Suicide Can Be Prevented!.
  • 2004 – Saving Lives, Restoring Hope.
  • 2005 – Prevention of Suicide is Everybody’s Business.
  • 2006 – With Understanding New Hope.
  • 2007 – Suicide prevention across the Life Span.
  • 2008 – Think Globally, Plan Nationally, Act Locally.
  • 2009 – Suicide Prevention in Different Cultures.
  • 2010 – Families, Community Systems and Suicide.
  • 2011 – Preventing Suicide in Multicultural Societies.
  • 2012 – Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope.
  • 2013 – Stigma: A Major Barrier to Suicide Prevention.
  • 2014 – Light a candle near a Window.
  • 2015 – Preventing Suicide: Reaching Out and Saving Lives.
  • 2016 – Connect, Communicate, Care.
  • 2017 – Take a Minute, Change a Life.
  • 2018 – Working Together to Prevent Suicide.
  • 2019 – Working Together to Prevent Suicide.
  • 2020 – Working Together to Prevent Suicide.

Priorities

Suicide prevention’s priorities, as declared on the 2012 World Suicide Prevention Day event, are stated below:

  • We need to continue to research suicide and non-fatal suicidal behaviour, addressing both risk and protective factors.
  • We need to develop and implement awareness campaigns, with the aim of increasing awareness of suicidal behaviours in the community, incorporating evidence on both risk and protective factors.
  • We need to target our efforts not only to reduce risk factors but also to strengthen protective factor, especially in childhood and adolescence.
  • We need to train health care professionals to better understand evidence-based risk and protective factors associated with suicidal behaviour.
  • We need to combine primary, secondary and tertiary prevention.
  • We need to increase use of and adherence to treatments shown to be effective in treating diverse conditions; and to prioritise research into effectiveness of treatments aimed at reducing self-harm and suicide risk.
  • We need to increase the availability of mental health resources and to reduce barriers to accessing care.
  • We need to disseminate research evidence about suicide prevention to policy makers at international, national and local levels.
  • We need to reduce stigma and promote mental health literacy among the general population and health care professionals.
  • We need to reach people who do not seek help, and hence do not receive treatment when they are in need of it.
  • We need to ensure sustained funding for suicide research and prevention.
  • We need to influence governments to develop suicide prevention strategies for all countries and to support the implementation of those strategies that have been demonstrated to save lives.

Factors

Suicide has a number of complex and interrelated and underlying contributing factors … that can contribute to the feelings of pain and hopelessness. Having access to means to kill oneself – most typically firearms, medicines and poisons – is also a risk factor.

The main suicide triggers are:

  • Poverty;
  • Unemployment;
  • The loss of a loved one;
  • Arguments; and
  • Legal or work-related problems.

Suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour).

In richer countries, three times as many men die of suicide than women do, but in low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman.

In the United States, for example, males are four times more likely to die from suicide than are females. However, females are more likely to attempt suicide than are males.

The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die in men than women.

Physical and especially mental health disabling issues such as depression, are among the most common of the long list of complex and interrelated factors, ranging from financial problems to the experience of abuse, aggression, exploitation and mistreatment, that can contribute to the feelings of pain and hopelessness underling suicide. Usually substances and alcohol abuse also play a role.

Prevention strategies generally emphasise public awareness towards social stigma and suicidal behaviours.

Cultural and Religious Attitudes

In much of the world, suicide is stigmatised and condemned for religious or cultural reasons.

In some countries, suicidal behaviour is a criminal offence punishable by law. Suicide is therefore often a secretive act surrounded by taboo, and may be unrecognised, misclassified or deliberately hidden in official records of death.

Stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need.

The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it.

Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.

Links