Psychopharmacological interventions

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In meta-analyses of adult studies, lithium maintenance treatment greatly reduces (8.6-fold) the recurrence of suicide attempts in adults with bipolar or other major affective disorders. Further, when lithium is discontinued there is a sevenfold increase in the rate of suicide attempts and a ninefold increase in the rates of suicide. (42> Other mood stabilizers, such as valproate and carbamazepine, are also widely used to treat bipolar disorders in children and adolescents; although their efficacy has yet to be empirically demonstrated. Depressed suicidal children and adolescents with a history of bipolar disorder should first be treated with a mood stabilizer before receiving an antidepressant.

Studies in depressed adults have found that the selective serotonin reuptake inhibitor ( SSRI) antidepressants reduce suicidal ideation, and also reduce the frequency of suicide attempts in non-depressed patients with cluster B personality disorders with a past history of suicide-attempt behaviour. (43,) In contrast to the highly lethal potential of tricyclic antidepressants when taken in overdoses, SSRIs have low lethal potential. In a controlled trial of the depot neuroleptic flupenthixol, Montgomery and Montgomery(44> noted a significant reduction in suicide-attempt behaviour in adults who had made numerous previous attempts. Similar studies have yet to be conducted for adolescents.

In the past decade, there has been much controversy over whether the SSRI antidepressants can induce suicidal ideation and/or behaviour. A number of case reports appeared in 1990 describing patients who had developed suicidal preoccupations after starting treatment with fluoxetine. These reports were not supported by meta-analyses and reanalyses of large SSRI-treatment trials of depressed, bulimic, or anxious patients.(45,,46) The conclusion was reached that suicidal ideation is a common feature of depression and that the prevalence in SSRI-treated depressives was no greater than expected.

However, one reanalysis of the data presented in certain of these studies suggested that new ideation was significantly more common in SSRI-treated depressed patients who had not previously reported suicidal ideation. Further, in a naturalistic challenge study, Rothschild and Locke (4D were able to reinduce suicidal ideas in a small series of patients who had first experienced ideation after starting treatment with fluoxetine. These patients had also experienced akithesia as a complication of fluoxetine treatment, and a relationship between suicidality and fluoxetine-induced akithesia has been noted by others.

At this stage, the wisest course of action is for the practitioner to be particularly observant during the early stages of fluoxetine treatment of a depressed adolescent, to systematically enquire about suicidal ideation before and after treatment is started, and to be especially alert to the possibility of suicidality if SSRI treatment is associated with the onset of akithesia.

One must be careful about the risk of inducing suicidal ideation or behaviour through psychopharmacological activation or disinhibition. Clinicians should be cautious about prescribing medications that may reduce self-control, such as the benzodiazepines, and phenobarbitone (phenobarbital). These drugs also have a high lethal potential if taken in overdose. Montgomery(48) noted that benzodiazepines may disinhibit some individuals who then become aggressive and attempt suicide and that there are suggestions of similar effects from the antidepressants, maprotiline and amitriptyline, the amphetamines, and phenobarbitone. Amphetamines or other stimulant medication should only be prescribed when treating suicidal children and adolescents with attention-deficit hyperactivity disorder.

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