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Antidepressants and treatment emergent suicidality
- James Paul Pandarakalam (19 February 2007)
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James Paul Pandarakalam, consultant psychiatrist, 5 Borough Partnership NHS Trust St Helens North CMHT, Peasley Cross Resource Centre, St Helens, Merseyside WA 9 3DA
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Treatment emergent suicidality has been debated for a long time 1.There is now increasing concern about the apparent association between venlafaxine and suicide. Fluoxetine, paroxetine and mirtazapine have now been in the jury’s court. Treatment emergent suicidality has also been linked with psychotherapy. While debating about treatment emergent suicidality we should not overlook the fact that proper antidepressant treatment do prevent suicide and venlafaxine has been a valuable antidepressant when prescribed with all the cautions. Suicidality involves suicidal thinking and behaviour-suicidal ideation, planning, attempts and completion. Many theories have been proposed to explain the mechanism of treatment emergent suicidality .An acute effect of S.S.R.I. treatment include compensatory decrease in 5-HT neuronal firing, leading to suicidality in vulnerable patients. Antidepressants cause treatment emergent subjective agitation or akathesia like feelings soon after they have been initiated 2. Another suggestion is that SSRIs, improve energy levels and patients recover their initiatives before they experience lifting of the mood and they get access to their mental resources to work out the suicidal plans .The risk of suicide is higher among bipolar patients than monopolar patients and this is particularly so in the mixed affective states. The newer antidepressants unmask incipient bipolarity 3 and most often result in mixed state. This may be true of younger adults while the older depressed adults would have more likely declared their mania. “Rollback phenomenon” is another possible mechanism linked with the treatment emergent suicidality .4 This theory proposes that as depressive illness remits, it return in a reverse order through many of the stages and symptoms that were seen during the time it developed. So a patient who has been suicidal sometimes during a depressive episode and was not suicidal when drug treatment was initiated may re-experience suicidal thoughts as the episode remits. The biological models are not adequate to explain the treatment emergent suicidality due to psychotherapy. Tricyclic antidepressants with sedative effects were less linked with treatment emergent suicidality. But Tricyclics carried higher risk in the event of overdose. Bipolarity should be screened in all cases of monopolar depression. While this cannot be always accurate, one way of preventing treatment emergent bipolarity in doubtful cases is co prescribing antipsychotics or mood stabilisers to prevent hypomanic switch. Such a view needs further investigation. It is interesting to remember that combination drugs (e.g. Triptafen- amitryptiline hydrochloride and perphenanazine) were popular before the advent of S.S.R.I.s. Some antipsychotics and mood stabilisers have more anti manic properties than others. An adjunctive therapy has the advantage of negating the treatment emergent agitation. Unfortunately, newer antidepressants can become like the Trojan horse. References 1.Tricher MH, Glod C, Cole Jo. Emergence of intense suicidal preoccupations during fluoxetine treatment. American Journal of Psychiatry. 1990, 147: 207-210. 2.Healy D. The fluoxetine and suicide controversy. A review of the evidence. CNS Drugs 1991; 1(3): 223-231. 3.Smith J Daniel, Walters T James. Bipolarity is important during treatment with antidepressants.2007:334:327. 4.Fava M, Rosenbaum J,F. Suicidality and Fluoxetine: is there a relationship? J.Clinical Psychiatry 1991; 52: 108-111. Competing interests: None declared |
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