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Research compares benefits, risks of suicide treatments

Although a gold standard for suicide treatment remains to be found, researchers explored the evidence of risks and benefits of currently available treatments for suicide.

“Suicidal behaviors and communications are obvious concerns for psychiatrists,” Sean Bordelon, MD, and Stephen H. Dinwiddie, MD, both from Northwestern University Feinberg School of Medicine, wrote. “Whereas the infrequency of completed suicide makes it hard to study and the alternative construct of ‘suicidality’ is not uniformly defined across studies, associations can be found between treatments in the psychiatrist’s toolbox and possible suicide-protective effects.”

To inform psychiatrists on benefits and risks of several candidate treatments for suicide, the researchers reviewed evidence of psychotherapy, pharmacotherapy and electroconvulsive therapy.

Psychotherapy

Psychotherapy is typically associated with low physical risk, which makes it a more attractive treatment option for suicide, according to the researchers.

However, few studies have investigated potential risks.

A recent survey of 14,587 individuals in England and Wales who received psychotherapy indicated 5% reported long-term negative effects.

Pharmacotherapy

Ecological studies have indicated protective properties of antidepressants for suicide.

However, an FDA review of 24 drug trials with approximately 4,400 individuals showed an association between antidepressants and suicidality, but not completed suicides, in younger patients. Specifically, individuals who received antidepressants were 4% more likely to have suicidal behavior compared with 2% in those who received placebo.

Lithium has been associated with suicide-protective effects in mood disorders and decreased mortality from all causes.

Conversely, lithium’s low therapeutic index makes it particularly toxic in overdose, according to Bordelon and Dinwiddie.

“Even with proper use and monitoring, many patients treated with lithium experience side effects such as acne, tremor, gastrointestinal disturbance, weight gain and polyuria,” they wrote.

Although other agents can counteract these side effects, the patient’s pharmacological regimen can rapidly become complicated.

Anticonvulsants were associated with significantly higher rates of suicide attempts and deaths in a 2003 study published in JAMA.

Further, the FDA issued a labeling change for the anticonvulsant drug class to warn of an association with increased suicidality in 2008.

The FDA’s findings indicated an overall association between anticonvulsants and suicidality; however, there was no significant association when anticonvulsants were prescribed for a psychiatric indication.

Electroconvulsive therapy

The researchers stated there is substantial evidence for efficacy of electroconvulsive therapy (ECT) to quickly relieve suicidal ideation, which may indicate it has a short-term protective effect on suicide.

Despite this evidence, ECT “remains poorly understood by the public” and psychiatrists, they wrote.

Further, ECT is costly and often inconvenient.

“When it comes to completed suicide, at best, evidence suggests that some treatment options may better reduce rates over relatively short time frames (months to a few years),” Bordelon and Dinwiddie concluded. “In the absence of better longitudinal data, clinicians’ confidence in the ability of any treatment to prevent suicide over long time frames must remain based more on hope than knowledge. Nonetheless, we can be confident that we do have treatment options that, at a minimum, can ameliorate the anguish of severe illness and decrease the likelihood of a fatal and tragic outcome.” – by Amanda Oldt

Disclosures: Psychiatric Annals is a publication of SLACK Incorporated, publishers of Healio.com.