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Suicidality and Risks of
Medications Used to Treat
Mental Illness
A workshop presented
by the College of
Psychiatric and
Neurologic Pharmacists
Presenters
Steven Burghart, DPh, MBA, BCPP
(Moderator) Director of Pharmacy, Rolling
Hills Hospital, Franklin, TN
Jennifer Zacher, PharmD, BCPP
Captain James A. Lovell Federal Health
Care Center, North Chicago, IL
Kimberly Lintner, PharmD, BCPP
Meriter Hospital, Madison, WI
Objectives
• Identify common signs and symptoms that
should raise concerns about a person’s safety
and the risk of self harm.
• Explain how medications used to improve
depression can contribute to suicidal behavior.
• Describe how consumers, families and support
networks can help manage the risk of
medications in light of current regulatory actions
regarding antidepressant and antiepileptic
medications.
Disclosures
• Steven Burghart has no relevant conflicts of
interest to disclose.
Definitions
• Suicide- intentionally killing oneself.
• Suicidality- the likelihood of an individual
committing suicide.
• Suicidal Ideation- mental thoughts and images
which hinge around committing suicide.
Suicide Facts
• Suicide is the eleventh leading cause of
death for all age groups.
• Over 34,000 suicides in 2007.
– One suicide every 15 minutes.
• Over 376,000 emergency room treatment for
self-inflicted injuries that same year.
• One suicide for every 25 attempted suicides.
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Facts-Gender
• Males four times as likely as females to
complete suicide
– 78.8% of all suicides.
• Females attempt suicide 2-3 times as often
as males.
• Males use firearms (55.7%).
• Females use poisons or medications
(40.2%).
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Facts-Age
• Suicide is second leading cause of death among
25-34 year olds.
• Third leading cause of death among 15-24 year
olds.
• 13.8% of students in grades 9-12 considered
suicide in the past 12 months.
• 6.3% of students reported at least on suicide
attempt in that same time period.
• Rate among those age 75 or older was 16 per
100,000, compared to 11.26 per 100,000 for all age
groups.
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Facts-Race
• Rates among Native Americans aged 15-34
were 1.8 times higher than national average.
• Hispanic and Black high school students
reported higher percentage of suicide
attempts compared to White, non Hispanics.
– 11.1% and 10.4% compared to 6.5%.
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Affects Families
• Suicides and attempts devastate families.
• Family and friends feel shock, anger, guilt,
depression.
• Suicide survivors often face chronic health
problems.
– Injuries
– Organ failure
– Brain damage
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Risk Factors
• Adults
– Mood Disorders such as depression
• More than 90% of suicide completers have
diagnosable illness at the time of death.
– Alcohol or other drug abuse
• Youth
– Same as adults, but also
– History of aggressive or disruptive behaviors
– History of physical or sexual abuse
Suicide Risk Factors
• Other risk factors include
– Previous suicide attempts
– Family history of suicide or violence
– Physical illness
– Feeling alone
www.cdc.gov/violenceprevention accessed 5/13/2011
Suicide Warning Signs
•
•
•
•
•
Suicide threats
Previous suicide attempts
Sudden changes in behavior
Depression
Final arrangements
The Jason Foundation 2001
Video Warning Signs PSA
http://www.youtube.com/watch?v=pZhVuZHD8po&feature=youtube_gdata_player
IS PATH WARM?
How do you Remember
the Warning Signs of
Suicide? Here’s an
Easy-to-Remember
Mnemonic:
http://www.suicidology.org/web/guest/stat
s-and-tools/warning-signs
accessed 5/16/2011
I Ideation
S Substance Abuse
P Purposelessness
A Anxiety
T Trapped
H Hopelessness
W Withdrawal
A Anger
R Recklessness
M Mood Change
IS PATH WARM?
• IDEATION Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill
him/herself; and/or, • Looking for ways to kill him/herself by seeking access to firearms,
available pills, or other means; and/or, • Talking or writing about death, dying or suicide,
when these actions are out of the ordinary.
• SUBSTANCE (alcohol or drug) use
• No reason for living; no sense of PURPOSE in life
• ANXIETY, agitation, unable to sleep or sleeping all the time
• Feeling TRAPPED - like there’s no way out
• HOPELESSNESS
• WITHDRAWING from friends, family and society
• Uncontrolled ANGER, seeking revenge or rage
• Acting RECKLESS or engaging in risky activities, seemingly without thinking
• Dramatic MOOD changes
http://www.suicidology.org/web/guest/stats-and-tools/warning-signs
accessed 5/16/2011
Jennifer Zacher, PharmD, BCPP
How medications used to improve
depression can contribute to suicidal
behavior
Jennifer Zacher has no relevant conflicts of
interest to disclose.
Symptoms of Depression
• Symptoms of depression
– Low mood
– Lack of interest in activities
– Guilty feelings
– Low energy
– Poor concentration
– Changes in appetite
– Changes in sleep pattern
– Slowed movements
– Suicidal thoughts
DSM IV- TR
FDA Concerns Regarding
Antidepressants and Suicide Risk
• Case reports in 1990 that new antidepressant
medications were associated with increased
risk of suicidal thoughts.
• From June 2003-2004, the FDA released 5
different safety warnings related to increased
risk of suicide in children treated with
antidepressants
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Suicidality and Antidepressants
WARNING: SUICIDALITY AND ANTIDEPRESSANT DRUGS
Antidepressants increased the risk compared to placebo of suicidal thinking
and behavior (suicidality) in children, adolescents, and young adults in
short-term studies of Major Depressive Disorder (MDD) and other
psychiatric disorders. Anyone considering the use of Pristiq or any other
antidepressant in a child, adolescent, or young adult must balance this risk
with the clinical need. Short-term studies did not show an increase in the
risk of suicidality with antidepressants compared to placebo in adults
beyond age 24; there was a reduction in risk with antidepressants compared
to placebo in adults aged 65 and older. Depression and certain other
psychiatric disorders are
themselves associated with increases in the risk of suicide. Patients of all
ages who are started on antidepressant therapy should be monitored
appropriately and observed closely for clinical worsening, suicidality, or
unusual changes in behavior. Families and caregivers should be advised of
the need for close observation and communication with the prescriber.
Pristiq® Prescribing Information
Mechanisms for AntidepressantInduced Suicidality
•
•
•
•
•
Timeline of antidepressant action
Unrecognized bipolar disorder
Side effects
Worsening of depression
Other psychiatric or medical conditions
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Timeline of Antidepressant Action
• It may take up to 6-8 weeks to see full
therapeutic effects of antidepressants.
• Some patients may have suicidal thoughts
prior to starting antidepressants but lack the
energy to carry out a plan
• Energy levels usually improve before mood
and guilty feelings.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Undiagnosed Bipolar Disorder
• Many patients have depressed episodes prior
to manic episodes.
• Bipolar patients who take antidepressant
medications without an additional mood
stabilizer are at risk of becoming manic of
hypomanic.
• Patients may attempt suicide due to mania.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Side Effects of Antidepressants
• Antidepressant medications can cause
jitteriness or akathisia (feeling of intense
restlessness).
• Akathisia may result in agitation and an
increase in suicide attempts.
• Antidepressants may also cause insomnia,
which increases risk for suicide.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Worsening of Depression
• About 70% of patients will have some effect
from an antidepressant medication  the rest
of patients may have no effect or worsening
depression.
• Patients with different types of depression
may have worsening of symptoms such as
agitation, inner tension, and racing thoughts,
which may increase suicide risk.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Impact of FDA Warning on
Antidepressant Prescribing
• In 2005, a 20-30% decrease in antidepressant
prescribing was seen in children and
adolescents with an increase seen in
adolescent suicide rates.
• Decrease in diagnosis of new cases of
pediatric depression seen in US.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Suicidality and Antidepressants
Nemeroff et al. Arch Gen Psychiatry 2007;64:466-72.
Suicidality and Antidepressants
CDC,MMWR Weekly Report 2007;56:905-908
Take Home Points
• Data on risk of suicidality with antidepressant
use is mixed.
• Children, adolescents, and young adults
seem to be at highest risk.
• Monitoring is key
– Frequent contact with provider is necessary when
starting an antidepressant or increasing the dose.
– Patients should be observed closely for changes
in behavior or signs of suicidality by friends and
family as well.
CNS Neurosci Ther 2010. Aug;16(4):227-34.
Kimberly Lintner, PharmD, BCPP
Manage the risk of medications in light of
current regulatory actions regarding
antidepressant and antiepileptic
medications.
Disclosure:
Kimberly Lintner has no relevant conflicts of
interest to disclose.
Monitoring for safe outcomes
• FDA (U.S. Food and Drug Administration)
– Responsible for protecting the public health by
assuring the safety, efficacy, and security of
human drugs.
– Advances public health by making medications
more effective, safer, and more affordable.
www.fda.gov accessed 4/12/11
Monitoring for safe outcomes
Initial
studies
Some safety
information
Final
studies
More safety
information
General
use
Best safety
information
Resources
• FDA Medwatch
Understanding those leaflets
• Consumer information
• Patient package insert
• Medication guides
• How do you pick out what is important?
– What it is used for, common side effects, serious
side effects, when should it start working
Understanding those leaflets
• Study done with adults, education up to high
school
• Asked seven questions and could use the
materials to answer (less than half did)
The key information relating to suicide risk in
teens (emphasized in all materials) was identified
by 60%
• More is not better, recommendation to FDA to
have a single standardized document
Shiffman S, Gerlach KK, Sembower MA, Rohay JM. Consumer
understanding of prescription drug information: an illustration using an
antidepressant medication. Ann Pharmacother. 2011;45:452-458.
Resources
Pharmacists involvement
• Provide medications
• Help sort through “information”
– Commercials
– Newspaper ads
– Printed and Internet resources
• Is it working? How do you/we know?
• Safe use
– Selecting particular medications/amounts
– Supervision and assistance
Resources
Abuse of prescription medications
• Nonmedical uses of prescriptions are
dramatically rising
– Visits to Emergency Departments doubled in 5
years (600,000 -> 1.2 million)
• Oxycodone 250%
• Alprazolam 150%
• Hydrocodone 125%
• Sources- friends, family members
prescriptions, visitors to the home
www.drugabuse.gov accessed 5/26/11
Resources
Safe medication disposal
• Appropriate removal will help ensure safety for
people, pets and the environment
• Community collection events are becoming
more common-best option
• At home you can crush and mix with coffee
grounds/kitty litter and place in sealed
container in the trash
– Strong pain medications should be flushed down
the toilet
– If you are not sure, ask your pharmacist
Resources
One page (two-sided) handout
available for your use.
Take action!
Information and education
• Advocate for yourself/others
• Be willing to ask questions
“Ask the Pharmacist” sessions
• Let others help- keep those appointments
• Have the tools you need
Refilling medications, safety plan
Take home messages
• Medications are more helpful than harmful, but
not without risks
• Everyone involved should be watchful of the
responses to medications
• The pharmacist plays a key role in maximizing
treatment
Questions and Discussion
What Would You Do?
• You have a (family member, friend,
acquaintance) who shares that a week a go
they started taking an antidepressant. They
have an urge to hurt themselves- maybe even
kill themselves.
• What information would you share with them
based on today’s presentation?