in individuals 25 and older. Some studies have suggested that using SSRIs (Lexapro, Prozac) result in a greater reduction of suicide ideation compared to selective serotonin and norepinephrine reuptake inhibitors including Cymbalta, PRISTIQ or norepinephrine-dopamine reuptake inhibitors serotonin reuptake inhibitors, such as Celexa, Lexapro, Luvox, Paxil, Pexeva, Prozac, Sarafem, or Zoloft. Clozapine is the only medication currently approved by the FDA to reduce the risk of a suicidal ideation and behavior, but 22 medications are approved to treat depression (AFSP, 2018). Since there is no accurate test to match a person’s symptoms and complaints with the right medication, there is no way to know which drug will work best for a particular person. The person who may be depressed should discuss medication choice with their doctor and how to take it, as well as the potential side effects. Sometimes a patient may be required to try a few different medications before finding the one that gives the best result with minimum side effects. When the optimal dose with the best medication is achieved, the antidepressant may take from four to 12 weeks to achieve maximum benefit, but it is possible for one or two symptoms to improve in the first few weeks. When patients start antidepressants or increase dosage, a few, especially children, adolescents and young adults, may experience increased anxiety, agitation, restlessness, irritability, or anger which may lead to suicidal thoughts or attempts. These potential side effects should be outlined by the doctor before starting treatment. Severe depression and suicide attempts are usually treated with a combination of prescription medications and therapy (Ax, 2018). While not every patient requires medication to help overcome their symptoms tied to mood changes, many do. Medication alone is usually not the sole treatment used for depressed patients, however, because it often does not solve all the patient’s underlying psychological issues, and the drugs can stop working over time or pose many side effects. Interestingly, in patients younger than 25, antidepressant therapy has not been shown to decrease suicidal ideation and behaviors, although it does decrease signs and symptoms of depression (Kazim, 2017). In 2004, the United States Food and Drug Administration (FDA) issued a warning regarding the risk of increased suicidality associated with antidepressant use in young people up to age 25. Since then, the rates of diagnosis of depression and prescriptions of antidepressants for people 24 or younger has declined. However, the incidence of overdose using psychotropic drugs and the incidence of suicide in this group have both increased (Perlis et al., 2016). In its 2004 warning, the FDA also issued a black box warning on the use of six SSRIs for individuals less than 18 years of age (Asarnow & Mehlum, 2019). Since then, the warning has expanded to all antidepressant and anti-epileptic medications, and the age range has expanded through the age of 24. However, the incidence of overdose using psychotropic drugs and the incidence of suicide in this group have both increased (Perlis et al., 2016). Eventually, 64 medications contained the black box warning. Even professionals who do not prescribe medications should be aware of the consequences of these warnings; they are far-reaching and may impact the care of their patients. Further, when clinicians treating adolescents recommend a psychopharmacology consultation, it is helpful for the clinician to be armed with current information in the event that parents are concerned about even talking with a psychiatrist or other prescribing professional. First, the black box warning does not discourage providers from prescribing the medications, but rather it encourages increased monitoring when initiating antidepressant treatment or changing the dose of a current antidepressant (FDA, 2005, 2007). Unfortunately, only a small number of prescribers actually follow
FDA recommendations for patient follow-up frequency (Asarnow & Mehlum, 2019). Second, clinicians should be aware of the evidence that resulted in the black box warning. Antidepressant use may be associated with a small increase in suicidality among patients under the age of 25. Even though there is some evidence for increased suicidal thoughts and behaviors, antidepressant treatment is not associated with increased risk for death by suicide (Pozzi, Radice, Clementi, Molteni, & Nobile, 2016). In fact, in the 23 treatment studies reviewed by the FDA, not one of the over 4,000 youth participants died by suicide (Cooper et al., 2014; Food and Drug Administration, 2007). What is more troubling is that the reclassification of suicidal thoughts and behaviors for the FDA review found that only 18 of the 23 studies utilized standardized measures of suicide risk throughout the treatment trials. These studies found no significant differences between the antidepressant and placebo groups (Asarnow & Mehlum, 2019). Finally, all clinicians working with adolescent or adult patients on antidepressants should be aware of signs of clinical worsening that may be related to antidepressant use. These signs include anxiety, agitation, panic attacks, fatigue, dizziness, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, weight changes, sexual dysfunction, and other unusual changes in behavior, worsening of depression, and suicidal ideation (Courtet & Lopez- Castroman, 2017). Other pharmacological approaches While the bulk of research on treatment of suicide with medication has focused on antidepressants and SSRIs, other options are available. Another at-risk group for suicidal behavior is people with bipolar disorder, which is characterized by mood swings from high (manic) to low (depressed), often with periods of feeling normal between (AFSP, 2018). Those with bipolar disorder are at greatest risk for suicide when they are in a depression or have a mixed-mood state (Stanley, Hom, Luby, Joshi, Wagner, et al., 2017). With bipolar disorder, medication treatment typically begins with a mood stabilizer such as lithium, mood-stabilizing anticonvulsants, or antipsychotics (AFSP, 2018). Medications that address bizarre thinking and/or severe anxiety, like clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify), have also been found to decrease the likelihood of individuals dying by suicide (Dryden-Edwards, 2016). Mood stabilizers may also have potential to reduce suicidal behavior (Smith & Cipriani, 2017). Studies have shown that the higher the lithium content in water, the lower the suicide rates in that region (Barjasteh-Askari, Davoudi, Amini, Ghorbani, et al., 2020). Even though the exact mechanism of action through which lithium works to reduce suicidal behaviors remains unknown, it has been theorized that it may function by reducing mood disorder episodes or by decreasing impulsive and aggressive behaviors. Another pharmacological treatment with a growing evidence base is Ketamine (Ketalar), a glutamatergic drug used as an anesthetic, which has been used to treat suicidal behavior with many acute benefits, even during intense suicidal distress (Ionescu, Swee, Pavone, Taylor, et al., 2016). Trials have demonstrated that low doses of ketamine used as an antidepressant invoked a positive response within minutes of administration in patients with suicidal ideation and effects can last up to one week (Wilkinson, Ballard, Bloch, Mathew, et al., 2018). Given its ability to act rapidly, ketamine is quickly becoming a promising treatment for patients with suicidal behaviors in emergency settings. The main drawbacks to its use include potential for abuse and misuse, the short-lived nature of the responses it invokes, and the adverse cardiac and psychotomimetic side effects it causes (Perlis et al., 2016).
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