Depression and Suicide _ ______________________________________________________________________
[337; 338]. Several case reports document a perinatal syndrome in infants (e.g., jitteriness, irritability, bowel obstruction, urinary retention) with maternal use of TCAs and most of the SSRIs, although it is unclear whether the neonates were exhibiting symptoms of SSRI toxicity or SSRI withdrawal at birth. Also, they may have been more irritable and difficult to settle due to maternal depression, anxiety, and exposure to psychological stressors [328; 339; 340; 341; 342]. There is a lack of evidence suggesting that reducing or discontinuing antidepressants in late pregnancy will reduce adverse neonatal effects [343]. Women with a history of depression who are planning to become pregnant should carefully consider the choice and timing of an antidepressant [340]. Although SSRIs taken dur- ing pregnancy may be associated with adverse neonatal effects that are mostly mild and short-lived, women with a history of recurrent or severe depression who discontinue antidepres- sants during pregnancy increase the risk of potentially adverse outcomes for both the mother and fetus/infant. The minimum effective antidepressant dose to achieve and maintain remission should be used throughout pregnancy in women who continue their medication, and these patients should be monitored on an ongoing basis [339]. Women who discontinue medication relapse significantly more frequently over the course of their pregnancy compared with women who maintain their medi- cation [344]. The decision to continue treatment during the pregnancy should balance the risks and benefits to the mother and child and should be made on a case-by-case basis [21]. LACTATION The Academy of Breastfeeding Medicine Protocol Com- mittee suggests that TCAs and SSRIs are relatively safe, but they should only be used when clearly needed. Assessments weighing the potential benefits with the potential risks to the nursing infant should be performed in all cases [345]. Also, the mother-infant pair should be monitored for the emergence of adverse effects or complications [345; 346]. Regarding the use of specific medications during lactation, several observa- tions and recommendations have been made [21; 347; 348]. Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeed- ing; nortriptyline, paroxetine, and sertraline may be preferred choices in breastfeeding women. Use of imipramine during breastfeeding is not recommended by the manufacturer [175]. The lack of adverse effects among infants exposed to fluoxetine justifies its use, especially if prescribed during the pregnancy or if there is a preferential response history. However, its use during breastfeeding is not recommended by the manufacturer [175]. The TCA doxepin should be avoided due to a case report of infant respiratory distress [175]. Data on citalopram, fluvoxamine, bupropion, and venlafaxine are more limited and their use cannot be recommended during breastfeeding [175]. One study evaluating the potential consequences of TCA exposure through breast milk followed exposed children
through preschool age and found that exposed children were developmentally similar to non-exposed children. No similar studies have been performed with SSRIs [21].
SUICIDE For the past 50 years, suicide prevention research has focused on identifying demographic and clinical factors that reliably predict suicide risk. Examining population-level data, research- ers found clinical and demographic factors that correlated with suicidality [349]. These variables, including depression, most psychiatric disorders, trait impulsivity, family history of suicide, previous suicide attempts, and current suicidal ideation, became established as suicide risk factors [350; 351]. Suicide risk assessment intends to reduce clinician uncertainty of short-term patient risk of suicide so patients at imminent risk can receive rapid intervention [352; 353]. Decades-old convention holds that assessing suicide risk should culminate in a probability judgment of “low,” “moderate,” or “high” risk level [349]. Obtaining larger amounts of patient information was believed to be the best means to identify risk factors and reduce uncertainty [353; 354]. However, there is evidence that challenges these foundational assumptions of suicide, including risk factors and risk stratifi- cation, long-standing organizing principles of clinical suicide prevention. A 1983 study first identified the limitations of risk factors in suicide prediction, finding that 96.3% of high-risk suicide predictions were false positives and more than 50% of suicides occurred in low-risk patients (false negatives) [355]. Subsequent studies confirmed these results, demonstrating that the clinical reliance on traditional suicide risk assessment, risk factors, and scales were largely overstated [356; 357; 358; 359; 360; 361; 362; 363]. Traditional suicide risk factors are nonspecific, common, non-modifiable, and to varying degrees represent underly- ing vulnerabilities. These risk factors demonstrably predict lifetime and 12-month suicide ideation, but fail to predict suicide completion, suicide, or movement from ideation to suicide behavior [352]. Many patients have elevated risk pro- files, but their lifetime odds of suicide are remote. No study using population-based risk factors or combinations, rating scales, or assessment instruments has successfully predicted suicide in individual patients [350; 351; 364; 365; 366]. The failure to improve suicide prevention and the limited benefit of suicidality interventions suggest inadequate understanding of the mechanisms leading to suicidal behavior [367]. Acute suicide risk is now thought to result from recent psycho- social stressors superimposed on non-modifiable (traditional) risk factors, with psychosocial stressors the precipitants or “triggering events” to suicidal behaviors [364; 368]. Warn- ing signs, or the acute patient response to precipitants, are considered more useful to assess than risk factors [368]. The strongest suicide risk factor—previous suicide attempts—is a
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