Suicide is an all-too familiar consequence of depression. Up to 15% of patients with untreated or undertreated depression commit suicide. The goal of treatment for depressive disorders is to alleviate the symptoms of depression, which may include an inability to experience pleasure, a pessimistic attitude, and generalized anxiety. Patients with psychotic symptoms of depression — up to 10% of depressed patients — may also experience delusions, hallucinations, and a desire to harm themselves or others. Standard treatment approaches to depression include a balance of drug therapies, counseling, and behavior modification.

While the standard drug treatment options available have a successful record for returning patients to a normal, functioning social and work life, there is little evidence that antidepressants decrease the risk of suicide in severely depressed patients. Evidence suggests that, not only are antidepressants not successful in reducing the risk of suicide, but they may actually increase it. There have been many indications recently that several antidepressants increase the risk of suicide in adolescents, prompting black-box warnings on the drug labeling. Another small study found that patients hospitalized for depressive symptoms, including suicide attempts, were more likely to have been treated with a benzodiazepine or antidepressant prior to the suicide attempt. These patients were also less likely to have received an antipsychotic medication, antiepileptic mood stabilizer, or lithium than patients who did not attempt suicide.

A recent study published in the Journal of Clinical Psychiatry reported that adding the atypical antipsychotic drug risperidone to standard antidepressant drug therapy significantly reduced the risk of suicide. The 8-week, double-blind, placebo-controlled study examined 24 adult patients with a diagnosis of major depressive disorder. The patients received either low-dose risperidone or placebo in addition to their established antidepressant therapy and were evaluated periodically on their depressive symptoms, suicidal ideations, and impulsiveness. The results showed that risperidone significantly reduced the risk of suicide, as well as impulsiveness, compared to placebo. The effects were seen as early as 2 weeks into treatment, and lasted for the length of the study. The patients taking risperidone reported no significant adverse effects. This study included a small sample of patients, and was a short duration, but the results are promising that antipsychotics are effective in treating depression with suicidal ideations.

This is not the first time that antipsychotics have been used for severe and difficult-to-treat mood and anxiety disorders. Atypical antipsychotics — as opposed to typical antipsychotics like Haloperidol — are often used to treat acute manic phases of bipolar disorder, as well as to prevent relapse following successful treatment of mania. Further, small numbers of patients experiencing psychotic depression have been treated successfully with an atypical antipsychotic only. However, these agents tend to be expensive, and can cause metabolic side effects, including weight gain, increased cholesterol, and diabetes mellitus, and are not considered first-line agents.

Larger studies are needed to confirm the effects of antipsychotics on decreasing suicide risk, but the results of the latest work are promising and offer insights into potential treatment strategies for high-risk populations suffering from major depressive disorder.

References

B GAUDIANO, D YOUNG, I CHELMINSKI, M ZIMMERMAN (2008). Depressive symptom profiles and severity patterns in outpatients with psychotic vs nonpsychotic major depression? Comprehensive Psychiatry, 49 (5), 421-429 DOI: 10.1016/j.comppsych.2008.02.007

M RAJA, A AZZONI, A KOUKOPOULOS (2008). Psychopharmacological treatment before suicide attempt among patients admitted to a Psychiatric Intensive Care Unit Journal of Affective Disorders DOI: 10.1016/j.jad.2008.04.024

Reeves H, Batra S, May RS, Zhang R, Dahl DC, Li X (2008). Efficacy of Risperidone Augmentation to Antidepressants in the Management of Suicidality in Major Depressive Disorder: A Randomized, Double-Blind, Placebo-Controlled Pilot Study J Clin Psychiatry. e1-e9.

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