Recent Drug Warnings About Suicide




Psychiatry and Psychology CategoryDuring the holiday season, I was reminded of the old myth that suicide rates increase over the holidays. This medical myth has been debunked numerous times and it was one of the topics covered in a recent BMJ story about medical myths. For many years, people believed this myth because they felt that the depression worsens when depressed patients see other happy and celebrating with friends and family. Plus, in many areas, the winter seasons may lead to more rain, cloudy weather, and gloomy days for people who may be susceptible to seasonal affective disorder (SAD). So how about suicide? How often do depressed patients commit suicide? And what prompts depressed individuals to the verge of suicide? This is a very complex topic that has no simple explanation.

PillsA few years ago, the FDA added suicide warnings to common anti-depressants. This included drugs like:

  • Prozac (fluoxetine),
  • Zoloft (sertraline),
  • Paxil (paroxetine),
  • Luvox (fluvoxamine),
  • Celexa (citalopram),
  • Lexapro (escitalopram),
  • Wellbutrin (bupropion),
  • Effexor (venlafaxine),
  • Serzone (nefazodone), and
  • Remeron (mirtazapine).

This is a very long list of extremely common medications. When this happened, people asked, “Why do anti-depressants increase the risk of suicide?” Many different theories emerged, but this did not stop clinicians from prescribing these common agents for patients suffering from depression or anxiety. This warning was also considered very ironic since severely depressed patients are the ones who may commit suicide, yet they are the ones who need to be treated with anti-depressants. So how do you treat suicidal patients if the treatment may increase the risk of suicide? Many people wondered whether the drugs really increased suicide, or if the increased suicide was simply an association without causation. This matter still seems to be quite controversial among healthcare professionals. If you’re going to treat patients who are very suicidal with any type of drug, there is a high chance that some of them may still commit suicide.

More recently, the FDA added suicide warnings to anti-epileptic drugs. These agents are used to treat patients with seizure disorders (epilepsy). They are also used to treat certain types of nerve-related pain, also called neuropathy. Anti-epileptic agents are often used to treat certain migraines. Not sure which drugs fall into this class? Maybe you’ve heard of some of these:

  • Tegretol (carbamazepine),
  • Klonopin (clonazepam),
  • Depakote (divalproex),
  • Depakene (valproic acid),
  • Zarontin (ethosuximide),
  • Peganone (ethotoin),
  • Felbatol (felbamate),
  • Neurontin (gabapentin),
  • Lamictal (lamotrigine),
  • Vimpat (lacosamide),
  • Keppra (levetiracetam),
  • Mesantoin (mephenytoin),
  • Celontin (methsuximide),
  • Trileptal (oxcarbazepine),
  • Dilantin (phenytoin),
  • Lyrica (pregabalin),
  • Mysoline (primidone),
  • Gabitril (tiagabine),
  • Topamax (topiramate),
  • Tridione (trimethadione), and
  • Zonegran (zonisamide).

You may have also heard of suicide risks associated with the popular smoking cessation drug Chantix (varenicline).  In February 2008, the FDA issued a public health advisory about the risks of suicide associated with Chantix.

So what’s next? Will more psychotropic medications get a suicide black box warning? What about non-psychotropic medications? If the suicide warning gets added to so many different medications, then people may start ignoring the warning if it’s everywhere. How often do people read the Surgeon General’s warning on cigarette packs? That warning is ubiquitous. However, is it effective? Do people actually pay attention to that warning, or do they ignore it since they’ve seen it so many times?

How are healthcare professionals supposed to prescribe drugs that have a suicide black box warning? How are patients supposed to react to such warnings? This is a very confusing topic right now, and I’m eager to see what happens in the next few years as the FDA evaluates suicide association with other drugs.

References

R. C Vreeman, A. E Carroll (2007). Medical myths BMJ, 335 (7633), 1288-1289 DOI: 10.1136/bmj.39420.420370.25

FDA Public Health Advisory. Worsening Depression and Suicidality in Patients Being Treated With Antidepressant. FDA News. March 22, 2004.

FDA Issues Public Health Advisory on Chantix. FDA News. Feb 1, 2008.

  • Cheryl Soehl

    As someone who has survived the suicide of a family member who was prescribed an SSRI which precipitated the suicidal act, I feel I should point out that there is a very specific condition caused by these medications which can be observed, reported and, one hopes, quickly treated to prevent successful suicide. The condition is akathisia — an intense restlessness; a state in which the sufferer cannot find relief, cannot rest or sleep, and, when severe enough, sees suicide as the only escape.

    My sister was suffering with akathisia, was actively suicidal (searching for guns), and was admitted to a mental health facility. Unfortunately the facility saw fit to discharge her AMA at seven days (when her insurance ran out), whereupon she obtained a weapon and killed herself.

    Pharmaceutical companies would like us to believe that suicides completed while on SSRIs are due to the original depression for which the medication was prescribed rather than the medication-induced akathisia, thus little attention is paid to this condition or effective treatment for it.

  • meg

    Chantix needs the suicide warning, and behavior changes warning.. It is also important to look out for ANY behavior changes.. If someone you love takes this medicine.. you have to watch them closely.. This is not a safe drug..

  • The dilemma you point out is an important one. SSRIs will lead some people to be agitated. The surge of serotonin can have a stimulant effect. It might be better to prescribe a sedative to help deal with the period when the body adapts to the drug. I am not a fan of these drugs, but they do seem to work for some people. Deciding to avoid a drug, because it has serious side effects, requires an assessment of the possible benefits, too.

  • A friend of mine attempted suicide after being put on Zoloft. It increased their motivation – and what they were thinking about doing was committing suicide.

    A simple question, this is not rocket science, and a little intelligence would have prevented this.

  • Childless Mom

    Danielle was 32 years old, born on March 7, 1976. She was my heart & soul. At five years old she tested out at near genius level. Danielle had lapis blue eyes, natural ringlets’ curly auburn hair and a smile that would light up any room. She got married at 18 years old to a wonderful young man. He joined the USMC, while he was gone Dani developed severe mental illnesses, unbeknownst to anyone. We did not know the signs and would never have guessed that she was so ill. They divorced when he got home. Then came alcohol & drugs – she went through several treatment centers, even had 6 ECT’s done on her. Since she was “an adult” under the law, I had no say so with her care.

    Danielle was diagnosed with PTSD, severe depression, agoraphobia, Board Line Personality Disorder and board line sycophantic tendencies. This all took hold of her between 18 and 20 years old. Several times I had her live with me but she could not live with my rules (which were very few) and then would move on. She had such a good and giving heart that many, many times – she was taken advantage of by many people, in many ways. Board Line Personality is tough – the best book on it is “I Hate You, Don’t Leave Me”.

    Dani had been on SSI since she was 20 years old, therefore the mental health care was at no cost. We live in the country and I suppose she was rather isolated, just me, my husband, three dogs and three cats (counting hers). I would take her to all her appointments, as she would not drive anymore. We gardened together, enjoyed the same type of TV shows and she had chores to do on a regular basis. Due to Danielle being on SSI the state of Kansas appointed a primary care doctor to her. Three times we went to her office, never did she see my child, only ARNP’s. The first nurse “shooed” her out of the room and would not answer a list of questions that she had written down. Danielle smoked but cut down so much here, smoking is allowed only outside, so she decided she wanted to quit altogether. The second nurse wrote out not one but two prescriptions for the drug by Pfizer – CHANTIX. The nurse never told her any possible side effects and who reads all that little tiny type on the drug inserts? I know the Coroner in Topeka, and I called him and asked about Chantix after seeing a commercial on TV. He called four labs of which none of them test for the drug, he also did research concerning the interactions with the medications she was taking. I am not in denial of my daughter’s suicide BUT I do believe that Chantix was a huge factor in her choice. Complaints have been filed with the Kansas Medical Assoc. and Kansas Nursing Board.

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Joseph Kim, MD, MPH

Joseph Kim, MD, MPH, is a physician, engineer, technologist, and avid writer. He enjoys writing about advances in technology that are revolutionizing healthcare. Dr. Kim studied engineering at MIT, then received his medical degree from the University of Arkansas College of Medicine. He also has a master's degree in public health from the University of Massachusetts Amherst School of Public Health.
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