ADVANCES IN CLINICAL SUICIDOLOGY II

Therapeutic Intervention in Suicidal Behavior Mario Amore Department of Neuroscience University of Parma Effects of Medical Interventions on Suicidal Behavior Despite striking advances in the medical treatment of mood disorders in the past half-century, rates of suicidal acts have changed not much in the general population. Not much is known about specific effects of most psychiatric treatments or other interventions aimed at suicide prevention. An exception is substantial evidence of lower suicidal risk during longterm lithium treatment. Baldessarini and Jamison, 1999 Therapeutic Intervention in Suicidal Behavior 1. 50% of persons who commit suicide are undergoing psychiatric treatment 2. 58% have been seen by a doctor the week before suicide The First Intervention Evaluation of Suicide Risk 1. Multi-axial Evaluation 2. Evaluation of Suicidal Intent 3. Current and Complete Evaluation of the Risk of Suicidal Behavior Acute Treatment of Suicidal Behavior Provide real support, recognizing the discomfort and suffering of the patient Reduce psychological distress by removing sources of stress and by pharmacological treatment Offer Alternatives to Suicide Schneidman, 1985 Medium to Long-term Treatment of Suicidal Behavior TREATMENT OF THE UNDERLYING PSYCHIATRIC DISORDER Schneidman, 1985 Therapeutic Intervention in Suicidal Behavior Focus on: 1. Evaluation of Suicidal Risk 2. Treatment with Antidepressants Lithium Antipsychotics SUICIDE RISK AND THERAPEUTIC RESPONSE A) Immediate Evaluation of the necessity for hospitalization (voluntary or involuntary, according to the circumstances). The patient should be monitored constantly, should not be left alone, and family and health care workers (or police) should be actively involved, depending on the situation. B) Sedation: Atypical Antipsychotics/ NL, BDZ Severe or extreme risk SUICIDE RISK AND THERAPEUTIC RESPONSE Moderate Risk A) Repeated evaluation of the need for hospitalization. B) Increase in the frequency and duration of outpatient appointments to identify specific and defined stress factors, and to allow for symptomatic resolution. C) Active involvement of family members, if possible. D) Frequent reevaluation of the goals of treatment (for ex. symptomatic resolution, reduction in the frequency, intensity, or type of suicidal ideation, improvement in problem solving skills, adaptative coping, more hopeful feelings). E) 24 hour availability of crisis centers for the patient. F) Frequent reevaluation of suicide risk, evaluating specific changes that increase or decrease risk. G) Consider pharmacological treatment for evident symptoms if not already undertaken. H) Use of telephone contacts to monitor progress. I) Frequent input from family members regarding risk factors. SUICIDE RISK AND THERAPEUTIC RESPONSE No specific change. Repeated evaluation of risk as dictated by circumstances or by clinical presentation of the patient. Low or inexistent risk Suicide and Hospitalization Indications  Hospitalization must be considered when the patient’s safety is at risk (severity, lack of insight).  It allows for the contemporaneous evaluation and treatment of a sucidal patient.  It is indicated in more severe symptomatic cases, in case of uncontrollable behavioral disorders, and in the elderly with organic disease comorbidity.  In cases where social support is lacking.  Recent stressful events. A.P.A. 2003  Working to establish (and maintain) a cooperative Therapeutic Alliance and collaborative relationship Therapeutic alliance - careful attention to the concerns of patients and their family members and to their wishes for treatment  Empathy  Helping the patient feel emotionally supported  Increasing the patient’s sense of possible choices other than suicide  Continuum – possibility of intensive programs of ambulatory visits, facilitating treatment adherence and monitoring the patient’s progress and response to treatment Pharmacotherapeutic Intervention in Suicidal Behavior Reduction of Anxiety Antidepressant/Mood Stabilizing or Antipsychotic Treatment Treatment of Symptoms (ie pain) Treatment of the underlying Physiopathological Disorder in Suicidal Ideation Depression, Suicide, and Treatment-I  Select an AD with a low risk of lethality in overdose  Prescribe conservative quantities  For patients with prominent insomnia, use sedating AD or adjunctive hypnotic agent  For patients with prominent insomnia sedating antidepressants or an adjunctive hypnotic can be considered. BDZs on a short-term basis for patients with agitation, panic attacks, psychic anxiety  Low doses of novel APs in highly anxious and agitated patients  Trazodone, anticonvulsants (gabapentin or divalproex) Somatic Interventions: Antidepressants- II  Evidence of a decrease in suicide rates with antidepressant treatment is inconclusive  Long-term studies with relevant data are rare and too small to support any conclusions  SSRI antidepressants associated with increased risk of aggressive or impulsive acts – there is no evidence that suicide or suicidality is increased by treatment with specific types of antidepressants Bipolar Disorder: The link with suicide The risk of suicide among patients with bipolar disorder appears to vary from study to study, with lifetime risk of attempts estimated to be between 25 and 50%, actual rates of suicide being approximately 20%. Robins LN, et al.: Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, NY: The Free Press, 1991. Lithium  Strong and consistent evidence with recurring bipolar and major depressive disorder that long-term maintenance treatment with lithium is associated with major reductions in risk of both suicide and suicide attempts versus without long-term lithium maintenance found a highly statistically significant decrease in suicidal acts of almost 14-20 fold  Recent meta-analysis of studies of suicide rates with Lithium maintenance and suicide risk Before lithium treatment (mean = 8,38 years) Affective episodes: • frequency • duration Hospitalizations Percentage of time • ill • manic • depressed Lithium maintenance treatment (mean = 6,35 years) 58 pts made 90 suicide attempts. Suicidal acts were more common early in the course of illness before lithium. After the discontinuation of lithium, suicidal acts were more frequent in the first year than at later times or before starting lithium treatment Tondo et al. 1998 Suicidal risk before, during and after lithium treatment 8 7 6 5 4 3 2 1 0 Before Lithium (N=310) With Lithium First Year after (N=310) Lithium (N=185) Recent Years after Lithium (N=133) Suicide attempts/100 pt/year Meltzer e Baldessarini, 2003 Treatment of Bipolar Disorder Efficacy-Effectiveness Gap • Sustained remission in Bipolar Disorder occurs less frequently in routine clinical practice than was previously believed • Results obtained from naturalistic studies are less favourable than those obtained from controlled studies • 66% of bipolar patients respond to lithium under research conditions, but only about 33% show an equivalent benefit in clinical settings. • Non-adherence issues may explain the discrepancy between efficacy of prophylactic lithium in clinical trials and its effectiveness in naturalistic studies. Antipsychotics and Suicide Suicidio in Schizofrenia Pre-neuroleptic Era (Bleuler, 1976) Neuroleptic Era (Axelsson et al. 1992) Atypical AP Era Clozapine 9-13% 9-13% ? 0.02% (Reid et al. 1999) Meltzer, 2003 Clozapine and Suicide  Clozapine treatment has been associated with significant decreases in rates of suicide attempts and perhaps in suicidal individuals with schizophrenia and schizoaffective disorders  Clozapine treatment should be given serious consideration for psychotic patients with frequent suicidal ideations, attempts or both  Use of clozapine might be considered earlier in the treatment of individuals with schizophrenia or schizoaffetcive disorders Other second generation Aps are preferred over the first generation Aps A.P.A. 2003 Efficacy of clozapine on suicidal behavior 90 80 70 60 % of 50 patients 40 30 20 10 0 Before clozapine treatment During clozpine treatment Nessuno Pensieri, Autolesione Tentativi Piani non a Bassa intenzionale Probabilità Tentativi ad Alta Probabilità Meltzer e Okayli, 1995 Impact of Clozapine on Completed Suicide Am J Psych 2001; 158: 931-937 All patients over a 4-year period initiated treatment with clozapine while hospitalized  N=1.415 were matched with a schizophrenic control group (N=2.830)  Veterans exposed to clozapine while inpatients were significantlly less likely to die during follow-up  This was entirely attributable to lower rate of death due to respiratory disorders in clozapine group  There were no significant differences in rates of suicide or accidental death  These results fail to support the hypothesis that clozapine treatment is associated with significantly fewer deaths due to suicide Sernyak et al. 2001 Outcome on Suicide Monitoring Board (SMB)Determined Endpoints 30 25 20 % di 15 Pazienti 10 5 0 Tentativi di Totale Pazienti Ospedalizzazioni suicidio per prevenire il suicidio con SMB-Determined significativi Endpoints Clozapine Olanzapine Meltzer et al. 2003 Antipsychotic Agents - II  Use of first-generation antipsychotics with suicidal behavior currently is usually reserved for those needing enhanced treatment adherence afforded by depot forms of medication or those whose psychosis has not responded to a second-generation antypsichotic or when economic considerations are compelling  Clozapine and Olanzapine may also offer some protection against suicide attempts TRATTAMENTO FARMACOLOGICO DEL SUICIDIO Suicidal Behavior Clozapina orale Risperidone orale Olanzapina orale Aripiprazolo orale Quetiapina orale Atipico iniettabile long-acting Classico iniettabile long-acting depot Third Choice Second Choice First Cho Antipsychotic Agents and Suicide  Antipsychotic medications have been mainstay of somatic treatment for suicidal patients with psychotic disorders  First-generation antypsichotic agents are highly effective in treating delusions, hallucinations, agitation, aggression and confusion  May have some beneficial actions in major affective disorders  Particularly in highly agitated patients the beneficial effects of first-generation and modern antypsichotics may serve to reduce suicidal risk ECT and Suicide  Short-Term Effectiveness  Long-term Effectiveness to be Determined  Only 0.14% of patients completing suicide in a 12-month period have undergone ECT in the 3 months before suicide  Indications severe MDE, mixed states, schizophrenia, Patients resistent to therapy Psychotherapeutic Aspects The psychotherapist can focus on feelings, especially such distressing feelings as guilt, shame, fear, anger, thwarted ambiton, unrequited love, hopelessness, helplessness and loneliness. The key is the improvment of the external and internal situations. The immediate antidote for suicide lies in reduction of pertubation. Suicide is best understood not so much in terms of some sets of nosological boxes, but rather in terms of two dimension of general personality functioning: perturbation and lethality. Everyone is rateable on how disturbed, distressed or upset he or she is and, additionally, on how deathfully suicidal he or she is. (Shneidman, 1985) Conclusions  It is unknown whether long-term medication with antidepressants can lower the suicide risk and overall mortality of patients with affective disorders  Convincing evidence exists that appropriate long-term lithium prophylaxis reduces the suicide risk and can possibly normalize the excess mortality of patients with affective disorders (unipolar, bipolar, schizoaffective)  Particularly in highly agitated patients the beneficial effects of first-generation and modern antipsychotics may serve to reduce suicidal risk