Journal of Psychopharmacology The prevention of suicide in patients with recurrent mood disorder
Malcolm Peet J Psychopharmacol 1992 6: 334 DOI: 10.1177/0269881192006002091 The online version of this article can be found at:

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1988). Kiloh.sagepub. This review will examine the evidence for the effect of adequate psychotropic medication on suicide mortality. one before and one during the tricyclic antidepressant era. Keller et al. by studying mortality from suicide and other causes in a cohort of patients who have received adequate 1. It is well recognized that antidepressant treatment is frequently disorder. The effect of antidepressant treatment on the rate of suicide The effect of antidepressant treatment on the risk of suicide has been examined in two ways: by looking at the treatment that patients were receiving at the time of committing suicide. most studies have made no attempt to examine the adequacy or otherwise of pharmacological treatment during the follow-up period. recurrent mood disorder. 1970. In a survey of patients in the community with major depressive disorder. Specialized mood disorder clinics lead to better patient care than is possible in a routine psychiatric out-patient clinic.5 years. Key words: suicide. despite the availability of modern pharmacological treatment. However. lithium. with no significant difference between the two groups. and therefore the differences in overdose toxicity between antidepressants may be pertinent. Often. but more formal psychotherapy does not appear to be helpful. and will emphasize the usefulness of lithium clinics and mood disorder clinics as a means of ensuring that treatment is administered properly. Education of mental health workers regarding the effective treatment of mood disorders can help to reduce the rate of suicide. depressive episodes do not come to medical attention. who were followed up for an average of 4. Juel and Vaeth (1987) studied two patient cohorts. Johnson (1973) found that only 25% had been prescribed > 75 mg amitriptyline daily or its equivalent. This had led to the pessimistic conclusion that the introduction of modern psychotropic drugs has had little real impact on the outcome of recurrent mood disorder. Lee and by RAVI BABU BUNGA on October 29. it is important to examine the reasons for this and to suggest steps that could be taken to reduce suicide mortality. and the reduction in availability of hazardous methods of self-harm will also be discussed. Patients who do commit suicide have often received inadequate antidepressant or prophylactic lithium treatment. Other possible ways of reducing suicide mortality. A reduced availability of the most lethal methods of suicide may contribute epidemiologically to a reduced rate of suicide. Both groups showed a high rate of death from suicide and accident. In view of the continuing high suicide mortality. Andrews and Neilson. Even patients who are referred for psychosurgery because of chronic intractable depression have commonly had Downloaded from jop. Long-term treatment with lithium normalizes the excess mortality associated with recurrent mood disorders. specialist clinics ° Introduction It is well recognized that patients with recurrent mood disorder have a substantially increased risk of death by suicide (Guze and Robins. Patient education and psychological support can lead to improved compliance with prophylactic medication and early detection of relapse. 1988. Sheffield S5 7AU. UK Recurrent mood disorder carries a risk of suicide of &sim. In a study of depressed patients treated in general practice. 2. including that from suicide. and when they do so they are under-recognized and undertreated. (1982) found that only 34% had received antidepressants for at least 4 weeks and only 12% were given doses of tricyclic antidepressants that exceeded inadequate. 15%. 2011 . such as education of patients and general practitioners on the proper treatment of mood 334 150 mg daily. Weeke. Antidepressant medication is commonly used inadequately. Northern General Hospital. education. antidepressants.1992 British Association for Psychopharmacology The prevention of suicide in Malcolm Peet patients with recurrent mood disorder Department of Psychiatry.Journal of Psychopharmacology 6(2) Supplement (1992) 334-339 &copy. pharmacological treatment.

even though this was indicated. Thus. the high rate of undertreatment found in patients who successfully commit suicide suggests that adequate treatment will lower suicide mortality. which was defined rather modestly as 150 mg of a tricyclic antidepressant/day or a comparable dose of another antidepressant. compared to an expected number of 18. or no continuation or prophylactic treatment. particularly lithium. Muller-Oerlinghausen et al. Prophylactic therapy the rate of suicide and Even before the introduction of modern psychotropic drugs. Schou and Weeke (1988) examined a series of 92 Danish manic-depressive patients who committed suicide following a previous psychiatric admission. Modestin (1985) reported a series of 61 suicides who met diagnostic criteria for depressive disorder. Both of these studies suggest that the excess mortality associated with recurrent mood disorder. Ziskind. At the time of suicide. There were no deaths from suicide in the lithium-treated group. Of the patients who committed suicide. Contrasting results were reported by Vestergaard and Aagaard (1991). or at the corresponding time for the control group. It has been argued that the discrepancy in the findings between these two pairs of studies may be due to differences in the patient population. More recent evidence suggests that the excess mortality in affective disorder is now primarily related to suicide and accidental death rather than to increased cardiovascular and other mortality. He found that less than half of the patients had been treated with antidepressant drugs and only one fifth had received an adequate dose. a difference which almost reached statistical significance. 1991). Myers and Neal (1978) found that 63% of psychiatric patients in their series who committed suicide had seen a doctor within 1 month beforehand. (1990. is normalized by affective lithium treatment carried out in the setting of a specialized lithium clinic. The studies showing normal mortality during treatment with lithium involved patients who were well established in a programme of lithium treatment and were thus especially compliant (Vestergaard and Aagaard. therefore. of 44 patients with a known diagnosis of depressive illness for whom adequate information was available. it was recognized that both suicidal and general Downloaded from jop. 1948.sagepub. Modestin and Schwarzenbach (1992) compared the treatment received by 64 psychiatric patients who committed suicide within 1 year of hospital discharge with that of a matched patient control group who did not commit suicide. low drop out rate and substantial amelioration of affective morbidity (Coppen and AbouSaleh. including cardiovascular disease. Somerfeld-Ziskind and Ziskind.83. 1983). 2011 . it is perhaps not surprising that epidemiological studies of the outcome of depression have not shown any striking improvement since the introduction of antidepressant medication. In a subsequent study. Increased awareness of the frequent recurrence and chronicity of mood disorder has stimulated research into the effect of long-term prophylactic treatment on mortality. (1991) studied 813 patients attending four lithium clinics who had been receiving lithium for periods ranging between 6 months and 20 years. these suicides might have been mortality from depressive illness is reduced by effective treatment with ECT (Huston and Locher. However. 1945). particularly from suicide. which used to be more prominent (Eastwood et al. 1991) studied 103 patients attending a lithium clinic over 11years.31 in the general population. a significantly higher proportion of controls had been receiving drug treatment. In the clinic run by Coppen and by RAVI BABU BUNGA on October 29. They found that the cumulative mortality during did not differ significantly from that of a corresponding normal population. Of greater importance may be the fact that patients in the two positive studies were treated under very strictly controlled conditions in a lithium clinic. In view of the widespread undertreatment of depression. This excess occurred for both suicide and natural causes. patients are not pre-selected on the basis of compliance and yet the clinic achieves a very high compliance rate. who found that mortality in a group of patients treated with lithium over a 5-year period was four times greater than that expected in a normal population. Most patients who died of cardiovascular disease had clinical evidence of cardiovascular problems before treatment with lithium. Moreover. Norton and Whalley (1984) obtained mortality data on 791 patients treated with lithium in various settings throughout south-east Scotland and found a standardized mortality rate of 2. 1988).. and only one patient was receiving ECT. only five were taking antidepressant medication in a dose approaching that recommended by the manufacturer. Aagaard and Vestergaard (1990) treatment with lithium prevented by adequate pharmacotherapy. with particular regard to the adequacy of prophylactic or continuation treatment. Only 10 patients treated with lithium died. with excess mortality primarily attributable to suicide but also to cardiovascular disease. 1982). In contrast. Coppen et al. They concluded that 30% of the suicides were associated with inadequate treatment. It is. one third had no longer been in treatment and a further third had received therapy without psychotropic medication. not surprising that several studies have shown successful suicide to be associated with inadequate pharmacological treatment of the underlying mood disorder.335 prolonged periods of inadequate treatment with antidepressant drugs (Bridges. No patient on lithium in this study committed suicide.

However. hospital admission and special observation can be counterproductive. together with one-to-one discussion of the educational material) results in a substantial improvement in patients’ knowledge of their treatment and its hazards (Peet and Harvey. 1981). The development of trusting relationships between the and suitably experienced. patients included in such studies are not suffering major depressive disorder. such as akathisia. but does not prevent it (Frank. because of the ethical problems of allocating patients to a control group. which appears to be a risk factor for suicide (Shear. but this remains to be established (Blackburn. as well as the compliance with medication.. 2011 . as well as improved tablet compliance (Harvey and Peet. Knorring and Walinder (1989) reported on the effects of a systematic educational programme for general practitioners in Sweden. 1978). 1977. However. 1983). 1991).336 report that 42% of the patients attending their clinic discontinued lithium treatment at least once within a 2-year period and the clinical outcome was correspondingly poor. 1987). while valuable in helping some distressed people. Injections of low dose flupenthixol have been reported to reduce suicidal behaviour in patients with a personality disorder and a history of repeated suicide attempts (Montgomery et al. There is evidence that provision of a standard educational programme for patients (video tape lecture and written hand-out.. 1990). out-patient counselling has no advantage over care by general practitioners (Hawton et al. Studies of the psychotherapeutic after-care of patients who have attempted suicide have produced disappointing results. does not affect the actual rate of suicide. Many potentially suicidal patients can be managed in an effective community care programme without an increased incidence of suicide (Hoult. attempts to narrow Educational issues Because of the raise the threshold of these criteria result in falsenegative predictions so that many suicidal deaths are missed (Kreitman. the effect of such prophylactic treatment on the risk of suicide has not been adequately evaluated.. Downloaded from jop. possibly due to the induction of akathisia. it is customary to hospitalize patients whom the psychiatrist considers to be at a high risk from suicide.. Rutz. though symptomatic improvement was greater in the group undergoing behavioural therapy (Liberman and Eckman. sympathetic and available professional staff appears to be central to effective programmes of suicide prevention.sagepub. Jennings Barraclough and Moss. Hogan and Awad. are best avoided in depressive disorders. doses of neuroleptic drugs that are sufficient to cause extrapyramidal side effects. Thus. 1978) and behaviour therapy is no better than insight-orientated therapy as assessed by repeat suicide attempts. 1983). Cupfer and Perel. 1986). It is possible that cognitive therapy could help to prevent a relapse of major depressive disorder and thereby reduce the risk of suicide. 1991). 1986). with no intervention. such as the Samaritans has also been evaluated. High doses of neuroleptic drugs appear to be associated with an increased risk of suicide (Cheng et al. Education of patients is also important for those taking long-term prophylactic medication. An educational programme for naval instructors on aspects of attempted suicide resulted in a decreased rate of parasuicidal behaviour (McDaniel. In general. which resulted in better identification and more accurate treatment of depressive disorders. Such studies generally compare two different modes of intervention. Rock and Grigg. While antidepressants and carbamazepine can both be effective prophylactic agents. 1989). Frances and Weiden. Nevertheless. The possible role of non-statutory counselling and befriending services. there is a clear role for education of both psychiatrists and general practitioners regarding the proper management of patients with such a condition. Euson and Bishop. leading to an increased risk of suicide attempt in some individuals (Pauker and Cooper. 1990). 1989). 1989). Few systematic data are available on the effect of other psychotropic drugs on the rate of suicide. Interpersonal psychotherapy used as an adjunct to imipramine seems to delay depressive relapse. widespread pharmacological under- treatment of mood disorder. which improves the trust between patients and staff. and it is now accepted that such a by RAVI BABU BUNGA on October 29. The rate of suicide fell during the year after the educational programmes were introduced. An initial report which appeared to show that the Samaritans were responsible for a fall in the national suicide rate (Bagley. 1990. was subsequently rebutted (Barraclough and Jennings. Staff should be available at times of personal crisis and not only at fixed appointments. Comparisons of different psychosocial interventions have failed to show any real advantage for one type of intervention over another (Moller. 1979). regardless of how inaccurate this prediction may be. 1968). intensive case work from a social worker is no better than a routine after-care service (Gibbons et al. Most from a patient Non-pharmacological The clinical or interventions predictors of suicide are so broad that many false-positives are included. Proper patient education forms an essential part of the work of a mood disorder clinic.

Recently. which found a reduction in the use of domestic gas for suicide after it was detoxified. there has been a similar report from Japan. such as the management of resistant depression and the use of non-pharmacological treatments. Such clinics have considerable advantages. including reduced hospitalization costs and avoidance of the loss of productivity. but also for other aspects of the diagnosis and treatment of affective disorders. 1987). Adequate treatment of recurrent affective disorder. including the use of less toxic drugs where possible. provides a contact point for patients and relatives who may be worried about early signs of relapse or lithium intoxication. with no evidence that potential suicides used alternative methods (Lester and Abe. 1989). Overdoses of antidepressant drugs are commonly taken by patients attempting suicide. there has been considerable focus on the relative toxicity of the antidepressant drugs which are commonly prescribed during depressive episodes when the risk of attempting suicide is enhanced. such as the specific 5-HT uptake inhibitors which have been shown to be effective prophylactically (Montgomery et al. The clinics facilitate the education of patients and their relatives. Peet correspondence Department of Psychiatry Northern General Hospital Sheffield S5 7AU UK Peselow. Kreitman (1989) argued that the evidence for the reduction in the overall rate of suicide resulting from the restriction of hazardous methods of suicide is sufficient for psychiatrists to support the limitation of potentially lethal means of self damage. 1989). First. The available evidence on overdose toxicity clearly shows that the older tricyclic antidepressants. Arrangements are made for the monitoring of lithium levels and other biochemical variables in a systematic fashion so that valuable information does not get lost or delayed. such as dothiepin and amitriptyline. as well as professionals in the process of training. may be instrumental in reducing the rate of suicide. serotonin) re-uptake inhibitors (Henry. trazodone and the specific 5-hydroxytryptamine (5-HT.. 1981). The more developed clinics use specific monitoring systems with rating scales for mood disorder and side effects. are substantially more toxic in overdose than the ’second generation’ by RAVI BABU BUNGA on October 29. There may also be advantages in using newer less toxic drugs. not only for treatment with lithium. There is much evidence to suggest that affective disorder is widely undertreated. therefore. 2011 . both in the short. 1987). Education of practitioners and the establishment of specialist lithium clinics or mood disorder clinics where skilled treatment and monitoring can be provided. including cognitive therapy. possibly because of the effectiveness of lithium therapy or because patients are educated about its toxicity so that parasuicidal behaviour involving lithium is relatively uncommon. has also been highlighted (Peselow and Fieve. receive the best possible care under optimal conditions from a multidisciplinary team.and long-term. 1988). Mood disorder clinics Specialist lithium clinics have been in operation since the 1960s and have been established in increasing numbers. Some clinics are aimed primarily at optimizing lithium treatment. but there is as yet no evidence that long-term treatment with these agents leads to a reduced rate of suicide. and it would seem prudent for psychiatrists to use the relatively less toxic agents for the treatment of acute depressive episodes. 1987). However. The clinic. Downloaded from jop. but can also have an effect on the overall rate of suicide. can bring about a substantial reduction in mortality from suicide. which produce valuable longitudinal data. Lithium overdose is seldom used as a means for suicide. as well as adequate pharmacological treatment. they offer a centre of expertise. Patients with long-term mood disorder need appropriate psychological support.337 Availability of hazardous methods for suicide attempts There is evidence that the availability of lethal methods for suicide affects not only the rate of suicide for that method. The cost-effectiveness of a lithium clinic. The mood disorder clinic is a good focus for support groups and self-help groups (Rook. Patients. The best known example is the decline in the specific and total rate of suicide which was associated with the detoxification of domestic gas in the UK (Lowe et al. despite advances in modern psychopharmacological treatment. 1988) both correlate with the rate of suicide by these means. 1987) and the restriction of gun ownership in the USA (Lester. including a substantial risk of suicide. Conclusion Affective disorder still carries a poor long-term prognosis. whereas others are mood disorder clinics which offer a broader spectrum of treatment (Fieve and Address for M. Well-run clinics will have an established contact and follow-up system for any patient who may default from an appointment. with regular staff skilled in the management of affective disorder. both during the acute phase and prophylactically.sagepub.. such as lofepramine. Emission controls on car exhausts in the USA (Clarke and Lester.

J Am Med Assoc 248: 1848-1855 Kiloh L G. Neilson M (1988) The long-term outcome of depressive by RAVI BABU BUNGA on October 29. Klerman G L. of personality and attitude on health information : acquisition and compliance. Ray D H. J Affect Disorders 18: 259-266 Bagley C (1968) The evaluation of a suicide prevention scheme by an ecological method. Cupfer D J. Psychol Med 8: 413-422 Johnson D A W (1973) Treatment of depression in general practice. Br J Psychiatr 158: 197-200 Downloaded from jop. Jennings C (1977) Suicide prevention by the Samaritans: a controlled study of its effectiveness. Acta Psychiatr Scand 80 (Suppl. Vestergaard P. Eckman T (1981) Behaviour therapy versus insight-overlooked therapy for repeated suicide attempters.). Oxford. 27-229 Montgomery S A. Bishop S (1986) A two year naturalistic follow-up of depressed patients treated with cognitive therapy. O’Connor M. Ravi S J. Lancet i: 1347 Coppen A. Acta Psychiatr Scand 80: 180-182 Liberman R P. Beuzen J N. 354): 37-45 Hogan T P. J Affect Disorders 10: 67-75 Bridges P K (1983) "and a small dose of antidepressant might help". gun ownership and suicide prevention. Wolf R (1991) Reduced mortality of manic depressive patients in long-term lithium treatment: an international collaboration study by IGSLI. Houston G. Volk J. Br J Psychiatr 149: 137-144 Huston P E. Butler J. Coryell W. Hermon C (1991) Does lithium reduce the mortality of recurrent mood disorder? J Affect Disorders 23: 1-7 Eastwood M R. 127-129 Frank E. Standish-Barry H. Arch Neurol Psychiatr 59: 385-394 Jennings C. Can J Psychiatr 28: 277-281 Hoult J (1986) Community care of the acutely mentally ill. Vestergaard P (1990) Predictors of outcome in prophylactic lithium treatment: a 2 year prospective study. pp. Moron P. Hermon C (1990) Long-term lithium and mortality. Whalley L J (1984) Mortality of a lithium-treated population. Urwin P. IRL Press. Br J Psychiatr 117 437-438 : Peet M (1991) Lithium maintenance 2: effects Harvey N. Grigg JR (1990) Suicide prevention at a United States navy training command. Montgomery D. Grof E. Grof P. Milit Med 155: 173-175 Modestin J (1985) Antidepressive therapy in depressed clinical suicides. Silcocks P. Silcocks P. Lester D (1987) Toxicity of car exhaust and opportunity for suicide: comparison between Britain and the United States. Acta Psychiatr Scand 71 111-116 : Modestin J. Suicide Life Threat Behav 18: 176-180 Lester D. Arch Gen Psychiatr 46: 397-400 Gibbons J S. Ottawa. Farmer R D T. Danion J N. McKeown S. Pierredon M A (1989) The prophylactic efficacy of fluoxetine in unipolar depression. Psychol Med 17 751-761 : Henry J A (1989) A fatal toxicity index for antidepressant poisoning. Lenz G. Levng C M. Cooper AM (1990) Paradoxical patient reactions to psychiatric life support: clinical and ethical considerations. Gailledreau J. In Johnson F N (ed. Woogh C M (1982) Mental illness and mortality. Abe K (1989) The effect of restricting access to lethal methods for suicide: study of suicide by domestic gas in Japan. Gibbons J L (1978) Evaluation of a social work service for self-poisoning patients. Rock M. Brion S. Psychiatr Res 36: 329-331 Myers D H.sagepub. Br J Psychiatr 145: 277-282 Pauker S L. Andrews G. Proc X Int Congress for Suicide Prevention. Standish-Barry H. Thau K. pp. Br J Psychiatr 158 200-204 Hawton K. Robins E (1970) Suicide and primary affective disorders.338 References Aagaard J. Bailey J. Br J Psychiatr 133: 111-118 Guze S B. Perel M (1989) Early recurrence in unipolar depression. Depression and mania: modern lithium therapy. Stiasny S. Acta Psychiatr Scand 85 Moller H J (1989) Efficacy of different strategies of aftercare for patients who have attempted suicide. Shaw P J (1979) Maintenance therapy in repeat suicide behaviour: a placebo controlled trial. Harvey N (1991) Lithium maintenance 1: a standard education programme for patients. Songer L. Endicott J (1982) Treatment received by depressive patients. Br Med J 2: 18-20 Keller M B. Lo W H. Acta Psychiatr Scand 81 : 220-224 Clarke R V. Soc Sci Med 2: 1-14 Barraclough B M. Bailey J. Barraclough B M. 3): 69-76 Muller-Oerlinghausen B. Arch Gen Psychiatr 38: 1126-1130 Lowe A A. Lavori P W. Br J Psychiatr 142: 626-628 Cheng K K. Day A. Dufour H. Matrin P. Moss J R (1978) Have the Samaritans lowered the suicide rate? A controlled study. Br J Psychiatr 153: 752-757 Kreitman N (1989) Can suicide and parasuicide be prevented? J R Soc Med 82: 648-652 Lee A S. Houston G. Psychol Med 11 359-368 : McDaniel WW. Abou-Saleh M T (1988) Lithium therapy: from clinical trials to practical management. Fawcett J A. Am J Psychiatr 147: 488-491 Peet M. Murray R M (1988) The long-term outcome of Maudsley depressives. Schwarzenbach F (1992) Effect of psychopharmacotherapy on suicide risks in discharged : 173-175 psychiatric inpatients. Parant-Lucena N. Jones D R. Acta Psychiatr Scand 78: 754-762 Coppen A. Yule J (1987) Evaluation of out-patient counselling compared with general practitioner care following overdoses. Ferrey G. Comp Psychiatr 23: 377-385 Fieve R R. Br J Psychiatr 133: 38-44 Norton B. J Epidemiol Community Health 41 : 114-120 Coppen A. Euson K M. Br J Psychiatr 153: 741-751 Lester D (1988) Research note: gun control. 2011 . Br J Psychiatr 153 (Suppl. Locher L M (1948) Involutional psychosis: course when untreated and treated with electric shock. Neal C D (1978) Suicide prevention in psychiatric patients. Awad A G (1983) Pharmacotherapy and suicide risk in schizophrenics. pharmacotherapy and a combination of both. J R Soc Med 82: 643-647 Montgomery S A. Rohde J R (1981) Suicide in England and Wales: an analysis of 100 years 1876-1975. Peselow E D (1987) The lithium clinic. Meier R. Schou M. Laqueille X. Lam T H (1990) Risk factors of suicide among schizophrenics. Lancet 2: 237-238 Blackburn I M.

Oxford. IRL Press. J Affect Disorders 13: 287292 Ziskind E.). Frances A. Vaeth M (1987) Cardiovascular death and manic-depressive by RAVI BABU BUNGA on October 29. Oxford. Somerfeld-Ziskind E. J Clin Psychopharmacol 13: 235-236 Vestergaard P. 129-132 Rutz W. Knorring K. Depression and mania: modern lithium therapy. Walinder J (1989) Frequency of suicide on Gotland after systematic postgraduate education of general practitioners.339 Peselow E D. Weeke A (1988) Did manic-depressive patients who committed suicide receive prophylactic or continuation treatment at the time? Br J Psychiatr 153: 324-327 Shear M K. Fieve R R (1987) Cost effectiveness of a lithium clinic. Juel K. Aagaard J (1991) Five-year mortality in lithium-treated manic depressive patients. 2011 . Weiden P (1983) Suicide associated with akathisia and depot fluphenazine treatment. J Affect : 21 Disorders 33-38 Weeke A. IRL Press. Arch Neurol Psychiatr 53: 212-217 Downloaded from jop. Ziskind L (1945) Metrazol and electroconvulsive therapy of the affective psychoses. In Johnson F N (ed. pp. Depression and mania: modern lithium therapy. pp.sagepub. 259-261 Rook J A J (1987) Lithium self-help groups. In Johnson F N (ed.). Acta Psychiatr Scand 80: 151-154 Schou M.