Suicidality and Risks of Medications Used to Treat Mental Illness

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Suicidality and Risks of Medications Used to
Treat Mental Illness

• A workshop presented by the College of
  Psychiatric and Neurologic Pharmacists

2
Presenters

• Steven Burghart, DPh, MBA, BCPP (Moderator)
  Director of Pharmacy, Rolling Hills Hospital,
  Franklin, TN
• Jennifer Zacher, PharmD, BCPP
• Captain James A. Lovell Federal Health Care
  Center, North Chicago, IL
• Kimberly Lintner, PharmD, BCPP
• Meriter Hospital, Madison, WI

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Objectives

• Identify common signs and symptoms that should
  raise concerns about a persons safety and the
  risk of self harm.
• Explain how medications used to improve
  depression can contribute to suicidal behavior.
• Describe how consumers, families and support
  networks can help manage the risk of medications
  in light of current regulatory actions regarding
  antidepressant and antiepileptic medications.

4
Disclosures

• Steven Burghart has no relevant conflicts of
  interest to disclose.

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Definitions

• Suicide- intentionally killing oneself.
• Suicidality- the likelihood of an individual
  committing suicide.
• Suicidal Ideation- mental thoughts and images
  which hinge around committing suicide.

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Suicide Facts

• Suicide is the eleventh leading cause of death
  for all age groups.
• Over 34,000 suicides in 2007.
• One suicide every 15 minutes.
• Over 376,000 emergency room treatment for
  self-inflicted injuries that same year.
• One suicide for every 25 attempted suicides.
• www.cdc.gov/violenceprevention accessed 5/13/2011

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Suicide Facts-Gender

• Males four times as likely as females to complete
  suicide
• 78.8 of all suicides.
• Females attempt suicide 2-3 times as often as
  males.
• Males use firearms (55.7).
• Females use poisons or medications (40.2).
• www.cdc.gov/violenceprevention accessed 5/13/2011

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Suicide Facts-Age

• Suicide is second leading cause of death among
  25-34 year olds.
• Third leading cause of death among 15-24 year
  olds.
• 13.8 of students in grades 9-12 considered
  suicide in the past 12 months.
• 6.3 of students reported at least one suicide
  attempt in that same time period.
• Rate among those age 75 or older was 16 per
  100,000, compared to 11.26 per 100,000 for all
  age groups.
• www.cdc.gov/violenceprevention accessed 5/13/2011

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Suicide Facts-Race

• Rates among Native Americans aged 15-34 were 1.8
  times higher than national average.
• Hispanic and Black high school students reported
  higher percentage of suicide attempts compared to
  White, non Hispanics.
• 11.1 and 10.4 compared to 6.5.

www.cdc.gov/violenceprevention accessed 5/13/2011
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Suicide Affects Families

• Suicides and attempts devastate families.
• Family and friends feel shock, anger, guilt,
  depression.
• Suicide survivors often face chronic health
  problems.
• Injuries
• Organ failure
• Brain damage
• www.cdc.gov/violenceprevention accessed 5/13/2011

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Suicide Risk Factors

• Adults
• Mood Disorders such as depression
• More than 90 of suicide completers have
  diagnosable illness at the time of death.
• Alcohol or other drug abuse
• Youth
• Same as adults, but also
• History of aggressive or disruptive behaviors
• History of physical or sexual abuse
• AHRQ Systematic Evidence Review No.32 May 2004

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Suicide Risk Factors

• Other risk factors include
• Previous suicide attempts
• Family history of suicide or violence
• Physical illness
• Feeling alone
• www.cdc.gov/violenceprevention accessed 5/13/2011

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Suicide Warning Signs

• Suicide threats
• Previous suicide attempts
• Sudden changes in behavior
• Depression
• Final arrangements
• The Jason Foundation 2001

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Video Warning Signs PSA

• http//www.youtube.com/watch?vpZhVuZHD8pofeature
  youtube_gdata_player

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IS PATH WARM?

• How do you Remember the Warning Signs of Suicide?
  Heres an Easy-to-Remember Mnemonic
• http//www.suicidology.org/web/guest/stats-and-too
  ls/warning-signs
• accessed 5/16/2011

• I Ideation
• S Substance Abuse
• P Purposelessness
• A Anxiety
• T Trapped
• H Hopelessness
• W Withdrawal
• A Anger
• R Recklessness
• M Mood Change

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IS PATH WARM?

• IDEATION Threatening to hurt or kill him or
  herself, or talking of wanting to hurt or kill
  him/herself and/or, Looking for ways to kill
  him/herself by seeking access to firearms,
  available pills, or other means and/or,
  Talking or writing about death, dying or suicide,
  when these actions are out of the ordinary.
• SUBSTANCE (alcohol or drug) use
• No reason for living no sense of PURPOSE in life
  
• ANXIETY, agitation, unable to sleep or sleeping
  all the time
• Feeling TRAPPED - like theres no way out
• HOPELESSNESS
• WITHDRAWING from friends, family and society
• Uncontrolled ANGER, seeking revenge or rage
• Acting RECKLESS or engaging in risky activities,
  seemingly without thinking
• Dramatic MOOD changes
• http//www.suicidology.org/web/guest/stats-and-too
  ls/warning-signs
• accessed 5/16/2011

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Jennifer Zacher, PharmD, BCPP

• How medications used to improve depression can
  contribute to suicidal behavior
• Jennifer Zacher has no relevant conflicts of
  interest to disclose.

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Symptoms of Depression

• Symptoms of depression
• Low mood
• Lack of interest in activities
• Guilty feelings
• Low energy
• Poor concentration
• Changes in appetite
• Changes in sleep pattern
• Slowed movements
• Suicidal thoughts

DSM IV- TR
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FDA Concerns Regarding Antidepressants and
Suicide Risk

• Case reports in 1990 that new antidepressant
  medications were associated with increased risk
  of suicidal thoughts.
• From June 2003-2004, the FDA released 5 different
  safety warnings related to increased risk of
  suicide in children treated with antidepressants

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Suicidality and Antidepressants

• WARNING SUICIDALITY AND ANTIDEPRESSANT
  DRUGS
• Antidepressants increased the risk compared
  to placebo of suicidal thinking and behavior
  (suicidality) in children, adolescents, and young
  adults in short-term studies of Major Depressive
  Disorder (MDD) and other psychiatric disorders.
  Anyone considering the use of Pristiq or any
  other antidepressant in a child, adolescent, or
  young adult must balance this risk with the
  clinical need. Short-term studies did not show an
  increase in the risk of suicidality with
  antidepressants compared to placebo in adults
  beyond age 24 there was a reduction in risk with
  antidepressants compared to placebo in adults
  aged 65 and older. Depression and certain other
  psychiatric disorders are
• themselves associated with increases in the
  risk of suicide. Patients of all ages who are
  started on antidepressant therapy should be
  monitored appropriately and observed closely for
  clinical worsening, suicidality, or unusual
  changes in behavior. Families and caregivers
  should be advised of the need for close
  observation and communication with the prescriber.

Pristiq Prescribing Information
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Mechanisms for Antidepressant-Induced Suicidality

• Timeline of antidepressant action
• Unrecognized bipolar disorder
• Side effects
• Worsening of depression
• Other psychiatric or medical conditions

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Timeline of Antidepressant Action

• It may take up to 6-8 weeks to see full
  therapeutic effects of antidepressants.
• Some patients may have suicidal thoughts prior to
  starting antidepressants but lack the energy to
  carry out a plan
• Energy levels usually improve before mood and
  guilty feelings.
• .

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Undiagnosed Bipolar Disorder

• Many patients have depressed episodes prior to
  manic episodes.
• Bipolar patients who take antidepressant
  medications without an additional mood stabilizer
  are at risk of becoming manic of hypomanic.
• Patients may attempt suicide due to mania.

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Side Effects of Antidepressants

• Antidepressant medications can cause jitteriness
  or akathisia (feeling of intense restlessness).
• Akathisia may result in agitation and an increase
  in suicide attempts.
• Antidepressants may also cause insomnia, which
  increases risk for suicide.

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Worsening of Depression

• About 70 of patients will have some effect from
  an antidepressant medication ? the rest of
  patients may have no effect or worsening
  depression.
• Patients with different types of depression may
  have worsening of symptoms such as agitation,
  inner tension, and racing thoughts, which may
  increase suicide risk.

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Impact of FDA Warning on Antidepressant
Prescribing

• In 2005, a 20-30 decrease in antidepressant
  prescribing was seen in children and adolescents
  with an increase seen in adolescent suicide
  rates.
• Decrease in diagnosis of new cases of pediatric
  depression seen in US.

CNS Neurosci Ther 2010. Aug16(4)227-34.
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Suicidality and Antidepressants
Nemeroff et al. Arch Gen Psychiatry
200764466-72.
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Suicidality and Antidepressants
CDC,MMWR Weekly Report 200756905-908
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Take Home Points

• Data on risk of suicidality with antidepressant
  use is mixed.
• Children, adolescents, and young adults seem to
  be at highest risk.
• Monitoring is key
• Frequent contact with provider is necessary when
  starting an antidepressant or increasing the
  dose.
• Patients should be observed closely for changes
  in behavior or signs of suicidality by friends
  and family as well.

CNS Neurosci Ther 2010. Aug16(4)227-34.
30
Kimberly Lintner, PharmD, BCPP

• Manage the risk of medications in light of
  current regulatory actions regarding
  antidepressant and antiepileptic medications.
• Disclosure
• Kimberly Lintner has no relevant conflicts of
  interest to disclose.

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Monitoring for safe outcomes

• FDA (U.S. Food and Drug Administration)
• Responsible for protecting the public health by
  assuring the safety, efficacy, and security of
  human drugs.
• Advances public health by making medications more
  effective, safer, and more affordable.

www.fda.gov accessed 4/12/11
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Monitoring for safe outcomes

Initial studies
Some safety information
More safety information
Final studies
General use
Best safety information
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Resources

• FDA Medwatch

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Understanding those leaflets

• Consumer information
• Patient package insert
• Medication guides
• How do you pick out what is important?
• What it is used for, common side effects, serious
  side effects, when should it start working

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Understanding those leaflets

• Study done with adults, education up to high
  school
• Asked seven questions and could use the materials
  to answer (less than half did)
• The key information relating to suicide risk in
  teens (emphasized in all materials) was
  identified by 60
• More is not better, recommendation to FDA to have
  a single standardized document

Shiffman S, Gerlach KK, Sembower MA, Rohay JM.
Consumer understanding of prescription drug
information an illustration using an
antidepressant medication. Ann Pharmacother.
201145452-458.
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Resources

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Pharmacists involvement

• Provide medications
• Help sort through information
• Commercials
• Newspaper ads
• Printed and Internet resources
• Is it working? How do you/we know?
• Safe use
• Selecting particular medications/amounts
• Supervision and assistance

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Resources

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Abuse of prescription medications

• Nonmedical uses of prescriptions are dramatically
  rising
• Visits to Emergency Departments doubled in 5
  years (600,000 -gt 1.2 million)
• Oxycodone 250
• Alprazolam 150
• Hydrocodone 125
• Sources- friends, family members prescriptions,
  visitors to the home

www.drugabuse.gov accessed 5/26/11
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Resources

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Safe medication disposal

• Appropriate removal will help ensure safety for
  people, pets and the environment
• Community collection events are becoming more
  common-best option
• At home you can crush and mix with coffee
  grounds/kitty litter and place in sealed
  container in the trash
• Strong pain medications should be flushed down
  the toilet
• If you are not sure, ask your pharmacist

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Resources

One page (two-sided) handout available for your
use.
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Take action!

• Information and education
• Advocate for yourself/others
• Be willing to ask questions
• Ask the Pharmacist sessions
• Let others help- keep those appointments
• Have the tools you need
• Refilling medications, safety plan

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Take home messages

• Medications are more helpful than harmful, but
  not without risks
• Everyone involved should be watchful of the
  responses to medications
• The pharmacist plays a key role in maximizing
  treatment

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Questions and Discussion

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What Would You Do?

• You have a (family member, friend, acquaintance)
  who shares that a week ago they started taking an
  antidepressant. They have an urge to hurt
  themselves- maybe even kill themselves.
• What information would you share with them based
  on todays presentation?