SUMMARY 

Australian suicide rates are increasing. GPs have a key role in the early detection and management of suicidality and the treatment of commonly associated mood disorders and substance misuse.

Drugs are indicated for moderate to severe depression. They can also be considered for patients who have been unable to access, do not want or have not responded to psychological treatments.

Selective serotonin reuptake inhibitors are less toxic than serotonin noradrenaline reuptake inhibitors. Tricyclic antidepressants are the most dangerous in overdose. Mood stabilising drugs can be prescribed, but in large quantities they are dangerous in overdose.

In depressed adolescents psychological therapies are first-line treatments. When drugs are indicated, in older people selective serotonin reuptake inhibitors are generally well tolerated, but paroxetine and fluoxetine are best avoided.

Introduction

Suicide accounts for 1.4% of all deaths worldwide.1,2 In Australia, suicide is the leading cause of death among those aged 16–24 years, while the suicide rates in men aged over 85 years are the highest for any age group.3 In 2015, 3027 Australians died by suicide, more than the national road toll.3 In 2006 the death rate from suicide was 10.2 per 100 000 people. This rose to 12.6 per 100 000 in 2015.3 For every death by suicide, around 25 people will attempt suicide4 and many more will engage in non-suicidal self-injury (such as self-cutting). Self-injury is associated with a greater likelihood of suicidal thoughts and behaviours.5

Prevention

Suicide results from a convergence of genetic, biological, psychological, social and cultural factors often combined with an experience of trauma and loss.1 Despite the rising toll, suicide is still a comparatively rare event. Given the complexity of its causation, it is unsurprising that no single suicide prevention strategy clearly stands out above the others.1,2 These facts also explain the counterintuitive finding that no single risk factor that is statistically significantly associated with an increase in suicide – such as a history of self-harm or depressed mood – provides any practical assistance in predicting which particular patients might take their own life.1,6,7 Prevention strategies therefore need to be multifactorial and tailored to the individual patient.

There are suicide risk assessment tools, but these should be used as guides only and not as replacements for clinical decision making.8,9

Suicide prevention is most likely to be effective if a combination of evidenced-based strategies are used both at the individual and population levels.1,4

One of the strongest evidence-based strategies for suicide prevention is the education of primary care clinicians.10 In Australia, GPs are the most frequent providers of mental health care and many patients who attempt suicide visit their GP in the preceding months.11 This makes GPs well placed to help reduce the rate of suicide. Doctors should remember that a therapeutic relationship can be protective.12-14 

The approach to the suicidal patient

Most suicidal patients will be distressed and many will feel stigmatised and ashamed. Clinicians should offer comfort, reassurance and hope, and avoid judgement.15 When a patient admits to suicidal thoughts or behaviour, understanding their predicament begins with an exploration of these phenomena (Box 1). This includes the nature of the thoughts or behaviours, any plans, previous suicide attempts and access to means of harm, for example firearms, poisons, and medicines that are dangerous in overdose such as quetiapine, opioids and tricyclic antidepressants. The clinician should then review the circumstances that might be contributing to the patient’s suicidality (Box 2). 

Box 1 - Questions to assess a patient’s suicidality

 

Tell me about your thoughts of suicide – what goes through your mind?

How long have you had these thoughts?

How often do you have them?

Do you find it hard to push these thoughts away?

Do you think you would carry out these thoughts?

Have you made any plans to suicide? If so, what are they? (Consider access to especially lethal means, such as firearms, medicines or hanging).

Have you ever tried to commit suicide in the past? If so, what happened?

Who is important to you? Do they know how you have been feeling?

If you could change a couple of things in your life, what would they be?

Do you have any ideas, things that you may have tried in the past, that could help you feel differently/better?

How can I help?

Box 2 - Factors contributing to suicidal thoughts

 

Bereavement

Relationship problems

Non-adherence to treatment

Increased alcohol or other drug use or established dependence

Depressive illness

Other existing mental illnesses (recent discharge from a psychiatric unit is a time of higher risk)

Chronic pain or physical illness

History of severe psychological trauma

Loss of hope

Loss of support

Management plans should be negotiated with the patient. In most cases family, friends or other psychosocial supports should be involved.15

A key element of any management plan will be to consider the least restrictive environment for safely starting treatment. Most patients can be managed in the community. However, if in doubt (because, for example, the burden of stressors threatens to overwhelm the patient, or if psychosocial supports are unavailable), obtaining a second opinion about whether hospitalisation is necessary through the local acute mental health team, or the emergency department, is sound clinical practice. Patients whose severe depression or psychotic symptoms make them unable to cooperate with community treatment can be compelled to have such an assessment under mental health legislation.

All management plans include reinforcement of protective factors including the involvement of family and friends where possible, provision of emergency contacts, formulation of an individualised self-care plan and encouragement to avoid alcohol and other substances (which increase impulsivity). Every suicidal patient should be seen at least weekly until the acute crisis resolves. Good communication between care providers is essential.

Substance use and depression

Substance misuse (especially alcohol) is a common method of self-medication for depression and anxiety, but it increases the likelihood of suicidal behaviour. The patient’s substance use must be explored in the assessment and addressed in the management plan.

Patients should be encouraged to stop drinking alcohol. Motivational interviewing is the first-line intervention for alcohol misuse. Many online treatments for depression (such as MyCompass) use motivational interviewing principles to help people begin to address substance misuse. Several online treatments specifically for alcohol misuse are currently being developed and evaluated including Shade, Daybreak, Hello Sunday Morning and OnTrack Alcohol and Depression.

Early intervention in depression

Patients appreciate their GP asking about their mental health, although they may not volunteer psychological symptoms. Consider psychological causes when patients present with physical symptoms that are trivial or for which no underlying cause is evident, especially when there is no positive response to reassurance. GPs should be alert to body language or other cues suggesting an underlying mood disorder.

Around 5% of adults will experience an episode of major depressive disorder each year.16 GPs who wish to assess patients for the symptoms and severity of depression (and associated anxiety) may use well-validated, self-report scales such as the Patient Health Questionnaire (PHQ-9) or the Generalised Anxiety Disorder 7 (GAD7).17-19 The Patient Health Questionnaire includes a question regarding suicidality which can be a useful springboard for further discussion.20

Early and successful treatment can significantly reduce the length and severity of episodes of depression and associated suicidal thoughts or behaviour. Patients with mild–moderate depression will often respond to psychological therapies. These include cognitive behaviour therapy or interpersonal psychotherapy and may be delivered face-to-face, or via self-guided or clinician-assisted evidence-based e-mental health interventions (Box 3). Patients with moderate–severe depression are likely to also require antidepressants as may those who have not benefited from psychological therapies or cannot or do not want to access them.20 

Box 3 - Examples of e-mental health interventions

 

myCompass – free, with a pre-registration overview 

This Way Up – registration and a small fee are required 

MindSpot – free, GP referral required

Psychological therapy

There is much evidence that psychological therapies can reduce suicidality and promote well-being in all age groups and across a range of diagnoses including depression, bipolar disorder, schizophrenia and borderline personality disorder.1

In adolescents, multisystem and family-based treatments are effective.1 Family-focused interventions are invariably necessary in the treatment of the depressed adolescent. These may include psycho-education and support for parents, family therapy or the treatment of mental illness in a parent. School-based interventions focusing on mental health literacy, suicide risk awareness and skills training (in dealing with adverse life events and stress) can reduce suicidal thinking and attempts, including at 12-month follow-up.1

Ongoing collaborative care, especially involving specialist mental health and primary healthcare services, has been shown to be feasible, acceptable and effective in reducing suicidal ideation compared to standard care in the general adult population. Similar programs for depressed and suicidal older patients are also effective.1 

Choosing an antidepressant 

The choice of antidepressant must consider individual patient factors such as age (Box 421,22 and Box 5). It is also guided by efficacy, tolerability, the prominence of certain symptoms, the depressive subtype, adverse effects, the potential for drug–drug interactions and the drug’s safety in overdose

Box 4 - Antidepressants for adolescent depression

 

Fluoxetine is recommended by National Institute for Health and Care Excellence (UK) and Beyond Blue for the treatment of depression in young people when psychological therapies (such as cognitive behaviour therapy or interpersonal psychotherapy) are refused, unavailable, or ineffective, and when symptoms are severe.21,22

Starting fluoxetine (or another selective serotonin reuptake inhibitor) can cause a temporary increase in anxiety or agitation which may be associated with an increase in suicidal ideation or self-harming behaviour.

While unwanted effects can be minimised with a ‘start low, go slow’ dosing strategy, young people and their families should be warned of a possible increase in suicidality when starting antidepressants. They should be encouraged to report this immediately to their parents, or their doctor.

Fluoxetine has a long half-life and can therefore be ceased abruptly if required.

Young patients starting an antidepressant should be seen at least weekly until the severity and suicidality, if present, are no longer of clinical concern.

Box 5 - Antidepressants for suicidal older people 

 

People in late life are more likely to have chronic physical illness, experience pain, be isolated and be bereaved, all of which contribute to suicidality. Depression in older people is undertreated and the incidence of suicide is high.

The choice of antidepressant should be based on the optimal adverse effect profile and the risk of drug–drug interactions. Due to the metabolic changes of ageing, older patients are at a greater risk of potentially fatal toxicity and drug–drug interactions when they deliberately or inadvertently take larger quantities of antidepressants.

Most of the selective serotonin reuptake inhibitors (SSRIs) and mirtazapine, moclobemide and desvenlafaxine are relatively safe in older people. Having fewer anticholinergic effects than other antidepressants, these drugs are well tolerated by patients with cardiovascular disease and are less likely to impair cognition, cause constipation or lead to urinary retention.

When considering SSRIs avoid paroxetine which has the most anticholinergic adverse effects and fluoxetine which has a long half-life. 

Suicidality

There is no specific drug for preventing suicide, although antidepressants reduce the intensity of suicidal thoughts over time in depressed patients. It has been suggested that antidepressants could increase the risk of suicide, but this is unlikely (Box 6).20,23-30 

Box 6 - Do antidepressant drugs cause suicide?

 

A meta-analysis of trial data submitted to the US Food and Drug Administration (FDA) confirmed that suicidal behaviour did not differ between those taking placebo and those taking antidepressants.23

There is strong evidence that the risk of suicide is highest in the month before starting an antidepressant, declines quickly during the first week of treatment, and steadily decreases to even lower, stable rates with continued treatment.24

A number of epidemiological studies over the last several decades have shown an inverse relationship between the number of prescriptions for antidepressants and the frequency of suicides.25

The FDA black box warning in 2004 cautioned prescribers about an increase in suicidal thinking and behaviour (although not successful suicides) in young people prescribed antidepressants. However subsequently several studies26-28 have shown an inverse relation between successful suicide and antidepressant prescribing in this age group.

Overall, in children and adolescents with depression, the evidence does not support avoiding antidepressants because of an increased risk of suicidal behaviour. The Treatment for Adolescents with Depression Study found that cognitive behaviour therapy plus fluoxetine might lead to less suicidal ideation and behaviour than just fluoxetine alone.29,30

Source: Adapted from reference 20

Danger in overdose

Tricyclic antidepressants, particularly dothiepin, are the most dangerous of the antidepressants in overdose, followed by serotonin noradrenaline reuptake inhibitors (desvenlafaxine is less toxic then venlafaxine) and then others such as mirtazapine. Selective serotonin reuptake inhibitors are the least dangerous, although citalopram and escitalopram have a significant risk of seizures and QT prolongation31 and fluoxetine has a long half-life. If suicidal patients require an antidepressant, we recommend using a drug which is less toxic and that only a week’s supply be prescribed (or dispensed) at a time. 

Mood stabilisers

Lithium can significantly reduce the incidence of suicide attempts and completed suicide in patients with major mood disorders, compared to those not treated with lithium.16,32

Lithium, valproate, carbamazepine and lamotrigine are dangerous in overdose and lethal quantities may be available on a single prescription. 

Antipsychotics

Clozapine has been reported to be more effective than olanzapine in the treatment of suicidality in patients with schizophrenia and schizoaffective disorder.33

Conclusion

For depression and substance misuse, psychological therapies and drugs are key components of treatment. Drugs are especially important for moderate to severe depression. With an empathic approach and awareness of which drugs are most efficacious, tolerable and least dangerous in overdose, GPs are well placed to intervene early to prevent or reduce suicide.

In the past three years Henry Brodaty has been on an advisory committee for Nutricia. He is a consultant for Eli Lilly and Lundbeck in the field of dementia and his centre has been funded to undertake trials for Alzheimer’s disease by Tau Therapeutics, Servier and Sanofi.

If you prescribe subscribe

References

  1. Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 2016;3:646-59.
  2. World Health Organization. Mental health. Suicide data. Geneva: WHO; 2017. [cited 2017 Sep 1]
  3. Australian Bureau of Statistics. 3303.0 - Causes of death, Australia, 2015. Canberra: Commonwealth of Australia; 2016. [cited 2017 Sep 1]
  4. LifeSpan. Integrated Suicide Prevention [Internet]. 2016. [cited 2017 Sep 1]
  5. Fox KR, Franklin JC, Ribeiro JD, Kleiman EM, Bentley KH, Nock MK. Meta-analysis of risk factors for nonsuicidal self-injury. Clin Psychol Rev 2015;42:156-67.
  6. Large MM, Ryan CJ. Suicide risk categorisation of psychiatric inpatients: what it might mean and why it is of no use. Australas Psychiatry 2014;22:390-2.
  7. Large M, Ryan C, Nielssen O. The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry 2011;19:507-12.
  8. Health NS. Suicide risk assessment and management protocols: mental health in-patient unit. Sydney: NSW Department of Health; 2004. [cited 2017 Sep 1]
  9. Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric inpatients. Acta Psychiatr Scand 2011;124:18-19.
  10. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294:2064-74.
  11. Pearson A, Saini P, Da Cruz D, Miles C, While D, Swinson N, et al. Primary care contact prior to suicide in individuals with mental illness. Br J Gen Pract 2009;59:825-32.
  12. Cole-King A, Lepping P. Suicide mitigation: time for a more realistic approach. Br J Gen Pract 2010;60:e1-e3.
  13. Collins S, Cutcliffe JR. Addressing hopelessness in people with suicidal ideation: building upon the therapeutic relationship utilizing a cognitive behavioural approach. J Psychiatr Ment Health Nurs 2003;10:175-85.
  14. McLean J, Maxwell M, Platt S, Harris F, Jepson R. Risk and protective factors for suicide and suicidal behaviour: a literature review. Edinburgh: Scottish Government Social Research; 2008. [cited 2017 Sep 1]
  15. Ryan CJ, Large M, Macfarlane M, Ilchef R, Tietze T. Assessing and managing suicidal patients in the emergency department. Australas Psychiatry 2015;23:513-6.
  16. Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013;14:334-85.
  17. SAMHSA-HRSA Center for Integrated Health Solutions. Screening tools. Depression screening tools. Patient Health Questionnaire (PHQ-9). [cited 2017 Sep 1]
  18. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006;166:1092-7.
  19. SAMHSA-HRSA Center for Integrated Health Solutions. Screening tools. Anxiety disorders screening tools. GAD-7 (Generalized Anxiety Disorder). [cited 2017 Sep 1]
  20. Anderson J, Galvez V, Loo C, Mitchell PB. Adult depression: a step-by-step guide to treatment. Med Today 2015;16:16-24
  21. National Institute for Health and Care Excellence. NICE guideline. Depression in children and young people: identification and management. London: NICE; 2005. [cited 2017 Sep 1]
  22. Beyondblue. Clinical practice guidelines: depression in adolescents and young adults. Melbourne: Beyondblue: the national depression initiative; 2010. [cited 2017 Sep 1]
  23. Stone M, Laughren T, Jones ML, Levenson M, Holland PC, Hughes A, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to the US Food and Drug Administration. BMJ 2009;339:b2880.
  24. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163:41-7.
  25. Sartorius N, Baghai TC, Baldwin DS. Antidepressant medications and other treatments of depressive disorders: a CINP Task Force based on a review of evidence. Int J Neuropsychopharmacol 2007;10 Suppl 1:S1-207.
  26. Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, et al. Early evidence on the effects of regulators’ suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 2007;164:1356-63.
  27. Katz LY, Kozyrskyj AL, Prior HJ, Enns MW, Cox BJ, Sareen J. Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults. CMAJ 2008;178:1005-11.
  28. Isacsson G, Ahlner J. Antidepressants and the risk of suicide in young persons – prescription trends and toxicological analyses. Acta Psychiatr Scand 2014;129:296-302.
  29. The TADS Team. The Treatment for Adolescents with Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry 2007;64:1132-43. https://doi.org/10.1001/archpsyc.64.10.1132.
  30. Friedman RA. Antidepressants’ black-box warning - 10 years later. N Engl J Med 2014;371:1666-8.
  31. Hawton K, Bergen H, Simkin S, Cooper J, Waters K, Gunnell D, et al. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry 2010;196:354-8.
  32. Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J. Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review.Bipolar Disord 2006;8:625-39.
  33. Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R, Bertoldi A, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 2003;60:82-91.