Dr. Jeff's and Dr. Tanya's Blog

Who is at risk for the development of emerging or worsening suicidal thinking when prescribed antidepressant medication?

Although a recent study from the United Kingdom found no relationship between the use of SSRIs in adolescents and self-harm events, nevertheless, other studies have shown that as high as 15% of patients who are prescribed antidepressants can experience emerging or worsening suicidal thinking. A study in Acta Psychiatr Scand 2008 Apr; 117:271 was able to determine which patients may be more at risk for developing suicidal thinking on antidepressants. This study was reviewed in Journal Watch Psychiatry, volume 14, Number 6. EEGs were performed on 82 patients before treatment and after treatment with a variety of different SSRIs and Effexor. Eight patients who had no prior suicidal thinking developed suicidal thinking four weeks after treatment. These patients showed significant differences in the results of their EEG as compared to the patients whose suicidal thinking stayed the same or decreased. “This difference remained significant after adjustments for sex, baseline suicidal ideation, specific antidepressant mediation taken, and interactions among these features”. The results of this study were interesting but the study was funded a manufacturer of EEG equipment, thereby, raising the possibility of bias in the study. This study does, nevertheless, raise interesting questions. Will at some point in the future a more quantitative measurement of vulnerability to worsening suicidal thinking in patients receiving antidepressant medication emerge that is practical, convenient, and inexpensive enough to be used in a busy clinical practice? And, are there clinical techniques that are currently available that can predict a negative response to antidepressant medication?

The Bottom Line: The results of this study suggest that there may be a subgroup of patients who are at risk for the development of emerging or worsening suicidal thinking when prescribed antidepressant medications whose vulnerability may be discovered by EEG.

Dr. Tanya Korkosz
Dr. Jeffrey Speller
Psychopharmacology Associates
of New England
www.psychopharmassociates.com

Do SSRIs increase self-harm events in adolescents? A study from the United Kingdom.

The use of SSRIs in the treatment of adolescents has been controversial for several years on both sides of the Atlantic. There is conflicting evidence in the research literature as to whether SSRIs increase suicidal thinking or other self-harm events in adolescents. A new study published in the BMJ 2008 Mar 8: 336:515 sheds further light on this issue. This study was reviewed in the June 2009 edition of Journal Watch, Psychiatry. This study examined deaths and hospitalizations due to self-harm events of adolescents aged 12 to 17 in the United Kingdom between the years of 1993 to 2005. This data was then compared to antidepressant and SSRI prescribing patterns in adolescents during the same period of time. The analysis of the data showed no relationship between prescribing patterns of antidepressants and SSRIs and self-harm events in adolescents in the UK. The results of this study may reassure parents of adolescents who and currently prescribed antidepressants and SSRIs.

The Bottom Line: This study found no relationship between the prescription use of SSRIs in adolescents and self-harm events in the United Kingdom.

Dr. Tanya Korkosz
Dr. Jeffrey Speller
Psychopharmacology Associates
of New England
www.psychopharmassociates.com

Is suicidal thinking, planning, and attempting suicide a world-wide phenomenon?

A study published in Br J Psychiatry 2008 Feb; 192:92 looked at suicidal thinking, planning, and actual attempts around the world. The study was reported in the May 2008 edition of the Journal Watch. More than 84,000 individuals from seventeen countries and five different continents were surveyed with a standard mental health questionnaire. The results of the survey showed that rates of suicidal attempts, plans, and thinking showed no significant difference between developed and developing countries, a surprising finding considering the significant life stressors in developing countries and the lack of access to high quality mental health treatment services in developing countries. The prevalence of suicidal thinking was 9.2%, planning 3.1% and attempts 2.7% for both developing and developed countries—indicating a major mental health problem world-wide. No matter what the country the risk factors for suicidal thinking and behaviors were the same: “female sex, younger age, lower education, and unmarried status. Mental illnesses (most strongly, mood and impulse-control disorders) also predicted suicidal ideation…” Given the new data, there are questions to ponder for patients and mental health professionals. If a patient is female, young, unmarried, and of low educational attainment, what, if any, preventive measures should be taken to lessen the risk of suicidal thinking, planning, and attempts? What are the most common life experiences in these patients that would trigger such suicidal behaviors? And what is the risk of a patient moving from the thinking stage to the planning and attempt stage? The answers to these questions will undoubtedly have to await further research.

The Bottom Line: The prevalence of suicidal thinking, planning, and attempts is a world-wide problem in both developing and developed countries.

Dr. Tanya Korkosz
Dr. Jeffrey Speller
Psychopharmacology Associates
of New England
www.psychopharmassociates.com

Nonsuicidal Self-injury in Adolescents is becoming a rising problem nationally.

An article in the New York Times published May 6, 2008 quoted experts who said that an increasing number of adolescents are self-injuring themselves. College student surveys indicate that nearly 20% of college students have engaged in self-harm activities. Other data also points to nearly 17% of high school adolescents are engaging in self-injurious behavior. Dr. Brian Smith in the Psychiatric Times article published in June of 2008 entitled: “Adolescent Nonsuicidal Self-Injury: Evaluation and Treatment” reports a number of interesting points. Dr. Smith defines nonsuicidal self-injury (NSSI) liberate, self-directed tissue injury inflicted without conscious intent to kill oneself”.
The most common forms of self-injury include burning, biting, cutting, and scratching of the skin mostly on the arms and legs. Also hair pulling is considered a form of self-injurious behavior. The injuries to the skin are often hidden by clothing. This type of behavior can begin as early as childhood and can peak in adolescence. Amazingly, one study conducted at an Ivy League college indicated that nearly 10 percent of the students engaged in self-injurious behavior on a repeated basis. It is not clear why this type of behavior is rising among adolescent. Theories include increasing levels of family divorce, separation, and dysfunction. Other theories point to the influence of self-injurers on vulnerable adolescents in the development of a peer culture of self-injury. Individuals in who engage in self-injurious behavior often state that “it makes me feel better” but is unclear exactly what the connection is between physical pain and emotional pain. Other data points to the fact that more than fifty percent of individuals who engage this type of behavior also have a history of trauma, physical, emotional, or sexual. Many of these individuals come from chaotic family circumstances. Individuals who also have other psychiatric disorders such as substance abuse, depression, eating disorders, obsessive compulsive disorder, borderline personality disorder, and anxiety disorders are at higher risk for self-injurious behavior. Although the common perception among mental health professionals is that self-injurious behavior occurs mostly among girls, the data shows that males and females equally engage in this type of behavior. It may be that females may be more likely to seek professional help for their problem. Another common perception is that this behavior occurs primarily in adolescents but the data shows that self-injurious behavior can and does occur in adults. The most effective treatment is cognitive behavioral therapy, specifically, dialectical behavioral therapy, combined with psychiatric medication to treat the other co-occurring psychiatric disorders. New data also indicates that there are several medications that act on the serotonin, dopamine, and glutamate systems to reduce self-injurious behavior.

The Bottom Line: Self-injury in adolescents and adults is rising nationally. Effective treatment for this behavior is now available including cognitive behavioral therapy, dialectical behavioral therapy, and psychiatric medication to treat the underlying neurobiology and the other co-occurring psychiatric disorders.

Sources: New York Times, See blogposts in: Psychiatric Disorders: Depression

Dr. Jeffrey Speller
Dr. Tanya Korkosz
Psychopharmacology Associates
of New England
www.psychopharmassociates.com