Psychopharmacology for Suicide Prevention
Pp. 114-127 (14)
Ross J. Baldessarini and Leonardo Tondo
Therapeutic research on suicide was virtually unknown a decade ago, but recently a great deal of
clinically important information has emerged. A landmark event was approval by the US FDA of
antisuicidal effects of clozapine in schizophrenia patients in 2003. Interest in effects of psychotropic drug
treatments on suicidal behavior was strongly stimulated by recent regulatory warnings of increased risk of
suicidal thoughts or behaviors in juveniles and young adults treated with modern antidepressants. This
chapter reviews recent research findings pertaining to effects of psychoactive drugs on suicide risk.
Antipsychotics other than clozapine are not known to reduce suicidal risk. Lithium has compelling evidence
of long-term effectiveness in reducing risks of suicide and attempts by as much as 80% among patients with
bipolar disorders, a mix of major affective disorders, and possibly also recurrent major depressive disorder.
Its effects may be superior to those of some mood-stabilizing anticonvulsants. Several ecological studies,
especially in the US and Nordic countries, find inverse associations between prescriptions for modern
antidepressants and temporal or regional variance in suicide rates. However, suicide rates decreased in the
same countries even before introduction of modern antidepressants, and other factors may be involved.
Notably, lower regional suicide rates are associated with indices of greater access to clinical care. Many
large cohort and case-control studies have found reduced suicidal risk with long-term antidepressant
treatment; a minority found increased risk, which may be confounded by association of antidepressant
treatment with more severe illness and selection of relatively nontoxic modern antidepressants for patients at
increased suicidal risk. In many randomized, controlled trials in adults, antidepressants show reductions in
suicidal ideation, along with other depressive symptoms, but without consistent effects on rates of suicidal
acts. The FDA finds evidence of increased risk of suicidal thoughts and perhaps of attempts in juvenile and
young adult patients treated with modern antidepressants vs. a placebo. It has long been recognized that
some depressed patients experience increased agitation soon after exposure to antidepressants, and such
reactions may increase suicidal risk. These effects usually can be anticipated and minimized by timely
clinical interventions. The findings of beneficial effects of antidepressant treatment on suicidal ideation but
not behavior, and of reduced risk of suicidal behaviors by lithium and clozapine, suggest differential
pharmacologic effects on particular components of “suicidality,” in that reduction of anger, aggression and
impulsivity evidently can limit progression from suicidal ideation to acts. Effective suicide prevention
requires focused assessment and supervision, especially early in clinical management of patients with major
mood disorders, with appropriate pharmacological and psychosocial interventions.
Psychopharmacology, suicide, prevention, mood disorders, schizophrenia.
Mailman Research Center, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106 USA