Journal of Psychopharmacology

http://jop.sagepub.com/ 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: http://jop.sagepub.com/content/6/2_suppl/334

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Journal of

Psychopharmacology 6(2) Supplement (1992)

334-339

©1992 British Association for Psychopharmacology

The prevention of suicide in

Malcolm Peet

patients with recurrent mood disorder

Department of Psychiatry, Northern General Hospital, Sheffield S5 7AU, UK

Recurrent mood disorder carries a risk of suicide of ∼ 15%. Patients who do commit suicide have often received inadequate antidepressant or prophylactic lithium treatment. Long-term treatment with lithium normalizes the excess mortality associated with recurrent mood disorders, including that from suicide. A reduced availability of the most lethal methods of suicide may contribute epidemiologically to a reduced rate of suicide, and therefore the differences in overdose toxicity between antidepressants may be pertinent. Education of mental health workers regarding the effective treatment of mood disorders can help to reduce the rate of suicide. Patient education and psychological support can lead to improved compliance with prophylactic medication and early detection of relapse, but more formal psychotherapy does not appear to be helpful. Specialized mood disorder clinics lead to better patient care than is possible in a routine psychiatric out-patient clinic.

Key words: suicide;

recurrent mood

disorder; lithium; antidepressants; education; 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, 1970; Lee and Murray, 1988; Kiloh, Andrews and Neilson, 1988). Weeke, Juel and Vaeth (1987) studied two patient cohorts, one before and one during the tricyclic antidepressant era, who were followed up for an average of 4.5 years. Both groups showed a high rate of death from suicide and accident, with no significant difference between the two groups. 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. However, most studies have made no attempt to examine the adequacy or otherwise of pharmacological treatment during the follow-up period. It is well recognized that antidepressant treatment is frequently

disorder, and the reduction in availability of hazardous methods of self-harm will also be discussed.

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; 2. by studying mortality from suicide and other causes in a cohort of patients who have received adequate
1.

pharmacological

treatment.

Often, depressive episodes do not come to medical attention, and when they do so they are under-recognized
and undertreated. Antidepressant medication is commonly used inadequately. In a survey of patients in the community with major depressive disorder, Keller et al. (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.
In view of the continuing high suicide mortality, despite the availability of modern pharmacological treatment, it is important to examine the reasons for this and to suggest steps that could be taken to reduce suicide mortality. This review will examine the evidence for the effect of adequate psychotropic medication on suicide mortality, and will emphasize the usefulness of lithium clinics and mood disorder clinics as a means of ensuring that treatment is administered properly. Other possible ways of reducing suicide mortality, such as education of patients and general practitioners on the proper treatment of mood
334

150 mg daily. In a study of depressed patients treated in general practice, Johnson (1973) found that only 25% had been prescribed > 75 mg amitriptyline daily or its equivalent. Even patients who are referred for psychosurgery because of chronic intractable depression have commonly had

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prolonged periods of inadequate treatment with antidepressant drugs (Bridges, 1983). It is, therefore, not surprising that several studies have shown successful suicide to be associated with inadequate pharmacological treatment of the underlying mood disorder. Myers and Neal (1978) found that 63% of psychiatric patients in their series who committed suicide
had seen a doctor within 1 month beforehand. However, of 44 patients with a known diagnosis of depressive illness for whom adequate information was available, only five were taking antidepressant medication in a dose approaching that recommended by the manufacturer, and only one patient was receiving ECT. Modestin (1985) reported a series of 61 suicides who met diagnostic criteria for depressive disorder. He found that less than half of the patients had been treated with antidepressant drugs and only one fifth had received an adequate dose, which was defined rather modestly as 150 mg of a tricyclic antidepressant/day or a comparable dose of another antidepressant. In a subsequent study, 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. Of the patients who committed suicide, one third had no longer been in treatment and a further third had received therapy without psychotropic medication. At the time of suicide, or at the corresponding time for the control group, a significantly higher proportion of controls had been receiving drug treatment, particularly lithium. No patient on lithium in this study committed suicide. Schou and Weeke (1988) examined a series of 92 Danish manic-depressive patients who committed suicide following a previous psychiatric admission, with particular regard to the adequacy of prophylactic or continuation treatment. They concluded that 30% of the suicides were associated with inadequate treatment, or no continuation or prophylactic treatment, even though this was indicated. Thus, these suicides might have been

mortality from depressive illness is reduced by effective treatment with ECT (Huston and Locher, 1948; Ziskind, Somerfeld-Ziskind and Ziskind, 1945). 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, which used to be more prominent (Eastwood et al., 1982). Increased awareness of the frequent recurrence and chronicity of mood disorder has stimulated research into the effect of long-term prophylactic treatment on mortality. Coppen et al. (1990, 1991) studied 103 patients attending a lithium clinic over 11years. Only 10 patients treated with lithium died, compared to an expected number of 18.31 in the general population, a difference which almost reached statistical significance. There were
no

deaths from suicide in the lithium-treated group.

Muller-Oerlinghausen et al. (1991) studied 813 patients attending four lithium clinics who had been receiving lithium for periods ranging between 6 months and 20 years. They found that the cumulative mortality during
did not differ significantly from that of a corresponding normal population. Both of these studies suggest that the excess mortality associated with recurrent mood disorder, particularly from suicide, is normalized by affective lithium treatment carried out in the setting of a specialized lithium clinic. Contrasting results were reported by Vestergaard and Aagaard (1991), 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. This excess occurred for both suicide and natural causes, including cardiovascular disease. 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 2.83, with excess mortality primarily attributable to suicide but also to cardiovascular disease. Most patients who died of cardiovascular disease had clinical evidence of cardiovascular problems before treatment with lithium. 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. 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, 1991). 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 the clinic run by Coppen and colleagues, patients are not pre-selected on the basis of compliance and yet the clinic achieves a very high compliance rate, low drop out rate and substantial amelioration of affective morbidity (Coppen and AbouSaleh, 1988). In contrast, Aagaard and Vestergaard (1990)
treatment with lithium

prevented by adequate pharmacotherapy. In view of the widespread undertreatment of depression, 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. Moreover, the high rate of undertreatment found in patients who successfully commit suicide suggests that adequate treatment will lower suicide mortality.

Prophylactic therapy
the rate of suicide

and

Even before the introduction of modern psychotropic drugs, it was recognized that both suicidal and general

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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. Few systematic data are available on the effect of other psychotropic drugs on the rate of suicide. While antidepressants and carbamazepine can both be effective prophylactic agents, the effect of such prophylactic treatment on the risk of suicide has not been adequately evaluated. 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., 1979). High doses of neuroleptic drugs appear to be associated with an increased risk of suicide (Cheng et al., 1990; Hogan and Awad, 1983), possibly due to the induction of akathisia, which appears to be a risk factor for suicide (Shear, Frances and Weiden, 1983). In general, doses of neuroleptic drugs that are sufficient to cause extrapyramidal side effects, such as akathisia, are best avoided in depressive disorders.

patients included in such studies are not suffering major depressive disorder. It is possible that cognitive therapy could help to prevent a relapse of major depressive disorder and thereby reduce the risk of suicide, but this remains to be established (Blackburn, Euson and Bishop, 1986). Interpersonal psychotherapy used as an adjunct to imipramine seems to delay depressive relapse, but does not prevent it (Frank, Cupfer and Perel, 1989). The possible role of non-statutory counselling and befriending services, such as the Samaritans has also been evaluated. An initial report which appeared to show that the Samaritans were responsible for a fall in the national suicide rate (Bagley, 1968), was subsequently rebutted (Barraclough and Jennings, 1977; Jennings Barraclough and Moss, 1978), and it is now accepted that such a service, while valuable in helping some distressed people, does not affect the actual rate of
suicide. The development of trusting relationships between the
and suitably experienced, sympathetic and available professional staff appears to be central to effective programmes of suicide prevention. Staff should be available at times of personal crisis and not only at fixed appointments.

Most from a

patient

Non-pharmacological
The clinical
or

interventions

predictors of suicide are so broad that many false-positives are included. However, 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, 1989). Nevertheless, it is customary to hospitalize patients whom the psychiatrist considers to be at a high risk from suicide, regardless of how inaccurate this prediction may be. However, hospital admission and special observation can be counterproductive, leading to an increased risk of suicide attempt in some individuals (Pauker and Cooper, 1990). Many potentially suicidal patients can be managed in an effective community care programme without an increased incidence of suicide (Hoult, 1986). Studies of the psychotherapeutic after-care of patients who have attempted suicide have produced disappointing results. Such studies generally compare two different modes of intervention, because of the ethical problems of allocating patients to a control group, with no intervention. Comparisons of different psychosocial interventions have failed to show any real advantage for one type of intervention over another (Moller, 1989). Thus, out-patient counselling has no advantage over care by general practitioners (Hawton et al., 1987), intensive case work from a social worker is no better than a routine after-care service (Gibbons et al., 1978) and behaviour therapy is no better than insight-orientated therapy as assessed by repeat suicide attempts, though symptomatic improvement was greater in the group undergoing behavioural therapy (Liberman and Eckman, 1981).

widespread pharmacological

under-

treatment of mood

disorder, there is a clear role for education of both psychiatrists and general practitioners

regarding the proper management of patients with such a condition. Rutz, Knorring and Walinder (1989) reported on the effects of a systematic educational programme for general practitioners in Sweden, which resulted in better identification and more accurate treatment of depressive disorders. The rate of suicide fell during the year
after the educational programmes were introduced. An educational programme for naval instructors on aspects of attempted suicide resulted in a decreased rate of parasuicidal behaviour (McDaniel, Rock and Grigg,

1990).
Education of patients is also important for those taking long-term prophylactic medication. There is evidence that provision of a standard educational programme for patients (video tape lecture and written hand-out, 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, 1991), as well as improved tablet compliance (Harvey and Peet, 1991). Proper patient
education forms an essential part of the work of a mood disorder clinic, which improves the trust between patients and staff, as well as the compliance with medication.

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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, but can also have an effect on the overall rate of suicide. 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., 1981). Recently, there has been a similar report from Japan, which found a reduction in the use of domestic gas for suicide after it was detoxified, with no evidence that potential suicides used alternative methods (Lester and Abe, 1989). Emission controls on car exhausts in the USA (Clarke and Lester, 1987) and the restriction of gun ownership in the USA (Lester, 1988) both correlate with the rate of suicide by these means. 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, including the use of less toxic drugs where possible. Lithium overdose is seldom used as a means for suicide, 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. However, 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. The available evidence on overdose toxicity clearly shows that the older tricyclic antidepressants, such as dothiepin and amitriptyline, are substantially more toxic in overdose than the second generation antidepressants, such as lofepramine, trazodone and the specific 5-hydroxytryptamine (5-HT, serotonin) re-uptake inhibitors (Henry, 1989). Overdoses of antidepressant drugs are commonly taken by patients attempting suicide, and it would seem prudent for psychiatrists to use the relatively less toxic agents for the treatment of acute depressive episodes. There may also be advantages in using newer less toxic drugs, such as the specific 5-HT uptake inhibitors which have been shown to be effective prophylactically (Montgomery et al., 1988), but there is as yet no evidence that long-term treatment with these agents leads to a reduced rate of suicide.

Such clinics have considerable advantages. First, they offer a centre of expertise, not only for treatment with lithium, but also for other aspects of the diagnosis and treatment of affective disorders, such as the management of resistant depression and the use of non-pharmacological

treatments, including cognitive therapy. Patients, therefore, receive the best possible care under optimal conditions from a multidisciplinary team. The clinics facilitate the education of patients and their relatives, as well as

professionals in the process of training. The more developed clinics use specific monitoring systems with rating scales for mood disorder and side effects, which produce valuable longitudinal data. 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. The clinic, with regular staff skilled in the management of affective disorder, provides a contact point for patients and relatives who may be worried about early signs of relapse or lithium intoxication. Well-run clinics will have an established contact and follow-up system for any patient who may default from an appointment. Patients with long-term mood disorder need appropriate psychological support, as well as adequate pharmacological treatment. The mood disorder clinic is a good focus for support groups and self-help groups (Rook, 1987). The cost-effectiveness of a lithium clinic, including reduced hospitalization costs and avoidance of the loss of productivity, has also been highlighted (Peselow and Fieve, 1987).

Conclusion
Affective disorder still carries a poor long-term prognosis, including a substantial risk of suicide, despite advances in modern psychopharmacological treatment. There is much evidence to suggest that affective disorder is widely undertreated, both during the acute phase and prophylactically. Adequate treatment of recurrent affective disorder, both in the short- and long-term, can bring about a substantial reduction in mortality from suicide. Education of practitioners and the establishment of specialist lithium clinics or mood disorder clinics where skilled treatment and monitoring can be provided, may be instrumental in reducing the rate of suicide.

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, whereas others are mood disorder clinics which offer a broader spectrum of treatment (Fieve and

Address for
M. Peet

correspondence

Department of Psychiatry Northern General Hospital

Sheffield S5 7AU UK

Peselow, 1987).

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338

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