Effects of somatic treatments on suicidal ideation and completed suicides

Lithium and clozapine are the only two somatic treatments with high-quality evidence of reducing suicide risk, in mood disorders and schizophrenia respectively; stopping lithium increases that risk. Ketamine and esketamine may offer a small, immediate antisuicide effect, though a disproportionate number of suicides occurred in esketamine-treated subjects versus placebo (3 vs. 0 among over 3500 subjects), requiring ongoing evaluation. The evidence for electroconvulsive therapy's antisuicide effect is low-quality. Antidepressants' effect is unclear: direct evidence shows they may increase suicidal ideation and risk in young people over the short term, while indirect evidence suggests they reduce risk over the long term. Clinicians have an expanding pharmacopeia, but some agents may also increase suicidality under specific circumstances.

Study at a glance

Abstract

Abstract Objective This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide. Methods Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides. Results Lithium and clozapine are the only two somatic treatments that have high‐quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low‐quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short‐term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term. Conclusions Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.