Suicidal Ideation and Somatic Treatments
According to the recent World Health Organization data, more than 700,000 people die to suicide every year. It is a serious public health epidemic that should be given a solution. Because in spite of increased awareness, it’s still a major problem not just in the US but all countries in the world. In fact, premature death from suicide is the tenth leading cause of death in the world. It’s as common as death from road traffic accidents.
But that’s not all. Suicide is not only a burden in terms of human life, it’s also monetarily damaging. It’s estimated that $58.4 billion annually in lost wages and medical expenditures is combined in the United States. What’s even more alarming is the increasing number of adults in the United States who have had suicidal thoughts within the past year. This begs for a need for effective treatment for those experiencing acute or chronic suicidal ideation.
Past studies have focused on identifying risk factors for suicide attempts, suicidal ideation, and completed suicides. Data suggests that 90% of suicide victims had mental health diagnosis before their death.
Studies also found that suicidal ideation is one of the key drivers of inpatient psychiatric hospitalization as a way of ensuring safety. Suicide also tends to happen soon after hospital discharge. The increasing rate of completed suicides is evidence that there should be more action and awareness in this field.
Depression is found to be the major contributing factor in completed suicides. Although it isn’t the only cause, it’s the reason for half of the completed suicides. For this reason, somatic interventions for depression are used as an indirect treatment for suicide ideation and prevention.
There are a couple of somatic interventions currently being used by clinicians and psychiatrists. Some of the most common are medications and electroconvulsive therapy (ECT). They also use psychosocial interventions such as psychotherapy, cognitive-behavioral therapy (CBT), and antidepressants. Antidepressants have always been controversial because of their immediate increased risk for suicide with indirect evidence, however, they have a reduced risk over the lifetime.
The research was conducted to understand the role of present somatic treatments in either increasing or reducing the risk for suicide.
A literature review of somatic treatments known to increase or reduce the risk for suicide was performed by the Members of the Suicide Prevention Task Group of the National Network of Depression Centers. The review covered all relevant information about the risk for both suicide ideation and completed suicides.
The review of agents was performed by individual investigators or small subgroups. All the assignments were based on the research interest and background knowledge of each group investigator.
A literature search was performed in the electronic database, PubMed. The following phrases were used: “SSRIs and suicide,” “antidepressants and suicide,” “suicide and lithium,” “suicide and clozapine,” “suicide and ketamine,” and “suicide and esketamine” with the applied filters of: human subjects, adult population, available in English, and full-text format. Each subgroup utilized its own criteria in choosing the relevant articles. Additional articles were found by researchers as they investigated their topic. The switch of the format of PubMed in May of 2020 may have affected the results in an unclear way.
A PubMed search of “oral ketamine and suicide” yielded 24 results, of which only nine were relevant to oral ketamine, and most of these were theoretical.
For intravenous (IV) ketamine, a literature search was performed in the electronic database PubMed through July 1, 2020. The following phrase was used: “suicide and ketamine” with the applied filters of human subjects, adult population, available in English, and full-text format. These combined searches yielded 100 articles that were then narrowed down to 37 based on relevance to the topic. From there, only articles that looked at explicit markers of suicidality were included with a greater emphasis on evidence levels I–III. Reference lists and appendices from identified articles were also manually searched for pertinent references. These articles included six open-label studies, 12 randomized controlled trials (RCTs), two meta-analyses/systematic reviews, and three posthoc analyses. Articles were excluded if not specific to suicidal ideation and/or attempts if the article lacked relevance to the administration of the specific medications examined in this review, if the focus of the article was simply to examine suicide in a specific population, or if the full article was not available. Literature was not excluded based on desired outcomes to limit any research bias. In addition to these electronic databases, the CDC and the WHO websites were accessed for statistical information, and the American Psychiatric Association (APA) was referenced as expert opinion for practice guidelines and recommendations on the proper treatment of suicidal patients.
Based on the data, only lithium and clozapine are the two somatic treatments which have high-quality documenting of antisuicide effects in mood disorders and schizophrenia. Furthermore, lithium discontinuation is linked with high suicide risk.
Ketamine and eskatamine have a small immediate antisuicide effect. It should be noted that despite the Food and Drug Administration approval of esketamine 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.
Also, the antisuicide effect of electroconvulsive therapy is based on low-quality data. This makes the effect of antidepressants unclear. However, there appears to be sufficient evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short term in young people. Still, this is indirect evidence that suggests antidepressants may reduce suicide risk in long term.
Overall, there are many treatments yet to be explored to address suicide potential in patients. Some methods with documented antisuicide effects may not always be reliable. Sometimes they can also increase suicidality under specific circumstances. This is a very important topic clinicians have to study and investigate further.
Clinicians should clearly identify the role of their treatments in the prevention of this fatal outcome of psychiatric disease. Additionally, clinicians need to reach beyond the lore and preconceived notions and base their actions on the highest quality evidence available. To achieve this, the National Network of Depression Centers established a subcommittee of the Suicide Prevention Taskforce to clarify the role of somatic treatments.
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