Risk of suicide attempt and suicide associated with benzodiazepine: A nationwide case crossover study

Empty bottles, rising risks: A case-crossover study on psychotherapeutic medication depletion and suicide triggers

OBJECTIVE

The use of psychotherapeutic medications can reduce the risk of suicide among people with mental health disorders, but little is known about the impact of exhausting these medications. This study analyzes the temporal relationship between running out of psychotherapeutic medications and suicide using a case-crossover study design.

METHODS

Pharmacy and medical claims data from the Arkansas All-Payers Claims Database were linked to death certificates to identify decedents of suicide from 2013 through 2021. Psychotherapeutic medications were categorized using a National Drug Code (NDC) ontology from First DataBank®. The dispensed date and days' supply from pharmacy claims estimated when a decedent would exhaust any prescribed psychotherapeutic. A dichotomous variable indicated if a decedent exhausted at least one psychotherapeutic during the hazard window - the seven days leading up to and including the date of death. This exposure was compared to 11 control windows - the 11 weeks immediately preceding the hazard window. Conditional logistic regression analysis estimated the odds of exhausting at least one medication during the hazard window relative to the control windows.

RESULTS

Among 853 decedents who received 4375 psychotherapeutic prescriptions, 17.0 % exhausted at least one psychotherapeutic in the hazard window, the highest among all study windows. There was a 46 % increase in the odds of exhausting at least one psychotherapeutic during the hazard window compared to the control windows (AOR: 1.46; p = 0.0001).

CONCLUSION

There is a temporal relationship between exhausting at least one psychotherapeutic medication and suicide, highlighting the need for close monitoring of medication supply for patients treated with psychotherapeutics.

Associations of medical outcomes with substances involved in suicide attempt cases age 50 and older reported to U.S. Poison Centers, 2016-2023

Background and aims

After a slight decline in suicide rates during the COVID-19 pandemic, suicide rates and suicide attempts in the U.S. have been increasing again in 2022 and 2023. Compared to younger age groups, the 50+ age group has significantly higher rates of serious medical outcomes from suicide attempts. In this study, we examined the medical outcome severities associated with different classes of substances involved in suicide attempt cases age 50 and older who were reported to poison centers.

Methods

We used the America's Poison Center's National Poison Data System from 2016 to 2023 (N = 335,171 cases age >50). Following descriptive statistics on the characteristics of suicide attempters and involved substances by medical outcomes (no/minimal effects, moderate effects, major effects, death, and unable to follow), we fitted multinomial and binary logistic regression models to examine the associations of medical outcomes with involved substances.

Results

Of all cases, 22.5% used antidepressants, 21.1% benzodiazepines, 16.4% cardiovascular drugs, and 12.5% prescription opioids; 44.1% had no/minimal effect, 37.9% had a moderate effect, 12.5% had a major effect, 1.2% resulted in death, and 4.4% were unable to follow, but the proportions of major effects and death were higher in 2022-2023 than in 2016-2017. Tricyclic antidepressants were associated with the highest risks of major effects [relative risk ratios (RRR) = 5.57, 95% CI = 5.26-5.90] and death (RRR = 4.26, 95% CI = 3.67-4.94). Large RRRs were also shown for bupropion and serotonin-norepinephrine reuptake inhibitors for major outcomes and death. Cardiovascular drugs, opioids, and muscle relaxants were also associated with consistently higher risks of moderate and major effects and death. Our results also show that older ages were associated with higher death rates and that female sex was associated with higher odds of moderate/major effects compared to minimal effects but lower odds of major effects/death.

Implications

Healthcare providers, including pharmacists, can play an important role in promoting medication safety for older adults. Healthcare workers need training in assessing and recognizing signs of suicide risk in older adults who are prescribed antidepressants and sedatives. Our findings also point to the importance of better non-pharmacological chronic pain management than reliance on opioids.

Associations of treatment with hypnotics with suicide and attempted suicide: A nationwide cohort study

BACKGROUND

Hypnotics have been linked to suicidal behaviors. While existing evidence has established findings of associations, more knowledge is needed regarding benzodiazepine (BZD) and non-benzodiazepine (n-BZD) hypnotics.

AIM

To examine whether individuals in treatment with hypnotics had higher rates of suicide and suicide attempts than those not in treatment.

METHODS

A longitudinal nationwide cohort design was applied to individual-level register data, including all individuals aged 15+ years who lived in Denmark from 1995 to 2021. Incidence rate ratios (IRR) for suicide and suicide attempts were estimated using Poisson regression models. Using the National Prescription Registry, individuals who redeemed prescriptions for hypnotics at pharmacies were identified. Death by suicide was identified in the Cause of Death Register.

RESULTS

A total of 7,311,630 individuals were observed over 122,681,369 person-years. In all, 678 males and 553 females died by suicide while in treatment with BZD, resulting in respective adjusted IRRs of 2.1 (95% CI: 1.9-2.4) and 2.6 (95% CI: 2.3-3.0), when compared to those not in treatment. A total of 1774 males and 1212 females died by suicide while in treatment with n-BZD and the adjusted IRRs were 3.4 (95% CI: 3.1-3.7) and 3.6 (95% CI: 3.4-3.9), respectively.

CONCLUSIONS

While confounding by indication is likely to be a major contributor, the fact that individuals in treatment with BZD or n-BZDs had higher rates of suicide and suicide attempts when compared to those not in treatment emphasizes the need to carefully monitor their mental state.

Suicide and suicide attempt in users of GLP-1 receptor agonists: a nationwide case-time-control study

Background

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are extensively evaluated for the risk of suicidal behaviors or ideation; the influence of psychiatric history or obesity on this potential effect remains to be investigated. Therefore, we aimed to assess the association between GLP-1 RA and suicide or suicide attempt, considering these factors.

Methods

Patients ≥18 y who died by suicide or were hospitalized for suicide attempt (2013-2021) with at least one GLP-1 RA dispensing within the 180 preceding days were selected from the French National Health Data System (SNDS). A case-time-control design compared, for each patient, GLP-1 RA exposure in the 30 days preceding the outcome (composite of suicide or suicide attempt) to three earlier 30-day reference periods. Potential exposure trend bias was controlled using up to five time-controls matched on age, sex, psychiatric history, obesity, calendar time. Analyses were adjusted for time-varying confounders. Finally dipeptidyl peptidase-4 (DPP-4) inhibitors were studied as negative controls for potential biases.

Findings

This study included 1102 cases and 5494 controls. Mean case age was 57.4 years (SD 11.4); 44.6% were male, 67.6% had a recent psychiatric history and 51.3% had obesity. GLP-1 RA use was not associated with an increased risk of suicide or suicide attempt (OR, 0.62; 95% CI, 0.51-0.75), with consistent results for DPP-4 inhibitors (0.75; 0.67-0.84). Results obtained according to recent psychiatric history and obesity were comparable.

Interpretation

This large nationwide case-time-control study provides reassurance about the short-term psychiatric safety of GLP-1 RA, showing no specific risk for patients with psychiatric disorders or obesity.

Funding

French Medicines Agency.

Suicide deaths and substance use in Spain between 2010 and 2022

Background

Suicide is a serious public health problem that affects our entire country. The aim of this research was to study the variation in completed suicide rates between 2010 and 2022 in Spain and their relationship with the consumption of addictive substances.

Methods

Completed suicide data from the Spanish Statistical Office (INE) were analyzed with a joinpoint regression model to determine time trends. The relationship between the variation in completed suicide rates with sociodemographic variables, including depression rates, obtained from the Spanish Statistical Office and variables related to the consumption of substances obtained from the survey on alcohol and other drugs in Spain (EDADES) of the Government Delegation for the National Plan on Drugs (DGPNSD) was also studied using an exploratory analysis and also performing a Generalized Additive Model.

Results

The joinpoint regression model did reveal a point of significant change in the period studied for Spain showing a trend of increased suicide death rates for the studied period. The following variables correlated positively with the variation in completed suicide rates in the Generalized Additive Model: alcohol use in the past 12 months, alcohol use in the last 30 days, daily alcohol use in the last 30 days, binge drinking in the last 12 months, binge drinking in the last month, positive Alcohol Use Disorder Test for risky alcohol use, benzodiazepine use in the last 12 months, benzodiazepine use in the last month, daily benzodiazepine use in the last month, use of illegal substances in the last 12 months, use of illegal substances in the last month, mean age and depression rates.

Conclusion

Applying preventive strategies on the risky consumption of alcohol, benzodiazepines and illegal substances would help reduce the rates of completed suicide in Spain.

Assessing suicide risk in chronic pain management: a narrative review across drug classes

INTRODUCTION

Chronic pain presents a multifaceted challenge in clinical practice, necessitating a nuanced understanding of pharmacological interventions to optimize treatment outcomes. This review provides an outline of various pharmacological agents commonly used in chronic pain management and highlights their safety considerations, particularly regarding suicide risk.

AREAS COVERED

This review discusses the role of antidepressants, anticonvulsants, GABA receptor agonists, NMDA receptor antagonists, corticosteroids, cannabis and cannabinoids, bisphosphonates, calcitonin, and alpha-2 adrenergic receptor agonists in chronic pain management. It assesses their therapeutic benefits, potential for misuse, and psychiatric adverse effects, including the risk of suicide. Each pharmacological class is evaluated in terms of its efficacy, safety profile, and considerations for clinical practice. We searched peer-reviewed English literature on the topic using the MEDLINE database without time restrictions.

EXPERT OPINION

While pharmacological interventions offer promise in alleviating chronic pain, healthcare providers must carefully weigh their benefits against potential risks, including the risk of exacerbating psychiatric symptoms and increasing suicide risk. Individualized treatment approaches, close monitoring, and multidisciplinary collaboration are essential for optimizing pain management strategies while mitigating adverse effects. Ongoing research efforts are crucial for advancing our understanding of these pharmacological interventions and refining pain management practices.

Risk of suicide attempts and intentional self-harm on alprazolam

BACKGROUND

From 2000-2021, U.S. suicide deaths have risen 36 %. Identification of pharmacological agents associated with increased suicide risk and safer alternatives may help reduce this trend.

METHODS

An exposure-only within-subject time-to-event pharmacoepidemiologic study of the dynamic association between alprazolam treatment and suicide attempts over 2-years. Parallel analyses were conducted for diazepam, lorazepam and buspirone. Data for 2,495,520 patients were obtained from U.S. private insurance medical claims MarketScan from 2010 to 2019.

FINDINGS

Alprazolam was associated with over a doubling of risk of suicide attempts (HR=2.21, 95 % CI=2.06,2.38). A duration-response analysis for the modal dose (0.5 mg) revealed a 5 % increase in suicidal events per additional month of treatment (HR=1.05, 95 % CI=1.04,1.07). Parallel analyses with long-acting (diazepam) and short-acting (lorazepam), found similar associations (diazepam HR=2.87, 95 % CI=2.56,3.21; lorazepam HR=1.83, 95 % CI=1.69,2.00), whereas the non-benzodiazepine anxiolytic, buspirone, showed significantly less risk (HR=1.25, 95 % CI=1.13,1.38), and no increased risk in patients with an attempt history (HR=1.05, 95 % CI=0.70,1.59).

INTERPRETATION

This study confirmed an earlier signal linking alprazolam to increased suicide attempt risk. The increased risk extends to benzodiazepines in general, regardless of half-life and risk of withdrawal seizure. Buspirone appears to be a safer treatment than benzodiazepines, particularly in patients at increased risk for suicide.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Drug-induced psychiatric disorders: A pharmacovigilance update

The psychiatric risks associated with drugs are sometimes one of the few restrictions on the use of certain drug classes, such as corticosteroids in patients with a history of severe psychotic episodes associated with this drug class. In this non-exhaustive review, we propose to deal with the most recent issues concerning psychiatric disorders induced by drugs and encountered in doctors' clinical practice. Firstly, we look at depressive disorders and suicide risks, secondly at psychotic and manic disorders and thirdly at anxiety and sleep disorders. While lot of drugs are associated with psychiatric disorders, the confounding by indication represents an important methodological gap since information on the psychiatric profile of patients is not always available. This is particularly the case for serotonin reuptake inhibitors and esketamine used as antidepressants. Recent pharmacovigilance concerns of psychiatric disorders emerged with montelukast, orexin receptor antagonists or cystic fibrosis transmembrane regulator (CFTR) modulators.

Clinical predictive factors and trajectories of suicidal remission over 6 weeks following intravenous ketamine for suicidal ideation

BACKGROUND

Ketamine is efficient for short-term reduction of suicidal ideas. Predictive factors and outcome trajectories are poorly characterized.

METHODS

Secondary analyses were conducted on the KETIS study (Abbar et al. BMJ 2022): 156 suicidal patients were randomized to two intravenous infusions of racemic ketamine (0.5 mg/kg) or placebo. Response or remission was assessed over six weeks based on the Beck Scale for Suicidal Ideation (SSI). We calculated i) predictive values of 12 baseline variables on remission ii) outcome courses, and iii) positive (PPV) and negative predictive values.

RESULTS

In multivariate analyses, bipolar disorder, lower patient-rated suicidal ideas, and higher physical pain were predictive of suicidal remission at day 3. No clinical factor predicted remission at week 6. Twenty and 24 different clinical courses were identified in early (day 3) and later (week 6) follow-up, respectively, including around 40 % sustained remission, 50 % fluctuating course and 10 % no response. Suicidal remissions at day 1 and day 3 were highly predictive of remissions at day 3 and week 6 (PPV = 96.8 and 92.6 %).

LIMITATIONS

SSI may not be adapted for rapid variations and repeated measures.

CONCLUSIONS

Clinical factors were poorly predictive of remission. Fluctuations in suicidal ideas were frequent, even after ketamine (although less than placebo), necessitating vigilance and multimodal care. Remission at day 1 after one infusion was highly predictive of future remission. The benefits of a second infusion will have to be tested.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.