Suicide and antidepressants: what current evidence indicates

Depression in Persons With Epilepsy: Lessons From Case Review

BACKGROUND

Major depressive disorder is highly prevalent among persons with epilepsy (PWEs). Between 30% and 50% of PWEs suffer from depression. Many factors contribute to this prevalence, including the psychosocial impact of the diagnosis, restrictions on driving and certain types of work, and adverse effects associated with antiseizure medications. Without proper treatment, depressed PWEs have increased risks for suicide, strained relationships, lowered seizure control, and impairment in functioning. Our objective was to use the existing literature and insights from our experience in treating depression and anxiety in PWEs within an academic mood disorders center. We aimed to provide practical guidance for health care professionals who treat depression in this population.

METHODS

Persons with epilepsy and depression were identified by their treating psychiatrists. Their electronic health records were reviewed and compiled for this report, with a total of 12 included in this review. Records were reviewed regarding antiseizure medications, psychotropic medications, light therapy, psychotherapy, other interventions, and treatment response.

RESULTS

Based on our review of literature, as well as review of cases of individuals with epilepsy and comorbid psychiatric conditions, we recommend a step-wise evidence-based approach of optimizing psychiatric medication doses, augmenting with additional medication and/or implementing nonpharmacological interventions such as light therapy and psychotherapy.

CONCLUSIONS

In PWEs, improvement in depression, other psychiatric symptoms, and function are the goals of drug and nondrug interventions. Depression care has the potential to significantly improve the quality of life of PWEs and reduce both morbidity and mortality.

Pronounced Regional Variation in Esketamine and Ketamine Prescribing to US Medicaid Patients

Ketamine and esketamine are efficacious for treatment-resistant depression. Unlike other antidepressants, ketamine lacks a therapeutic delay and decreases the risk for suicide. This cross-sectional study geographically characterized ketamine and esketamine prescribing to United States (US) Medicaid patients. Ketamine and esketamine prescription rates and spending per state were obtained. Between 2009 and 2020, ketamine prescribing rates peaked in 2013 followed by a general decline. For ketamine and esketamine in 2019, Montana (967/million enrollees) and Indiana (425) showed significantly higher prescription rates, respectively, relative to the national average. A total of 21 states prescribed neither ketamine nor esketamine in 2019. There was a 121.3% increase in esketamine prescriptions from 2019 to 2020. North Dakota (1,423) and North Carolina (1,094) were significantly elevated relative to the average state for esketamine in 2020. Ten states prescribed neither ketamine nor esketamine in 2020. Medicaid programs in 2020 spent 72.7-fold more for esketamine ($25.3 million) than on ketamine (0.3 million). Despite the effectiveness of ketamine and esketamine for treatment-resistant depression and anti-suicidal properties, their use among Medicaid patients was limited and highly variable in many areas of the US. Further research to better understand the origins of this state-level variation is needed.

Suicidal ideation and suicide attempt following ketamine prescription in patients with treatment-resistant depression: a nation-wide cohort study

Ketamine, including esketamine, is an effective treatment for patients with treatment-resistant depression (TRD); however, its long-term efficacy in real-world populations remains poorly characterized. This is a retrospective cohort study using TriNetX US Collaborative Network, a platform aggregating electronic health records (EHRs) data from 93 million patients from 56 health care organizations in the US, and the study population includes 321,367 patients with a diagnosis of TRD who were prescribed relevant treatment in their EHRs. The prescription of ketamine (including esketamine) was associated with significant decreased risk of suicidal ideation compared to prescription of other common antidepressants: HR = 0.65 (95% CI: 0.53 - 0.81) at 1 day - 7 days, 0.78 (95% CI: 0.66 - 0.92) at 1 day - 30 days, 0.81 (95% CI: 0.70 - 0.92) at 1 day - 90 days, 0.82 (95% CI: 0.72 - 0.92) at 1 day - 180 days, and 0.83 (95% CI: 0.74 - 0.93) at 1 day - 270 days. This trend was especially robust among adults over 24 years of age, males, and White patients with TRD. No significant difference was observed for suicide attempts, except significantly increased risk for adolescents (aged 10-24) at 1 day - 30 days with HR = 2.22 (95% CI: 1.01-4.87). This study provides real-world evidence that ketamine has long-term benefits in mitigating suicidal ideation in patients with treatment-resistant depression. Future work should focus on optimizing dosage regimens for ketamine, understanding the mechanism, and the difference in various demographic subpopulations.

The Effect of Herbal Medicine on Suicidal Behavior: A Protocol for Systematic Review and Meta-Analysis

Suicide is an important social and medical problem worldwide, including in countries that use traditional East Asian medicine (TEAM). Herbal medicine (HM) has been reported to be effective against several suicide-related conditions. This systematic review aimed to investigate the efficacy and safety of HM in reducing suicidal behavior including suicidal ideation, attempts, or completed suicide. We conduct a comprehensive search in 15 electronic bibliographic databases from inception to September 2022. All types of prospective clinical studies-including randomized controlled clinical trials (RCTs)-involving HM without or with routine care are included. The primary outcomes of this review are validated measures of suicidal ideation including the Beck scale for suicidal ideation. The revised Cochrane's risk of bias tool and other tools including the ROBANS-II tool are used to assess the methodological quality of RCTs and non-RCTs, respectively. A meta-analysis is performed using RevMan 5.4 in cases of homogeneous data from controlled studies. The results of the systematic review provide high-quality evidence to determine the efficacy and safety of HM for suicidal behavior. Our findings are informative for clinicians, policymakers, and researchers, aimed at reducing suicide rates, especially in countries that use TEAM.

Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS)

BACKGROUND

Treatment-resistant depression (TRD) accounts for a large fraction of the burden of depression. The interventions currently used are mostly pharmacological and short-term psychotherapies, but their effectiveness is limited. The Tavistock Adult Depression Study found evidence for the effectiveness of long-term psychoanalytic psychotherapy (LTPP) plus treatment as usual (TAU), versus TAU alone, for TRD. Even after a 2-year follow-up, moderate effect sizes were sustained. This study assessed the cost-effectiveness of this LTPP + TAU.

METHODS

We conducted a within-trial economic evaluation using a Bayesian framework.

RESULTS

Quality-adjusted life years (QALYs) were 0.16 higher in the LTPP + TAU group compared with TAU. The direct cost of LTPP was £5500, with no substantial compensating savings elsewhere. Overall, average health and social care costs in the LTPP + TAU group were £5000 more than in the TAU group, employment rates were unchanged, and effects on other non-healthcare costs were uncertain. Accordingly, the incremental cost-effectiveness ratio was ≈£33,000/QALY; the probability that LTPP + TAU was cost-effective at a willingness to pay of £20,000/QALY was 18 %.

LIMITATIONS

The sample size of this study was relatively small, and the fraction of missing service-use data was approximately 50 % at all time points. The study was conducted at a single site, potentially reducing generalizability.

CONCLUSIONS

Although LTPP + TAU was found to be clinically effective for treating TRD, it was not found to be cost-effective compared with TAU. However, given the sustained effects over the follow-up period it is likely that the time horizon of this study was too short to capture all benefits of LTPP augmentation.

Designing Clinical Trials to Assess the Impact of Pharmacological Treatment for Suicidal Ideation/Behavior: Issues and Potential Solutions

Suicide is a serious and growing public health concern yet randomized controlled trials (RCTs) that inform pharmacologic treatment remain limited. We emphasize the overall need for such trials and review the literature to highlight examples of trials that have aimed to study patients at elevated risk of suicide. We discuss key examples of existing psychotropic medication trials as well as psychotherapy intervention studies that can yield important design insights. Medications that have been studied in individuals at risk for suicide include lithium, clozapine, zolpidem, prazosin, ketamine, esketamine, and aripiprazole. While important design challenges should be considered-RCTs to study suicide are feasible and much needed. Issues such as overall trial design, patient-selection criteria, and the scales/tools used to assess suicidality are discussed.

Suicidal Ideation and Obsessive-Compulsive Disorder: Links and Knowledge

Suicidal ideation (SI) is understudied in obsessive-compulsive disorder (OCD). Nonetheless, evidence suggests increased risk for SI in individuals with OCD compared to the general population. Understanding the relationship between SI and OCD involves investigating risk factors associated with SI. Furthering knowledge of links is essential for enhancing outcomes and decreasing experiences of SI through improving treatment interventions. Additionally, increasing awareness of factors that lead SI to suicide attempts (SA) is vital. To best illustrate the current state of knowledge, this scoping review examines risk factors for SI, including symptom profiles or phenotypes, comorbid diagnoses, sociodemographic and lifestyle factors, childhood trauma, and genetic and familial contributions. Important treatment considerations for targeting SI within the context of OCD are detailed with respect to the current evidence for psychotherapy, pharmacology, brain stimulation, and neurosurgery. Gaps in the literature and future directions are identified, broadly with respect to studies examining the treatment of SI within the context of OCD, particular OCD phenotypes, and factors influencing SI in pediatric OCD. Due to the relative novelty of this area of exploration, many unknowns persist regarding onset of SI in OCD, factors contributing to the maintenance of SI in OCD, and relevant treatment protocols. Findings suggest that individuals with previous SI or SA, history of childhood trauma, significant life stress, and psychiatric comorbidities, particularly depression, should be closely monitored and screened for SI.

Maternal separation affects Anxiety like behavior begin in adolescence continue through adulthood and related to Dnmt3a expression

Early life stress, including maternal separation, is among one of the main causes of anxiety in adolescents. DNA methyltransferase 3A (Dnmt3a) is a key molecule that regulates DNA methylation and is found to be associated with anxiety-like behavior. It is not clear whether maternal separation affects anxiety levels in mice at different developmental stages, or whether Dnmt3a plays a role in this process. Here, by using open field test to exploring the effect of maternal separation on anxiety-like behavior in mice of different age, it was found that maternal separation could successfully induce anxiety-like behavior in adolescent mice, and which continued through adulthood. By using western blot, we found the levels of Dnmt3a in the hippocampus and cortex have shown different trends in maternal separation mice on P17. Further, by using immunostaining, we have found that the expression levels of Dnmt3a in the cortex and hippocampus were significantly different, and decreased to varying degrees with the age of mice, which being the reason for different trends. Our results provide an experimental basis for further development of anxiety/depression treatment programs more suitable for adolescence.

Can we predict or prevent suicide?: An update

This article updates a 2006 review of empirical data concerning whether clinicians can predict whether patients will die by suicide, or whether fatality can be prevented. Based on further empirical data, a negative conclusion remains justified. There is good evidence that treatment programs, using psychotherapy and medication, can reduce suicide attempts. But people who die by suicide are a distinct population from attempters, and those at high risk do not necessarily present for treatment. Research on suicide prevention has not shown that fatalities among patients can be predicted, or that clinical interventions can reduce the risk. The strongest evidence for prevention derives from reducing access to means. Population-based strategies are more effective than high-risk strategies focusing on patients with suicidal ideas or attempts.

[Prevention of impulsive suicide with antidepressants in outpatients]

Self-poisoning is a common method of suicide, for which various medications are used, including antidepressants. A non-systematic review of Russian-language and English-language publications, by keywords, in the databases: ELibrary.ru, PubMed, Cochrane Database of Systematic Reviews. The purpose of the review was to analyze the literature on new risk factors and methods of their reduction in suicides with self-poisoning with antidepressants. Every fifth (20%) self-poisoning performed with antidepressants. In self-poisoning attempts, one drug used in 55% of cases, and more than one drug was used in 45% of cases. Impulsive suicides account for up to half of all suicide cases. Risk factors for impulsive suicides include the presence of impulsive character traits, female gender, young age, and the use of psychostimulants. The WHO Regional Office for Europe's mhGAP-IG guidelines recommend limiting access to a patient at risk of suicide to a weekly dose of an antidepressant. Preferably, the use of antidepressants from the group of SSRIs in small forms of release.

Long-Term Fluoxetine Administration Causes Substantial Lipidome Alteration of the Juvenile Macaque Brain

Fluoxetine is an antidepressant commonly prescribed not only to adults but also to children for the treatment of depression, obsessive-compulsive disorder, and neurodevelopmental disorders. The adverse effects of the long-term treatment reported in some patients, especially in younger individuals, call for a detailed investigation of molecular alterations induced by fluoxetine treatment. Two-year fluoxetine administration to juvenile macaques revealed effects on impulsivity, sleep, social interaction, and peripheral metabolites. Here, we built upon this work by assessing residual effects of fluoxetine administration on the expression of genes and abundance of lipids and polar metabolites in the prelimbic cortex of 10 treated and 11 control macaques representing two monoamine oxidase A (MAOA) genotypes. Analysis of 8871 mRNA transcripts, 3608 lipids, and 1829 polar metabolites revealed substantial alterations of the brain lipid content, including significant abundance changes of 106 lipid features, accompanied by subtle changes in gene expression. Lipid alterations in the drug-treated animals were most evident for polyunsaturated fatty acids (PUFAs). A decrease in PUFAs levels was observed in all quantified lipid classes excluding sphingolipids, which do not usually contain PUFAs, suggesting systemic changes in fatty acid metabolism. Furthermore, the residual effect of the drug on lipid abundances was more pronounced in macaques carrying the MAOA-L genotype, mirroring reported behavioral effects of the treatment. We speculate that a decrease in PUFAs may be associated with adverse effects in depressive patients and could potentially account for the variation in individual response to fluoxetine in young people.

The need for an integrated pharmacological response to the treatment of HIV/AIDS and depression

Introduction: The coexistence of depression and HIV infection affects more than 9 million people worldwide. A literature review revealed a large gap regarding the pharmacotherapy of depression among patients dually diagnosed with HIV and depression.Areas covered:In this review, the authors covered the various dimensions of deploying integrated pharmacological treatment of HIV/AIDS and depression. This topic was addressed in two ways; first, the direct results of integrated pharmacotherapy in syndemic patients; second, the indirect effects of the integrated model on other outcomes of HIV care.Expert opinion: An integrated pharmacological response to the treatment of HIV and depression can bring substantial benefits to HIV outcomes and reduce the burden of both diseases. The direct advantages regarding pharmacological response to the treatment of depression along with HIV care are improving adherence to antiretroviral therapy, optimizing pharmacotherapy, minimizing drug interaction, and prevention of additive adverse drug reactions. Furthermore, in some cases, medication can target both depression and other neuropsychiatric or somatic comorbidities among people living with HIV/AIDS. The integrated pharmacotherapy also has some potential indirect advantages on HIV care outcomes like minimizing loss of care, reducing ongoing HIV transmission, and improving the outcomes of both diseases.

Low dose oral ketamine treatment in chronic suicidality: An open-label pilot study

Recently, low-dose ketamine has been proposed as a rapid-acting treatment option for suicidality. The majority of studies to date have utilised intravenous (IV) ketamine, however, this route of administration has limitations. On the other hand, oral ketamine can be administered in a range of settings, which is important in treating suicidality, although studies as to safety and feasibility are lacking. n = 32 adults (aged 22-72 years; 53% female) with chronic suicidal thoughts participated in the Oral Ketamine Trial on Suicidality (OKTOS), an open-label trial of sub-anaesthetic doses of oral ketamine over 6 weeks. Participants commenced with 0.5 mg/kg of ketamine, which was titrated to a maximum 3.0 mg/kg. Follow-up assessments occurred at 4 weeks after the final dose. The primary outcome measure was the Beck Scale for Suicide Ideation (BSS) and secondary measures included scales for suicidality and depressive symptoms, and measures of functioning and well-being. Mean BSS scores significantly reduced from a high level of suicidal ideation at the pre-ketamine (week 0) timepoint to below the clinical threshold at the post-ketamine (week 6) timepoint. The proportion of participants that achieved clinical improvement within the first 6 weeks was 69%, whereas 50% achieved a significant improvement by the follow-up (week 10) timepoint. Six weeks of oral ketamine treatment in participants with chronic suicidality led to significant reduction in suicidal ideation. The response observed in this study is consistent with IV ketamine trials, suggesting that oral administration is a feasible and tolerable alternative treatment for chronic suicidality.

Relationship between suicide rate and antidepressant prescription: An ecological study in the People's Republic of China

OBJECTIVES

The objective of this study was to estimate the features of suicide rate and its association with antidepressant prescriptions during the past decade in China.

METHODS

Official data on suicides were obtained and stratified by four age groups, gender, urban/rural areas, and regions (East, Central, and West). The annual antidepressant prescriptions were expressed in pills per 100 persons calculated as the volume of prescriptions divided by the total population. Negative binomial regression was carried out to examine the association between suicide and other variables.

RESULTS

Suicide rates in each stratum typically decreased from 2008 to 2015, while annual antidepressant prescriptions were generally increased by the year. The suicide rate increased with age and was greater in adult males than in females; higher in the central area and greater in rural than in urban areas. Suicide rates are negatively associated with antidepressant prescriptions including selective serotonin reuptake inhibitors (Incidence rate ratio [IRR] 0.983, 95% confidence interval [CI] 0.983-0.983), serotonin-norepinephrine reuptake inhibitors (IRR 0.951, 95% CI 0.951-0.951), tricyclic antidepressant (IRR 0.925, 95% CI 0.925-0.925) and total antidepressants (IRR 0.990, 95% CI 0.990-0.990) during 2008-2012.

CONCLUSION

Suicide varied among different studied stratum. Suicide rates are negatively associated with antidepressant prescriptions.

The safety of agomelatine in standard medical practice in depressed patients: A 26-week international multicentre cohort study

OBJECTIVE

The present observational cohort study documented the safety of agomelatine in current medical practice in out-patients suffering from major depressive disorder.

METHOD

The 6-month evolution of agomelatine-treated patients was assessed with a focus on safety (emergent adverse events, liver acceptability), severity of depression using the Clinical Global Impression Severity (CGI-S) score, and functioning measured by the Sheehan Disability Scale (SDS).

RESULTS

A total of 8453 depressed patients from 761 centres in 6 countries were analysed (female: 67.7%; mean age: 49.1 ± 14.8 years). Adverse events reported were in accordance with the known safety profile of agomelatine. Cutaneous events were reported in 1.7% of the patients and increased hepatic transaminases values were reported in 0.9 % of the patients. The incidence of events related to suicide/self-injury was 1.0%. Two completed suicides, not related to the study drug, were reported. CGI-S total scores and SDS sub-scores improved and numbers of days lost or underproductive decreased over the treatment period.

CONCLUSIONS

In standard medical practice, agomelatine treatment was associated with a low incidence of side effects. No unexpected events were reported. A decrease in the severity of the depressive episode and improved functioning were observed.

TRIAL REGISTRATION NAME

Observational cohort study to evaluate the safety of agomelatine in standard medical practice in depressed patients. A prospective, observational (non-interventional), international, multicentre cohort study.

TRIAL REGISTRATION NUMBER

ISRCTN53570733.

Genetic Background Underlying 5-HT1A Receptor Functioning Affects the Response to Fluoxetine

The influence of genetic background on sensitivity to drugs represents a topical problem of personalized medicine. Here, we investigated the effect of chronic (20 mg/kg, 14 days, i.p.) antidepressant fluoxetine treatment on recombinant B6-M76C mice, differed from control B6-M76B mice by CBA-derived 102.73–110.56 Mbp fragment of chromosome 13 and characterized by altered sensitivity of 5-HT_1A receptors to chronic 8-OH-DPAT administration and higher 5-HT_1A receptor mRNA levels in the frontal cortex and hippocampus. Significant changes in the effects of fluoxetine treatment on behavior and brain 5-HT system in recombinant B6-M76C mice were revealed. In contrast to B6-M76B mice, in B6-M76C mice, fluoxetine produced pro-depressive effects, assessed in a forced swim test. Fluoxetine decreased 5-HT_1A receptor mRNA levels in the cortex and hippocampus, reduced 5-HT_1A receptor protein levels and increased receptor silencer Freud-1 protein levels in the hippocampus of B6-M76C mice. Fluoxetine increased mRNA levels of the gene encoding key enzyme for 5-HT synthesis in the brain, tryptophan hydroxylase-2, but decreased tryptophan hydroxylase-2 protein levels in the midbrain of B6-M76B mice. These changes were accompanied by increased expression of the 5-HT transporter gene. Fluoxetine reduced 5-HT and 5-HIAA levels in cortex, hippocampus and midbrain of B6-M76B and in cortex and midbrain of B6-M76C; mice. These data demonstrate that changes in genetic background may have a dramatic effect on sensitivity to classic antidepressants from the Selective Serotonin Reuptake Inhibitors family. Additionally, the results provide new evidence confirming our idea on the disrupted functioning of 5-HT_1A autoreceptors in the brains of B6-M76C mice, suggesting these mice as a model of antidepressant resistance.

Using genetic drug-target networks to develop new drug hypotheses for major depressive disorder

The major depressive disorder (MDD) working group of the Psychiatric Genomics Consortium (PGC) has published a genome-wide association study (GWAS) for MDD in 130,664 cases, identifying 44 risk variants. We used these results to investigate potential drug targets and repurposing opportunities. We built easily interpretable bipartite drug-target networks integrating interactions between drugs and their targets, genome-wide association statistics, and genetically predicted expression levels in different tissues, using the online tool Drug Targetor ( drugtargetor.com ). We also investigated drug-target relationships that could be impacting MDD. MAGMA was used to perform pathway analyses and S-PrediXcan to investigate the directionality of tissue-specific expression levels in patients vs. controls. Outside the major histocompatibility complex (MHC) region, 153 protein-coding genes are significantly associated with MDD in MAGMA after multiple testing correction; among these, five are predicted to be down or upregulated in brain regions and 24 are known druggable genes. Several drug classes were significantly enriched, including monoamine reuptake inhibitors, sex hormones, antipsychotics, and antihistamines, indicating an effect on MDD and potential repurposing opportunities. These findings not only require validation in model systems and clinical examination, but also show that GWAS may become a rich source of new therapeutic hypotheses for MDD and other psychiatric disorders that need new-and better-treatment options.

Integrated analysis of the genetic basis of suicidal behavior: what has been shown by structural genetic studies so far

OBJECTIVE

In recent decades, the role of genetic factors in the predisposition to suicidal behavior has attracted considerable attention. Although each genetic investigation appears to be valuable, no one study on its own can comprehensively explain the etiology of suicidal behavior.

METHODS

In this study, using a broad literature review, we found the suicide-associated gene coexpression network. In addition, cytoband, molecular function, biological process, cellular component, tissue-based expression, and disease/disorder enrichment analyses were carried out to determine the most central cellular and molecular infrastructures involved in suicidal behavior.

RESULTS

The reconstructed network consisted of 104 genes, including 91 previously known genes and 13 novel genes, and 354 interactions. Topological analysis showed that in total, CCK, INPP1, DDC, and NPY genes are the most fundamental hubs in the network. We found that suicide genes are significantly concentrated within chromosomes 11 and 6. Further analysis showed that monoaminergic signal transduction, especially through GPCRs, in the cingulate gyrus, superior prefrontal gyrus, dorsal striatum, and the cerebellum are the main, deficient routes in suicide. Moreover, it turned out that genetically, suicidal behavior is more likely in patients with mood and affective disorders.

CONCLUSION

Like other behavioral disorders, suicide has a complex and multifactorial basis and at present, the only approaches to the integrated study of such disorders are computer-based methods. The results of such studies, although subject to a degree of uncertainty, however, can pave the way for future basic and clinical studies.

Fighting against depression with TREK-1 blockers: Past and future. A focus on spadin

Depression is a devastating mood disorder and a leading cause of disability worldwide. Depression affects approximately one in five individuals in the world and represents heavy economic and social burdens. The neurobiological mechanisms of depression are not fully understood, but evidence highlights the role of monoamine neurotransmitter balance. Several antidepressants (ADs) are marketed to treat depression and related mood disorders. However, despite their efficacy, they remain nonspecific and unsafe because they trigger serious adverse effects. Therefore, developing new molecules for new targets in depression has become a real necessity. Eight years ago, spadin was described as a natural peptide with AD properties. This 17-amino acid peptide blocks TREK-1 channels, an original target in depression. Compared to the classical AD drugs such as fluoxetine, which requires 3-4 weeks for the AD effect to manifest, spadin acts rapidly within only 4 days of treatment. The AD properties are associated with increased neurogenesis and synaptogenesis in the brain. Despite the advantages of this fast-acting AD, the in vivo stability is weak and does not last for >7 h. The present review summarizes different strategies such as retro-inverso strategy, cyclization, and shortening the spadin sequence that has led to the development and optimization of spadin as an AD. Shortened spadin analogs present increased inhibition potency for TREK-1, an improved AD activity, and prolonged in vivo bioavailability. Finally, we also discuss about other inhibitors of TREK-1 channels with a proven efficacy in treating depression in the clinic, such as fluoxetine.

Focused Medical Assessment of Pediatric Behavioral Emergencies

There is no uniformly accepted standard of care for medical clearance of pediatric patients with psychiatric complaints. Emerging data argue for a thorough history and physical examination and against routine laboratory testing. The differential diagnosis of patients presenting with psychiatric health complaints is extensive and includes both medical and psychiatric disorders. Providers should remain mindful of anchoring or diagnosis momentum bias when caring for these patients, especially patients with a psychiatric history.

A Balanced Risk-Benefit Analysis to Determine Human Risks Associated with Pyrrolizidine Alkaloids (PA)-The Case of Herbal Medicinal Products Containing St. John's Wort Extracts (SJW)

OBJECTIVES

Pyrrolizidine alkaloids (PA) exist ubiquitously in our environment. More than 6000 plants, about 3% of the world’s flowering plants, are known to synthesize PA. As a consequence, many herbal ingredients, including St. John’s wort (SJW), are contaminated with PA that can possess acute and subchronic toxic effects as well as mutagenic and genotoxic properties. Therefore, the possible benefits of SJW as an herbal remedy against depression need to be weighed against the possible risks of unwanted PA intake.

METHODS

We searched the literature regarding the current knowledge on PA and evaluated the evidence on the antidepressant effects of quantified SJW extract based on a Cochrane Review and the current practice guidelines on depression. Risks are depicted in form of a risk ladder and benefits in form of an icon array.

RESULTS

Evidence from clinical studies indicates that quantified SJW extract is an effective treatment option for mild to moderate depression with fewer side effects than conventional antidepressants. Health statistics from different countries do not quantify cases of death caused by PA intake. However, deaths due to suicide, often triggered by depression, are common (11 in 1000 in Germany in 2015) and rank between fatalities due to liver diseases (16 in 1000) and household accidents (10 in 1000).

CONCLUSIONS

Quantified SJW extract is a safe and effective treatment option, and its potential of treating depression outweighs the (hypothetical) risk of unwanted PA intake.

Antidepressants: relationship to the time to psychiatric readmission and probability of being in hospital in depressive patients

Introduction: Although antidepressants play a major role in the treatment of patients with depression, it is unclear which specific antidepressants are more efficacious than others. This study aims to analyze the relationship between several antidepressant substances and the time to readmission as well as the probability of being in hospital in a given week by using prescription data.

Methods: The database was health-insurance claim data from the new Federal States in Germany. The analysis consisted of all patients with unipolar depression at their index admission in 2007 (N = 1803). Patients were followed up for 2 years after discharge from index hospitalization. Statistical analyses were conducted by discrete-time hazards models and general estimation equation models, accounting for various predictors.

Results: Of all prescribed antidepressant substances, sertraline was related to an increased time to readmission by 37% and to a reduction in the probability of being in hospital in a given week by 40%. However, it was prescribed to only about 5% of the patients.

Conclusion: In this study, only sertraline appeared to have clinical and economic advantages. It is remarkable that just a minority of patients received sertraline in our study, thus differing from the prescription pattern in the US.