It is unclear whether the action of AEDs in patients with affective disorders is similar to that in patients with seizure disorders. It is crucial to determine whether suicide risk with anticonvulsants and high-potency benzodiazepines with anticonvulsant activity carries over to psychiatric patients, because these drugs are widely used to treat serious psychiatric disorders.30Two studies have examined this potential association between AEDs and suicide risk, with inconclusive results.31,32
Reported investigations that examined suicide risk and AEDs are strikingly inconsistent in their rankings of relative risks associated with particular drugs. Nevertheless, levetiracetam(Drug information on levetiracetam), lamotrigine(Drug information on lamotrigine), and topiramate(Drug information on topiramate) were among the top 3 AEDs with the highest observed suicide risks in at least 2 of the 5 reported analyses. Levetiracetam was among the top 3 drugs in all 5 studies that found increased suicide risk. Lamotrigine and topiramate appeared in the top 3 in 3 of the 5 studies. Only topiramate has been associated with clinical depression. These 3 drugs differ in their pharmacodynamics. Thus, it is difficult to conclude which biological mechanisms lead to increased suicide risk.33
Lamotrigine monotherapy is an effective and well-tolerated treatment for mania and bipolar depression, and it may be used as an augmentation strategy for unipolar depression.34
Other pharmacological issues
Some pharmacological challenges go beyond diagnostic categories. There are many clinical challenges in which medications play key roles in reducing generalized symptoms, such as anxiety and insomnia, that worsen during a psychosocial crises and are associated with increased suicide risk. Adequate treatment of insomnia and agitation is important anecdotally in suicidal patients. Although suicide rates are surprisingly high among persons with anxiety disorders and severe anxiety may accompany suicidal behavior, evidence that antianxiety medications may alter suicide risk is limited.4 Acute relief of agitation in suicidal depressed patients may play a significant role in suicide prevention.
Adequate treatment of the underlying psychiatric illness consistently appears to be the most effective use of medication in suicidal patients. Although studies are limited, there are indications that some medications will provide specific antisuicidal protection. The use of illness-specific medication provided through the therapeutic relation-ship is key to decreasing the risk of suicide.
Clozapine has shown some efficacy at reducing suicide risk in schizophrenia, and olanzapine(Drug information on olanzapine) and quetiapine(Drug information on quetiapine) appear promising. Similarly, lithium(Drug information on lithium) has been shown to be effective for patients who have bipolar disorder. SSRIs are useful in the treatment of suicidal depressed adults. However, patients who are receiving SSRIs, especially adolescents, should be carefully monitored. Additional research is urgently needed to determine the safety of antiepileptic drugs.
A good therapeutic alliance is key to effective pharmacotherapy. By forging a therapeutic relationship, the prescribing psychiatrist encourages patient adherence and enables physician and patient to monitor suicide risk across the spectrum of diagnoses and possible adverse effects.