During the holiday season, I was reminded of the old myth that suicide rates increase over the holidays. This medical myth has been debunked numerous times and it was one of the topics covered in a recent BMJ story about medical myths. For many years, people believed this myth because they felt that the depression worsens when depressed patients see other happy and celebrating with friends and family. Plus, in many areas, the winter seasons may lead to more rain, cloudy weather, and gloomy days for people who may be susceptible to seasonal affective disorder (SAD). So how about suicide? How often do depressed patients commit suicide? And what prompts depressed individuals to the verge of suicide? This is a very complex topic that has no simple explanation.

A few years ago, the FDA added suicide warnings to common anti-depressants. This included drugs like:

• Prozac (fluoxetine),
• Zoloft (sertraline),
• Paxil (paroxetine),
• Luvox (fluvoxamine),
• Celexa (citalopram),
• Lexapro (escitalopram),
• Wellbutrin (bupropion),
• Effexor (venlafaxine),
• Serzone (nefazodone), and
• Remeron (mirtazapine).

This is a very long list of extremely common medications. When this happened, people asked, “Why do anti-depressants increase the risk of suicide?” Many different theories emerged, but this did not stop clinicians from prescribing these common agents for patients suffering from depression or anxiety. This warning was also considered very ironic since severely depressed patients are the ones who may commit suicide, yet they are the ones who need to be treated with anti-depressants. So how do you treat suicidal patients if the treatment may increase the risk of suicide? Many people wondered whether the drugs really increased suicide, or if the increased suicide was simply an association without causation. This matter still seems to be quite controversial among healthcare professionals. If you’re going to treat patients who are very suicidal with any type of drug, there is a high chance that some of them may still commit suicide.

More recently, the FDA added suicide warnings to anti-epileptic drugs. These agents are used to treat patients with seizure disorders (epilepsy). They are also used to treat certain types of nerve-related pain, also called neuropathy. Anti-epileptic agents are often used to treat certain migraines. Not sure which drugs fall into this class? Maybe you’ve heard of some of these:

• Tegretol (carbamazepine),
• Klonopin (clonazepam),
• Depakote (divalproex),
• Depakene (valproic acid),
• Zarontin (ethosuximide),
• Peganone (ethotoin),
• Felbatol (felbamate),
• Neurontin (gabapentin),
• Lamictal (lamotrigine),
• Vimpat (lacosamide),
• Keppra (levetiracetam),
• Mesantoin (mephenytoin),
• Celontin (methsuximide),
• Trileptal (oxcarbazepine),
• Dilantin (phenytoin),
• Lyrica (pregabalin),
• Mysoline (primidone),
• Gabitril (tiagabine),
• Topamax (topiramate),
• Tridione (trimethadione), and
• Zonegran (zonisamide).

You may have also heard of suicide risks associated with the popular smoking cessation drug Chantix (varenicline).  In February 2008, the FDA issued a public health advisory about the risks of suicide associated with Chantix.

So what’s next? Will more psychotropic medications get a suicide black box warning? What about non-psychotropic medications? If the suicide warning gets added to so many different medications, then people may start ignoring the warning if it’s everywhere. How often do people read the Surgeon General’s warning on cigarette packs? That warning is ubiquitous. However, is it effective? Do people actually pay attention to that warning, or do they ignore it since they’ve seen it so many times?

How are healthcare professionals supposed to prescribe drugs that have a suicide black box warning? How are patients supposed to react to such warnings? This is a very confusing topic right now, and I’m eager to see what happens in the next few years as the FDA evaluates suicide association with other drugs.

References

R. C Vreeman, A. E Carroll (2007). Medical myths BMJ, 335 (7633), 1288-1289 DOI: 10.1136/bmj.39420.420370.25

FDA Public Health Advisory. Worsening Depression and Suicidality in Patients Being Treated With Antidepressant. FDA News. March 22, 2004.

FDA Issues Public Health Advisory on Chantix. FDA News. Feb 1, 2008.