Evidence-Based Reviews

Atypical antipsychotics seldom cause tardive dyskinesia (TD), but we cannot let our guard down when prescribing them. Although they pose a much lower risk of TD than do conventional antipsychotics, atypicals can cause TD in vulnerable patients.

Less worrisome than in the past, TD’s associated problems linger, including insidious onset, tendency for persistence, and lack of reliably effective treatment. It is important, therefore, for psychiatrists to:

• identify patients at risk for developing TD
• recognize extrapyramidal symptoms (EPS) when they occur
• and manage these side effects appropriately.

A CHANGING CLINICAL PICTURE

The term “dyskinesias” covers a variety of abnormal involuntary movements (Box). The incidence and prevalence of TD have dropped markedly in the last 10 years, as:

• more and more older, chronically ill patients are switched from conventional to atypical agents
• younger psychotic patients are usually treated with atypicals as first-line therapy and are never exposed to conventional antipsychotics.

Box

TD prevalence of about 20%—as shown by earlier studies of long-term conventional agents¹—is declining. Newer studies comparing atypicals with conventional antipsychotics demonstrate much lower prevalence rates.^2,3

TD incidence—estimated by new cases of TD per year of drug treatment—may have declined 10-fold, from 5% with conventional antipsychotics to 0.5% with atypicals. Likewise, incidence in the elderly may have fallen from 25% to 2.5%.⁴

Risk factors. Despite these improvements, case reports^5-7 demonstrate that TD is possible in patients treated with atypicals, even without previous exposure to a conventional antipsychotic. Besides antipsychotic use, risk factors for developing TD include:

• older age
• negative symptoms of schizophrenia
• affective disorders
• acute EPS
• and diabetes mellitus.⁸

RECOGNIZING TD SYMPTOMS

Recognizing TD may be complicated by the presence of other EPS, particularly drug-induced parkinsonism (DIP). DIP typically develops early and often when treating patients with conventional antipsychotics (Table 1). TD and DIP may occur simultaneously in the same patient, making accurate diagnosis even more difficult.

Other dyskinesias may complicate the diagnosis. Three common TD variants, which may be acute or tardive (occurring after long-term antipsychotic therapy), are:

• akathisia, a distressing and at times irresistible urge to move the legs or other parts of the body
• dystonia, abnormal muscle tone and posture and muscle spasms
• tics, brief muscle contractions, usually in the face, including vocal tics.

AIMS testing. Defining a “case of TD” by dyskinetic movement severity is somewhat arbitrary. A commonly accepted definition is two area scores of “mild” or one rating of “moderate” using the Abnormal Involuntary Movement Scale (AIMS).⁹ The AIMS has been widely used in epidemiologic and treatment studies of TD and is easy to administer in a clinical setting (see Related Resources).

A careful drug history is required before TD can be diagnosed definitively. Spontaneous dys kinesias—usually orofacial—are sometimes seen in older patients who are not taking neuroleptics.⁸ Antidepressants, mood stabilizers, or antihistamines may infrequently trigger neurologic side effects—including dyskinesias, akathisia, and tremor—which are almost invariably reversible after the causative agent is withdrawn.^8,10

Table 1

Features that differentiate two common extrapyramidal symptoms

	Tardive dyskinesia (TD)	Drug-induced parkinsonism (DIP)
Onset	Late	Early
Type of movement	Choreoathetoid	Tremor
Amount of movement	Increased	Decreased
Muscle tone	Decreased	Increased
Most common site	Orofacial	Extremities
Response to anticholinergics	Tends to worsen	Tends to improve

MANAGING MILD TD

Atypical antipsychotics have radically altered the clinical outlook for patients with TD and improved our ability to manage their symptoms. The clinician treating a TD patient today rarely faces the dilemma that exists with conventional antipsychotics: discontinue treatment and risk psychotic relapse, or continue treatment and risk persistent TD.

Using atypicals. Today, patients who need antipsychotic therapy for TD are usually already taking atypicals, which may ameliorate TD and control psychotic symptoms. Case reports and some studies have shown therapeutic effects in patients with TD taking olanzapine,³ risperidone,² quetiapine,¹¹ ziprasidone,¹² aripiprazole,¹³ or the substituted benzamides (such as sulpiride), which are not marketed in the United States.¹⁴

 

Interestingly, TD triggered by taking one atypical may respond to treatment with another. Suzuki et al¹⁵ reported that three patients who had developed early-onset TD while taking risperidone showed TD remission after risperidone was replaced by olanzapine in one patient and by quetiapine in the other two.

The atypicals are well tolerated but not without side effects. Weight gain is the most common problem and one with potentially serious health consequences.¹⁶

Using conventional agents. Even though atypicals are available, the clinician may consider continuing therapy with conventional antipsychotics in patients with TD when:

• the patient’s mental status has been satisfactory while taking conventional agents
• TD has been mild and stable over an extended time
• the patient has no side effects other than TD.

The literature supports the clinical experience that mild TD rarely worsens with continued antipsychotic therapy. Studies of 5 years or more tend to show TD stability with continued conventional antipsychotic therapy.¹⁷ It is prudent to maintain stable chronic psychotic patients with mild TD on the lowest effective dosages of conventional antipsychotics and to monitor them regularly for changes in dyskinesia and psychiatric status.

MANAGING COMPLICATED TD

Managing severe TD or patients showing dystonia, tics, marked akathisia, or DIP coexisting with TD usually calls for more-aggressive interventions (Algorithm).

Algorithm Clinical management of tardive dyskinesia (TD)

Clozapine remains the first-line treatment for difficult TD; it has a very low propensity for inducing DIP and very rarely causes TD.¹⁸ Controlled studies,^18,19 case reports, and open trials demonstrate its efficacy for reducing TD of all types and severity at a usual dosage of 300 to 500 mg/d. Clozapine’s antidyskinetic effects may be attributed to the absence of rebound after withdrawal and its greater efficacy in more-severe cases.¹⁸

Long-term clozapine therapy is recommended for TD, as symptoms remit slowly. Because weight gain, sedation, and other side effects—as well as mandatory blood monitoring—make clozapine less-than-ideal in clinical practice, researchers are seeking other effective therapies for TD.

Other atypicals. The obvious place to look is the other atypicals, which are simpler than clozapine to administer long-term. To date, however, these drugs have not proven to be as reliably effective as clozapine for TD. A recent review concluded that among the atypicals only clozapine induces less EPS than low-potency conventional antipsychotics.²⁰

Nonantipsychotic agents. Other antidyskinetic drugs have come and gone; none has stood the test of time or proven effective in controlled trials. These agents may benefit some TD patients, but improvement is usually not dramatic.

Vitamin E was found to be effective in some TD treatment studies¹⁴ but not more effective than placebo in the largest controlled trial.²¹ Long-term treatment with dopamine-blocking antipsychotics is thought to cause oxidative stressinduced neurotoxicity in the nigrostriatal system.²² Lipid-soluble antioxidants such as vitamin E decrease free-radical formation, and it is possible that vitamin E may yet emerge as a helpful agent in preventing TD.²³

Melatonin, a stronger antioxidant than vitamin E, was found to reduce TD in a 6-week placebocontrolled study,²² but the degree of TD improvement was modest. Melatonin’s value as a therapeutic agent for TD remains dubious.²³

Miscellaneous. Case reports and studies with small series of TD patients have advanced numerous compounds as possible therapeutic agents (Table 2). Other drugs that occasionally have shown benefit in TD include buspirone, propranolol, pyridoxine (vitamin B6), ondansetron, clonidine, and the neuropeptide ceruletide.

ECT and diet. Suggested nondrug treatments of TD include electroconvulsive therapy (ECT)¹⁴ and a diet of mixed branched-chain amino acids.²⁴

Table 2

Compounds that occasionally show benefit in TD

Class	Example
Cholinergics	Lecithin
Catecholamine depletors	Tetrabenazine (investigational orphan drug)
Calcium channel blockers	Verapamil
Gabaergic compounds	Baclofen
Benzodiazepines	Clonazepam

MANAGING TD VARIANTS

TD variants are notoriously difficult to treat but tend to respond to clozapine.¹⁸ In addition:

• Tardive dystonia is often treated with reserpine, tetrabenazine, or high doses of anticholinergic drugs.²⁵ Botulinum toxin A injections into affected muscles may be remarkably effective but must be repeated regularly.²⁵
• Tardive akathisia may improve slowly with clozapine, propranolol, or benzodiazepines.²⁵

Managing severe or atypical TD is usually beyond the expertise of the practicing psychiatrist. Obtaining consultation from a psychopharmacologist or a neurologist experienced in treating movement disorders is highly recommended.

PREVENTING TD

Conventional antipsychotics are still prescribed by psychiatrists, internists, and family physicians and are often given in emergency rooms. Avoiding these drugs whenever possible and using the lowest effective dosages will reduce the risk of TD.²⁶

Patients at relatively high risk for TD—the elderly, those who are very sensitive to acute EPS, and those with affective disorders or diabetes mellitus—are rarely candidates for conventional neuroleptics if a suitable alternative exists. Genetic research may further identify individuals susceptible to TD.²⁷

 

Related resources

• Abnormal Involuntary Movement Scale (AIMS). www.dr-bob.org/tips/aims.html
• Bloom FE, Kupfer DJ (eds). Psychopharmacology: The fourth generation of progress. New York: Raven Press, 1995.
• Tandon R, Halbreich U (eds). Atypical antipsychotics: Efficacy and tolerability—achieving the optimal balance. Psychoneuroendocrinology 2003;28(suppl 1).

Drug brand names

• Aripiprazole • Abilify
• Baclofen • Lioresal
• Buspirone • BuSpar
• Clonazepam • Klonopin
• Clonidine • Catapres
• Clozapine • Clozaril
• Olanzapine • Zyprexa
• Ondansetron • Zofran
• Propranolol • Inderal
• Quetiapine • Seroquel
• Risperidone • Risperdal
• Verapamil • Calan, others
• Ziprasidone • Geodon

Disclosure

Dr. Gardos receives research grant support from Forest Laboratories.

Atypical antipsychotics seldom cause tardive dyskinesia (TD), but we cannot let our guard down when prescribing them. Although they pose a much lower risk of TD than do conventional antipsychotics, atypicals can cause TD in vulnerable patients.

Less worrisome than in the past, TD’s associated problems linger, including insidious onset, tendency for persistence, and lack of reliably effective treatment. It is important, therefore, for psychiatrists to:

• identify patients at risk for developing TD
• recognize extrapyramidal symptoms (EPS) when they occur
• and manage these side effects appropriately.

A CHANGING CLINICAL PICTURE

The term “dyskinesias” covers a variety of abnormal involuntary movements (Box). The incidence and prevalence of TD have dropped markedly in the last 10 years, as:

• more and more older, chronically ill patients are switched from conventional to atypical agents
• younger psychotic patients are usually treated with atypicals as first-line therapy and are never exposed to conventional antipsychotics.

Box

TD prevalence of about 20%—as shown by earlier studies of long-term conventional agents¹—is declining. Newer studies comparing atypicals with conventional antipsychotics demonstrate much lower prevalence rates.^2,3

TD incidence—estimated by new cases of TD per year of drug treatment—may have declined 10-fold, from 5% with conventional antipsychotics to 0.5% with atypicals. Likewise, incidence in the elderly may have fallen from 25% to 2.5%.⁴

Risk factors. Despite these improvements, case reports^5-7 demonstrate that TD is possible in patients treated with atypicals, even without previous exposure to a conventional antipsychotic. Besides antipsychotic use, risk factors for developing TD include:

• older age
• negative symptoms of schizophrenia
• affective disorders
• acute EPS
• and diabetes mellitus.⁸

RECOGNIZING TD SYMPTOMS

Recognizing TD may be complicated by the presence of other EPS, particularly drug-induced parkinsonism (DIP). DIP typically develops early and often when treating patients with conventional antipsychotics (Table 1). TD and DIP may occur simultaneously in the same patient, making accurate diagnosis even more difficult.

Other dyskinesias may complicate the diagnosis. Three common TD variants, which may be acute or tardive (occurring after long-term antipsychotic therapy), are:

• akathisia, a distressing and at times irresistible urge to move the legs or other parts of the body
• dystonia, abnormal muscle tone and posture and muscle spasms
• tics, brief muscle contractions, usually in the face, including vocal tics.

AIMS testing. Defining a “case of TD” by dyskinetic movement severity is somewhat arbitrary. A commonly accepted definition is two area scores of “mild” or one rating of “moderate” using the Abnormal Involuntary Movement Scale (AIMS).⁹ The AIMS has been widely used in epidemiologic and treatment studies of TD and is easy to administer in a clinical setting (see Related Resources).

A careful drug history is required before TD can be diagnosed definitively. Spontaneous dys kinesias—usually orofacial—are sometimes seen in older patients who are not taking neuroleptics.⁸ Antidepressants, mood stabilizers, or antihistamines may infrequently trigger neurologic side effects—including dyskinesias, akathisia, and tremor—which are almost invariably reversible after the causative agent is withdrawn.^8,10

Table 1

Features that differentiate two common extrapyramidal symptoms

	Tardive dyskinesia (TD)	Drug-induced parkinsonism (DIP)
Onset	Late	Early
Type of movement	Choreoathetoid	Tremor
Amount of movement	Increased	Decreased
Muscle tone	Decreased	Increased
Most common site	Orofacial	Extremities
Response to anticholinergics	Tends to worsen	Tends to improve

MANAGING MILD TD

Atypical antipsychotics have radically altered the clinical outlook for patients with TD and improved our ability to manage their symptoms. The clinician treating a TD patient today rarely faces the dilemma that exists with conventional antipsychotics: discontinue treatment and risk psychotic relapse, or continue treatment and risk persistent TD.

Using atypicals. Today, patients who need antipsychotic therapy for TD are usually already taking atypicals, which may ameliorate TD and control psychotic symptoms. Case reports and some studies have shown therapeutic effects in patients with TD taking olanzapine,³ risperidone,² quetiapine,¹¹ ziprasidone,¹² aripiprazole,¹³ or the substituted benzamides (such as sulpiride), which are not marketed in the United States.¹⁴

 

Interestingly, TD triggered by taking one atypical may respond to treatment with another. Suzuki et al¹⁵ reported that three patients who had developed early-onset TD while taking risperidone showed TD remission after risperidone was replaced by olanzapine in one patient and by quetiapine in the other two.

The atypicals are well tolerated but not without side effects. Weight gain is the most common problem and one with potentially serious health consequences.¹⁶

Using conventional agents. Even though atypicals are available, the clinician may consider continuing therapy with conventional antipsychotics in patients with TD when:

• the patient’s mental status has been satisfactory while taking conventional agents
• TD has been mild and stable over an extended time
• the patient has no side effects other than TD.

The literature supports the clinical experience that mild TD rarely worsens with continued antipsychotic therapy. Studies of 5 years or more tend to show TD stability with continued conventional antipsychotic therapy.¹⁷ It is prudent to maintain stable chronic psychotic patients with mild TD on the lowest effective dosages of conventional antipsychotics and to monitor them regularly for changes in dyskinesia and psychiatric status.

MANAGING COMPLICATED TD

Managing severe TD or patients showing dystonia, tics, marked akathisia, or DIP coexisting with TD usually calls for more-aggressive interventions (Algorithm).

Algorithm Clinical management of tardive dyskinesia (TD)

Clozapine remains the first-line treatment for difficult TD; it has a very low propensity for inducing DIP and very rarely causes TD.¹⁸ Controlled studies,^18,19 case reports, and open trials demonstrate its efficacy for reducing TD of all types and severity at a usual dosage of 300 to 500 mg/d. Clozapine’s antidyskinetic effects may be attributed to the absence of rebound after withdrawal and its greater efficacy in more-severe cases.¹⁸

Long-term clozapine therapy is recommended for TD, as symptoms remit slowly. Because weight gain, sedation, and other side effects—as well as mandatory blood monitoring—make clozapine less-than-ideal in clinical practice, researchers are seeking other effective therapies for TD.

Other atypicals. The obvious place to look is the other atypicals, which are simpler than clozapine to administer long-term. To date, however, these drugs have not proven to be as reliably effective as clozapine for TD. A recent review concluded that among the atypicals only clozapine induces less EPS than low-potency conventional antipsychotics.²⁰

Nonantipsychotic agents. Other antidyskinetic drugs have come and gone; none has stood the test of time or proven effective in controlled trials. These agents may benefit some TD patients, but improvement is usually not dramatic.

Vitamin E was found to be effective in some TD treatment studies¹⁴ but not more effective than placebo in the largest controlled trial.²¹ Long-term treatment with dopamine-blocking antipsychotics is thought to cause oxidative stressinduced neurotoxicity in the nigrostriatal system.²² Lipid-soluble antioxidants such as vitamin E decrease free-radical formation, and it is possible that vitamin E may yet emerge as a helpful agent in preventing TD.²³

Melatonin, a stronger antioxidant than vitamin E, was found to reduce TD in a 6-week placebocontrolled study,²² but the degree of TD improvement was modest. Melatonin’s value as a therapeutic agent for TD remains dubious.²³

Miscellaneous. Case reports and studies with small series of TD patients have advanced numerous compounds as possible therapeutic agents (Table 2). Other drugs that occasionally have shown benefit in TD include buspirone, propranolol, pyridoxine (vitamin B6), ondansetron, clonidine, and the neuropeptide ceruletide.

ECT and diet. Suggested nondrug treatments of TD include electroconvulsive therapy (ECT)¹⁴ and a diet of mixed branched-chain amino acids.²⁴

Table 2

Compounds that occasionally show benefit in TD

Class	Example
Cholinergics	Lecithin
Catecholamine depletors	Tetrabenazine (investigational orphan drug)
Calcium channel blockers	Verapamil
Gabaergic compounds	Baclofen
Benzodiazepines	Clonazepam

MANAGING TD VARIANTS

TD variants are notoriously difficult to treat but tend to respond to clozapine.¹⁸ In addition:

• Tardive dystonia is often treated with reserpine, tetrabenazine, or high doses of anticholinergic drugs.²⁵ Botulinum toxin A injections into affected muscles may be remarkably effective but must be repeated regularly.²⁵
• Tardive akathisia may improve slowly with clozapine, propranolol, or benzodiazepines.²⁵

Managing severe or atypical TD is usually beyond the expertise of the practicing psychiatrist. Obtaining consultation from a psychopharmacologist or a neurologist experienced in treating movement disorders is highly recommended.

PREVENTING TD

Conventional antipsychotics are still prescribed by psychiatrists, internists, and family physicians and are often given in emergency rooms. Avoiding these drugs whenever possible and using the lowest effective dosages will reduce the risk of TD.²⁶

Patients at relatively high risk for TD—the elderly, those who are very sensitive to acute EPS, and those with affective disorders or diabetes mellitus—are rarely candidates for conventional neuroleptics if a suitable alternative exists. Genetic research may further identify individuals susceptible to TD.²⁷

 

Related resources

• Abnormal Involuntary Movement Scale (AIMS). www.dr-bob.org/tips/aims.html
• Bloom FE, Kupfer DJ (eds). Psychopharmacology: The fourth generation of progress. New York: Raven Press, 1995.
• Tandon R, Halbreich U (eds). Atypical antipsychotics: Efficacy and tolerability—achieving the optimal balance. Psychoneuroendocrinology 2003;28(suppl 1).

Drug brand names

• Aripiprazole • Abilify
• Baclofen • Lioresal
• Buspirone • BuSpar
• Clonazepam • Klonopin
• Clonidine • Catapres
• Clozapine • Clozaril
• Olanzapine • Zyprexa
• Ondansetron • Zofran
• Propranolol • Inderal
• Quetiapine • Seroquel
• Risperidone • Risperdal
• Verapamil • Calan, others
• Ziprasidone • Geodon

Disclosure

Dr. Gardos receives research grant support from Forest Laboratories.

Atypical antipsychotics seldom cause tardive dyskinesia (TD), but we cannot let our guard down when prescribing them. Although they pose a much lower risk of TD than do conventional antipsychotics, atypicals can cause TD in vulnerable patients.

Less worrisome than in the past, TD’s associated problems linger, including insidious onset, tendency for persistence, and lack of reliably effective treatment. It is important, therefore, for psychiatrists to:

• identify patients at risk for developing TD
• recognize extrapyramidal symptoms (EPS) when they occur
• and manage these side effects appropriately.

A CHANGING CLINICAL PICTURE

The term “dyskinesias” covers a variety of abnormal involuntary movements (Box). The incidence and prevalence of TD have dropped markedly in the last 10 years, as:

• more and more older, chronically ill patients are switched from conventional to atypical agents
• younger psychotic patients are usually treated with atypicals as first-line therapy and are never exposed to conventional antipsychotics.

Box

TD prevalence of about 20%—as shown by earlier studies of long-term conventional agents¹—is declining. Newer studies comparing atypicals with conventional antipsychotics demonstrate much lower prevalence rates.^2,3

TD incidence—estimated by new cases of TD per year of drug treatment—may have declined 10-fold, from 5% with conventional antipsychotics to 0.5% with atypicals. Likewise, incidence in the elderly may have fallen from 25% to 2.5%.⁴

Risk factors. Despite these improvements, case reports^5-7 demonstrate that TD is possible in patients treated with atypicals, even without previous exposure to a conventional antipsychotic. Besides antipsychotic use, risk factors for developing TD include:

• older age
• negative symptoms of schizophrenia
• affective disorders
• acute EPS
• and diabetes mellitus.⁸

RECOGNIZING TD SYMPTOMS

Recognizing TD may be complicated by the presence of other EPS, particularly drug-induced parkinsonism (DIP). DIP typically develops early and often when treating patients with conventional antipsychotics (Table 1). TD and DIP may occur simultaneously in the same patient, making accurate diagnosis even more difficult.

Other dyskinesias may complicate the diagnosis. Three common TD variants, which may be acute or tardive (occurring after long-term antipsychotic therapy), are:

• akathisia, a distressing and at times irresistible urge to move the legs or other parts of the body
• dystonia, abnormal muscle tone and posture and muscle spasms
• tics, brief muscle contractions, usually in the face, including vocal tics.

AIMS testing. Defining a “case of TD” by dyskinetic movement severity is somewhat arbitrary. A commonly accepted definition is two area scores of “mild” or one rating of “moderate” using the Abnormal Involuntary Movement Scale (AIMS).⁹ The AIMS has been widely used in epidemiologic and treatment studies of TD and is easy to administer in a clinical setting (see Related Resources).

A careful drug history is required before TD can be diagnosed definitively. Spontaneous dys kinesias—usually orofacial—are sometimes seen in older patients who are not taking neuroleptics.⁸ Antidepressants, mood stabilizers, or antihistamines may infrequently trigger neurologic side effects—including dyskinesias, akathisia, and tremor—which are almost invariably reversible after the causative agent is withdrawn.^8,10

Table 1

Features that differentiate two common extrapyramidal symptoms

	Tardive dyskinesia (TD)	Drug-induced parkinsonism (DIP)
Onset	Late	Early
Type of movement	Choreoathetoid	Tremor
Amount of movement	Increased	Decreased
Muscle tone	Decreased	Increased
Most common site	Orofacial	Extremities
Response to anticholinergics	Tends to worsen	Tends to improve

MANAGING MILD TD

Atypical antipsychotics have radically altered the clinical outlook for patients with TD and improved our ability to manage their symptoms. The clinician treating a TD patient today rarely faces the dilemma that exists with conventional antipsychotics: discontinue treatment and risk psychotic relapse, or continue treatment and risk persistent TD.

Using atypicals. Today, patients who need antipsychotic therapy for TD are usually already taking atypicals, which may ameliorate TD and control psychotic symptoms. Case reports and some studies have shown therapeutic effects in patients with TD taking olanzapine,³ risperidone,² quetiapine,¹¹ ziprasidone,¹² aripiprazole,¹³ or the substituted benzamides (such as sulpiride), which are not marketed in the United States.¹⁴

 

Interestingly, TD triggered by taking one atypical may respond to treatment with another. Suzuki et al¹⁵ reported that three patients who had developed early-onset TD while taking risperidone showed TD remission after risperidone was replaced by olanzapine in one patient and by quetiapine in the other two.

The atypicals are well tolerated but not without side effects. Weight gain is the most common problem and one with potentially serious health consequences.¹⁶

Using conventional agents. Even though atypicals are available, the clinician may consider continuing therapy with conventional antipsychotics in patients with TD when:

• the patient’s mental status has been satisfactory while taking conventional agents
• TD has been mild and stable over an extended time
• the patient has no side effects other than TD.

The literature supports the clinical experience that mild TD rarely worsens with continued antipsychotic therapy. Studies of 5 years or more tend to show TD stability with continued conventional antipsychotic therapy.¹⁷ It is prudent to maintain stable chronic psychotic patients with mild TD on the lowest effective dosages of conventional antipsychotics and to monitor them regularly for changes in dyskinesia and psychiatric status.

MANAGING COMPLICATED TD

Managing severe TD or patients showing dystonia, tics, marked akathisia, or DIP coexisting with TD usually calls for more-aggressive interventions (Algorithm).

Algorithm Clinical management of tardive dyskinesia (TD)

Clozapine remains the first-line treatment for difficult TD; it has a very low propensity for inducing DIP and very rarely causes TD.¹⁸ Controlled studies,^18,19 case reports, and open trials demonstrate its efficacy for reducing TD of all types and severity at a usual dosage of 300 to 500 mg/d. Clozapine’s antidyskinetic effects may be attributed to the absence of rebound after withdrawal and its greater efficacy in more-severe cases.¹⁸

Long-term clozapine therapy is recommended for TD, as symptoms remit slowly. Because weight gain, sedation, and other side effects—as well as mandatory blood monitoring—make clozapine less-than-ideal in clinical practice, researchers are seeking other effective therapies for TD.

Other atypicals. The obvious place to look is the other atypicals, which are simpler than clozapine to administer long-term. To date, however, these drugs have not proven to be as reliably effective as clozapine for TD. A recent review concluded that among the atypicals only clozapine induces less EPS than low-potency conventional antipsychotics.²⁰

Nonantipsychotic agents. Other antidyskinetic drugs have come and gone; none has stood the test of time or proven effective in controlled trials. These agents may benefit some TD patients, but improvement is usually not dramatic.

Vitamin E was found to be effective in some TD treatment studies¹⁴ but not more effective than placebo in the largest controlled trial.²¹ Long-term treatment with dopamine-blocking antipsychotics is thought to cause oxidative stressinduced neurotoxicity in the nigrostriatal system.²² Lipid-soluble antioxidants such as vitamin E decrease free-radical formation, and it is possible that vitamin E may yet emerge as a helpful agent in preventing TD.²³

Melatonin, a stronger antioxidant than vitamin E, was found to reduce TD in a 6-week placebocontrolled study,²² but the degree of TD improvement was modest. Melatonin’s value as a therapeutic agent for TD remains dubious.²³

Miscellaneous. Case reports and studies with small series of TD patients have advanced numerous compounds as possible therapeutic agents (Table 2). Other drugs that occasionally have shown benefit in TD include buspirone, propranolol, pyridoxine (vitamin B6), ondansetron, clonidine, and the neuropeptide ceruletide.

ECT and diet. Suggested nondrug treatments of TD include electroconvulsive therapy (ECT)¹⁴ and a diet of mixed branched-chain amino acids.²⁴

Table 2

Compounds that occasionally show benefit in TD

Class	Example
Cholinergics	Lecithin
Catecholamine depletors	Tetrabenazine (investigational orphan drug)
Calcium channel blockers	Verapamil
Gabaergic compounds	Baclofen
Benzodiazepines	Clonazepam

MANAGING TD VARIANTS

TD variants are notoriously difficult to treat but tend to respond to clozapine.¹⁸ In addition:

• Tardive dystonia is often treated with reserpine, tetrabenazine, or high doses of anticholinergic drugs.²⁵ Botulinum toxin A injections into affected muscles may be remarkably effective but must be repeated regularly.²⁵
• Tardive akathisia may improve slowly with clozapine, propranolol, or benzodiazepines.²⁵

Managing severe or atypical TD is usually beyond the expertise of the practicing psychiatrist. Obtaining consultation from a psychopharmacologist or a neurologist experienced in treating movement disorders is highly recommended.

PREVENTING TD

Conventional antipsychotics are still prescribed by psychiatrists, internists, and family physicians and are often given in emergency rooms. Avoiding these drugs whenever possible and using the lowest effective dosages will reduce the risk of TD.²⁶

Patients at relatively high risk for TD—the elderly, those who are very sensitive to acute EPS, and those with affective disorders or diabetes mellitus—are rarely candidates for conventional neuroleptics if a suitable alternative exists. Genetic research may further identify individuals susceptible to TD.²⁷

 

Related resources

• Abnormal Involuntary Movement Scale (AIMS). www.dr-bob.org/tips/aims.html
• Bloom FE, Kupfer DJ (eds). Psychopharmacology: The fourth generation of progress. New York: Raven Press, 1995.
• Tandon R, Halbreich U (eds). Atypical antipsychotics: Efficacy and tolerability—achieving the optimal balance. Psychoneuroendocrinology 2003;28(suppl 1).

Drug brand names

• Aripiprazole • Abilify
• Baclofen • Lioresal
• Buspirone • BuSpar
• Clonazepam • Klonopin
• Clonidine • Catapres
• Clozapine • Clozaril
• Olanzapine • Zyprexa
• Ondansetron • Zofran
• Propranolol • Inderal
• Quetiapine • Seroquel
• Risperidone • Risperdal
• Verapamil • Calan, others
• Ziprasidone • Geodon

Disclosure

Dr. Gardos receives research grant support from Forest Laboratories.

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

 

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Condition	Relative risk	Incidence (%/year)	Lifetime risk (%)
Prior suicide attempt	38.4	0.549	27.5
Bipolar disorder	21.7	0.310	15.5
Major depression	20.4	0.292	14.6
Mixed drug abuse	19.2	0.275	14.7
Dysthymia	12.1	0.173	8.65
Obsessive-compulsive disorder	11.5	0.143	8.15
Panic disorder	10.0	0.160	7.15
Schizophrenia	8.45	0.121	6.05
Personality disorders	7.08	0.101	5.05
Alcohol abuse	5.86	0.084	4.20
Cancer	1.80	0.026	1.30
General population	1.00	0.014	0.72
* Estimated relative risks compared with the general population,2 with recently updated information about bipolar disorders.6 Annual rates are based on international general population average (14.3/100,000/year) × standardized mortality ratio; lifetime estimates are based on annual rates × 50 years as an estimate of lifetime exposure for years at major risk.

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

Treatment or sample	Suicides	Attempts	All acts	A/S ratio
With lithium	0.16	0.41	0.57	2.6
Without lithium	0.88	4.02	4.90	4.6
Off/on lithium ratio	5.5	9.8	8.6	—
General population	0.014	0.21	0.22	15.3
Off lithium/general population ratio	56.4	19.1	22.3	—
On lithium/general population ratio	11.4	2.0	2.6	—
A/S ratio: Attempts versus completed suicides
* Rates (acts/year/100 persons, or %/year), based on previously reported averages derived from analyses of data from 33 studies with 55 treatment-arms,12 from a more selected analysis of 22 studies of completed suicides,11 and updated estimates for general population rates.6

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

 

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

Treatments compared	Disorder treated	Benefit/risk ratio
Mood stabilizers
Lithium vs. none or placebo*	Bipolar disorder
Suicides		8.8 (4.1 to 19.1)a
Attempts		9.9 (5.0 to 14.8)b
Lithium vs. carbamazepine*	Bipolar disorder	≥2.5c
Lithium vs. divalproex*	Bipolar disorder	2.7 (1.2 to 6.2)d
Antidepressants
Antidepressants (any) vs. placebo/none	Major depressive disorder	1.1 (0.7 to 1.6)e
Tricyclics vs. SSRIs	Major depressive disorder	1.2 (0.7 to 2.1)e
Antipsychotics
Clozapine vs. any antipsychotic*	Schizophrenia
Suicides + attempts		3.3 (1.7 to 6.3)f
Attempts		2.9 (1.5 to 5.7)f
Clozapine vs. olanzapine*	Schizophrenia
Suicides + attempts		1.3 (1.0 to 1.7)g
a. Tondo et al, 200111
b. Baldessarini et al, 20035
c. Thies-Flechtner et al, 199517
d. Goodwin et al, 200218
e. Baldessarini et al, 20035
f. Baldessarini & Hennen, 200322
g. Meltzer et al, 200324
* First agent is statistically more effective, based on benefit/risk ratio (95% CI).

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

 

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

 

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Condition	Relative risk	Incidence (%/year)	Lifetime risk (%)
Prior suicide attempt	38.4	0.549	27.5
Bipolar disorder	21.7	0.310	15.5
Major depression	20.4	0.292	14.6
Mixed drug abuse	19.2	0.275	14.7
Dysthymia	12.1	0.173	8.65
Obsessive-compulsive disorder	11.5	0.143	8.15
Panic disorder	10.0	0.160	7.15
Schizophrenia	8.45	0.121	6.05
Personality disorders	7.08	0.101	5.05
Alcohol abuse	5.86	0.084	4.20
Cancer	1.80	0.026	1.30
General population	1.00	0.014	0.72
* Estimated relative risks compared with the general population,2 with recently updated information about bipolar disorders.6 Annual rates are based on international general population average (14.3/100,000/year) × standardized mortality ratio; lifetime estimates are based on annual rates × 50 years as an estimate of lifetime exposure for years at major risk.

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

Treatment or sample	Suicides	Attempts	All acts	A/S ratio
With lithium	0.16	0.41	0.57	2.6
Without lithium	0.88	4.02	4.90	4.6
Off/on lithium ratio	5.5	9.8	8.6	—
General population	0.014	0.21	0.22	15.3
Off lithium/general population ratio	56.4	19.1	22.3	—
On lithium/general population ratio	11.4	2.0	2.6	—
A/S ratio: Attempts versus completed suicides
* Rates (acts/year/100 persons, or %/year), based on previously reported averages derived from analyses of data from 33 studies with 55 treatment-arms,12 from a more selected analysis of 22 studies of completed suicides,11 and updated estimates for general population rates.6

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

 

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

Treatments compared	Disorder treated	Benefit/risk ratio
Mood stabilizers
Lithium vs. none or placebo*	Bipolar disorder
Suicides		8.8 (4.1 to 19.1)a
Attempts		9.9 (5.0 to 14.8)b
Lithium vs. carbamazepine*	Bipolar disorder	≥2.5c
Lithium vs. divalproex*	Bipolar disorder	2.7 (1.2 to 6.2)d
Antidepressants
Antidepressants (any) vs. placebo/none	Major depressive disorder	1.1 (0.7 to 1.6)e
Tricyclics vs. SSRIs	Major depressive disorder	1.2 (0.7 to 2.1)e
Antipsychotics
Clozapine vs. any antipsychotic*	Schizophrenia
Suicides + attempts		3.3 (1.7 to 6.3)f
Attempts		2.9 (1.5 to 5.7)f
Clozapine vs. olanzapine*	Schizophrenia
Suicides + attempts		1.3 (1.0 to 1.7)g
a. Tondo et al, 200111
b. Baldessarini et al, 20035
c. Thies-Flechtner et al, 199517
d. Goodwin et al, 200218
e. Baldessarini et al, 20035
f. Baldessarini & Hennen, 200322
g. Meltzer et al, 200324
* First agent is statistically more effective, based on benefit/risk ratio (95% CI).

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

 

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Which psychotropics reduce the risk of suicide in patients with psychiatric disorders? Although no drugs eliminate the risk, new evidence is clarifying that some therapeutic choices can make a difference:

• Long-term lithium treatment apparently reduces suicide risk in patients with affective disorders; mood-altering anticonvulsants are less well studied but show less benefit than lithium.
• Effects of antidepressants remain inconclusive without adequate long-term studies.
• At least one atypical antipsychotic—clozapine—probably lowers suicide risk, although direct comparisons of antipsychotic agents are rare.
• Surprisingly little evidence is available on nondrug interventions, including rapid hospitalization, psychotherapy, and electroconvulsive therapy.¹

Suicide is the leading cause of malpractice liability in psychiatry and of the heightened risk of death in persons with major affective and psychotic disorders (Box).^1-4 Here are the latest findings to help you choose medications for at-risk patients with bipolar disorder, major depression, or chronic psychoses.

Box

BIPOLAR DISORDER AND MOOD STABILIZERS

Bipolar disorder is associated with the highest suicide rate among all major psychiatric illnesses, with an international incidence averaging 0.31% of patients per year.⁴ This rate may slightly exceed the suicide rate of patients with major depression, which averages 0.29%/year.

Risk of suicidal behavior is similar among patients with bipolar type II (depression with hypomania) and type I disorder (depression with mania), supporting the view that type II is not a milder form of bipolar illness.^4-6 Indeed, one study of suicide attempts found a higher risk among bipolar II patients (24%) than in bipolar I patients (17%) as well as a higher risk in both bipolar types than in persons diagnosed with unipolar major depression (12%).⁴

Suicidal behavior in bipolar disorder is associated almost entirely with ongoing depression or dysphoria and is especially likely to follow severe and highly recurrent depressive episodes.^5,6 Combinations of depressive-dysphoric and irritable, agitated, anxious features in “mixed states” may be particularly dangerous and can be hard to diagnose with confidence. Moreover, DSM-IV criteria for mixed states are far too narrow in requiring symptoms to simultaneously fulfill criteria for both mania and major depression. More broadly defined mixed states are very common. Underdiagnosis risks underestimation of suicidal potential, and misdiagnosis as “agitated depression” encourages potentially dangerous overuse of antidepressants.^5,7

Depression or dysphoria is the most prevalent morbidity in patients with bipolar disorder. Major and minor depressive states and mixed-dysphoric phases account for nearly one-third of time in follow-up care, exceeding time in mania or hypomania by more than 4-fold.⁸ Ironically, however, bipolar depression is one of the least-studied forms of major depression. Suicidal bipolar patients are typically excluded from antidepressant studies because of the risks of inducing greater instability, agitation, or mania while treating them with an antidepressant but without a mood stabilizer.⁷

LITHIUM’S PROTECTIVE EFFECT

Decades of research and clinical use demonstrate substantially lower risks of suicide and serious suicide attempts when patients with bipolar disorder are treated long-term with lithium salts in standard clinical doses (serum concentrations typically 0.6 to 0.8 mEq/L). Lithium is highly effective in treating all phases of bipolar disorder. A recent meta-analysis of 26 long-term trials of lithium reported between 1967 and 2001 found an average 3.2-fold sparing of morbidity or relapse risk.⁹

Benefits in types I and II. A large European sample¹⁰ compared percent-time-ill in bipolar patients before and after they received lithium as maintenance treatment. Unexpectedly, lithium therapy reduced percent-time-ill to a greater extent among patients with type II than type I bipolar disorder. Time in mania and time in depression were reduced 2.5-fold and 2.0-fold, respectively, in type I patients, compared with nearly 5-fold for time in hypomania and 2.5-fold for time in depression among type II patients.

Because depression is associated with the highest rates of suicidal behavior in all phases of bipolar disorders, lithium’s effects in preventing depressive recurrence are especially important for reducing suicide risk.⁶

 

In a review of 22 studies¹¹ —some including patients with bipolar or recurrent unipolar major depression—risk of death by suicide was reduced at least 5-fold, based on an informal comparison of pooled rates in treated versus untreated samples. Based on quantitative meta-analysis, the pooled risk of death by suicide was reduced nearly 9-fold (or by 89%) in patients who received lithium maintenance treatment compared with those who did not. The risk for suicide attempts fell nearly 10-fold in a compilation of 33 studies (Table 2).¹² Available studies do not permit separate analysis of lithium’s effects on suicidal behavior among patients with bipolar disorder and recurrent unipolar depression, leaving the relative benefit by diagnosis uncertain.

Table 1

Suicide risks in selected psychiatric disorders*

Condition	Relative risk	Incidence (%/year)	Lifetime risk (%)
Prior suicide attempt	38.4	0.549	27.5
Bipolar disorder	21.7	0.310	15.5
Major depression	20.4	0.292	14.6
Mixed drug abuse	19.2	0.275	14.7
Dysthymia	12.1	0.173	8.65
Obsessive-compulsive disorder	11.5	0.143	8.15
Panic disorder	10.0	0.160	7.15
Schizophrenia	8.45	0.121	6.05
Personality disorders	7.08	0.101	5.05
Alcohol abuse	5.86	0.084	4.20
Cancer	1.80	0.026	1.30
General population	1.00	0.014	0.72
* Estimated relative risks compared with the general population,2 with recently updated information about bipolar disorders.6 Annual rates are based on international general population average (14.3/100,000/year) × standardized mortality ratio; lifetime estimates are based on annual rates × 50 years as an estimate of lifetime exposure for years at major risk.

Dangers of stopping lithium. In our study⁵ of more than 200 patients with DSM-IV bipolar I or II disorder, prophylactic lithium treatment for an average of 4 years reduced the risk of completed and attempted suicide by 6.5-fold. A subgroup of more than 100 patients discontinued lithium, usually after prolonged stability, and we excluded from analysis any cases of suspected emerging illness associated with discontinuation. Within 6 to 12 months after stopping treatment, this subgroup’s rates of suicidal behavior increased markedly—by 20-fold above treated rates.⁵ Thereafter, their rates returned to prelithium treatment levels.

Of particular clinical importance:

• discontinuing lithium gradually—over at least 2 weeks—was associated with a 2-fold lower suicide risk than more-abrupt discontinuation
• suicidal behavior after lithium discontinuation was almost always associated with emerging depression, which can provide an early warning of impending suicidal risk.

Table 2

Effect of lithium treatment on risk of completed and attempted suicide in patients with bipolar and recurrent depressive disorders*

Treatment or sample	Suicides	Attempts	All acts	A/S ratio
With lithium	0.16	0.41	0.57	2.6
Without lithium	0.88	4.02	4.90	4.6
Off/on lithium ratio	5.5	9.8	8.6	—
General population	0.014	0.21	0.22	15.3
Off lithium/general population ratio	56.4	19.1	22.3	—
On lithium/general population ratio	11.4	2.0	2.6	—
A/S ratio: Attempts versus completed suicides
* Rates (acts/year/100 persons, or %/year), based on previously reported averages derived from analyses of data from 33 studies with 55 treatment-arms,12 from a more selected analysis of 22 studies of completed suicides,11 and updated estimates for general population rates.6

This is not the first time we have found evidence of a dramatic—but time-limited—increase in risk of recurrent bipolar illness when lithium treatment was discontinued.¹³ Bipolar disorder patients who discontinue long-term lithium treatment abruptly are at high risk of recurrent depression and mania.¹³

Incomplete protection. Lithium’s protection against suicidal risk is incomplete, as one can see by comparing lithium-treated versus untreated bipolar patients’ suicide rates with those of the general population (Table 2).⁶

With lithium:

• suicides plus attempts declined 8.6-fold to levels 2.6 times greater than those of the general population
• suicide attempts fell 10-fold to levels that are about twice that of the general population
• risk of completed suicides declined 5.5-fold with lithium treatment but remained 11 times higher than that of the general population.

Without lithium:

• risk of suicide in bipolar patients is approximately 22 times greater than that of the general population
• ratio of attempts to suicides among bipolar disorder patients averages 4.6, suggesting that suicide attempts by patients with bipolar disorder are relatively lethal.⁶

Effect of delayed lithium therapy. Many patients with bipolar disorder do not receive sustained prophylactic treatment early in the illness.

Studies typically show an average 5- to 10-year gap between illness onset and the start of sustained lithium maintenance treatment. This delay averages more than 3 years longer among women with bipolar II disorder than men with bipolar I disorder, evidently reflecting major clinical dissimilarities between these groups.^6,14 In contrast, we found that nearly one-quarter of long-term risk of suicidal behavior emerges within the first year of bipolar illness.⁵ Clearly, patients with recurrent major affective illness require earlier intervention and more consistent clinical care.

We have also found that delayed maintenance treatment or the number of prior episodes of bipolar illness do not seem to limit therapeutic response to lithium.^14,15 These findings support the conclusion that prophylactic lithium treatment can be worthwhile, even after years of illness and many recurrences. Moreover, our recent meta-analysis of treatment options for rapid-cycling bipolar illness indicates that—even though all treatments have yielded inferior results compared with nonrapidly-cycling patients—no alternative has outperformed lithium.¹⁶

 

Anticonvulsants. Evidence regarding the effects of other mood stabilizers on suicide risk in bipolar disorder remains limited:

• In a European collaborative study, several hundred patients with bipolar or schizoaffective disorder were randomly assigned to receive lithium or carbamazepine for nearly 2 years. Rates of suicidal acts were 2.5%/year with the anticonvulsant, but there were no suicides or attempts in patients receiving lithium.¹⁷ Direct comparisons are rare, but this difference was both striking and statistically significant.
• Computerized records of approximately 20,000 patients diagnosed with bipolar disorder at two large American HMOs were analyzed to compare suicidal behaviors associated with specific treatments. Lithium yielded 2.7-fold greater protection against suicidal behavior (mainly attempts because suicides were rare) compared with anticonvulsants (mainly divalproex).¹⁸

Treatment recommendation. These observations support lithium’s value in long-term maintenance of patients with bipolar disorder. Lithium’s apparent reduction of suicide risk is striking and may be superior to that of other mood-stabilizers. Alternate treatments and lithium’s potential value for reducing suicide risk in patients with unipolar depression require further study.

It is important to emphasize that lithium can be toxic or even fatal in acute overdose. This risk is integral to the equation when you assess risks and benefits for individual patients.

MAJOR DEPRESSION AND ANTIDEPRESSANTS

Major depression and depressive components of other disorders are major risk factors for suicide.^1,2,6 Depression continues to be surprisingly underrecognized and undertreated, even though relatively safe and tolerable antidepressants are readily available.^1,6,19,20 Patients with recurrent unipolar major depression often remain inconsistently or inadequately treated, even after they attempt suicide.¹⁹

Recent reviews of suicide risk during research on antidepressant treatment in major depression suggest that:

• antidepressants of various kinds may tend to reduce the risk of suicidal behavior, but any such effect is small and statistically nonsignificant (Baldessarini et al, 2003, unpublished)
• tricyclic antidepressants may yield lower rates of suicidal behavior than selective serotonin reuptake inhibitors (SSRIs). Similarly, however, such trends reflect highly variable research methods and inconsistent findings and do not hold up to quantitative analysis (Baldessarini et al, 2003, unpublished).

The suicidal events encountered during research mainly involve attempts because suicides are rare, particularly in relatively brief treatment trials that exclude acutely suicidal subjects. Analyses are further complicated by trends toward paradoxically lower suicidal risks among depressed patients randomized to a placebo in controlled antidepressant trials. This paradox is paralleled by often earlier removal of patients treated with a placebo than with an active antidepressant, perhaps in association with emerging suicidality.²¹

Table 3

Preventing suicide: How effective are specific treatments?

Treatments compared	Disorder treated	Benefit/risk ratio
Mood stabilizers
Lithium vs. none or placebo*	Bipolar disorder
Suicides		8.8 (4.1 to 19.1)a
Attempts		9.9 (5.0 to 14.8)b
Lithium vs. carbamazepine*	Bipolar disorder	≥2.5c
Lithium vs. divalproex*	Bipolar disorder	2.7 (1.2 to 6.2)d
Antidepressants
Antidepressants (any) vs. placebo/none	Major depressive disorder	1.1 (0.7 to 1.6)e
Tricyclics vs. SSRIs	Major depressive disorder	1.2 (0.7 to 2.1)e
Antipsychotics
Clozapine vs. any antipsychotic*	Schizophrenia
Suicides + attempts		3.3 (1.7 to 6.3)f
Attempts		2.9 (1.5 to 5.7)f
Clozapine vs. olanzapine*	Schizophrenia
Suicides + attempts		1.3 (1.0 to 1.7)g
a. Tondo et al, 200111
b. Baldessarini et al, 20035
c. Thies-Flechtner et al, 199517
d. Goodwin et al, 200218
e. Baldessarini et al, 20035
f. Baldessarini & Hennen, 200322
g. Meltzer et al, 200324
* First agent is statistically more effective, based on benefit/risk ratio (95% CI).

These trends toward lower suicide risk among patients receiving a placebo are somewhat reassuring, given concern that placebo randomization for scientific purposes may endanger study subjects. However, these artifacts confound interpretation of results and make it difficult to measure the effects of antidepressant treatment.

Treatment recommendation. Clinical prudence requires us to treat potentially lethal major depressive illness aggressively, even though one cannot state with confidence that any antidepressant class lowers suicide risk or that one class is significantly more effective than others (Table 3).

SCHIZOPHRENIA AND ANTIPSYCHOTICS

For schizophrenia and other primary psychotic disorders, little research exists to indicate that atypical antipsychotics reduce suicide risk. Evidence is emerging, however, that clozapine may offer this benefit,²² in addition to its well-substantiated clinical superiority in treatment-resistant psychotic illness.²³

Pooled evidence from controlled trials comparing clozapine with other antipsychotics indicates a 2-fold lower risk of mortality from all causes.²³ This finding was highly suggestive but not statistically significant, and the specific contribution of suicide to this risk is unknown.²³ Our recent meta-analysis of the few available studies found that clozapine was associated with a statistically significant, 3.3-fold lower overall suicidal risk compared with other antipsychotic treatments.²²

A well-designed, 2-year study randomly assigned 980 patients with schizophrenia or schizoaffective disorder who were at high risk for suicide to clozapine (mean 274 mg/d) or olanzapine (mean 16.6 mg/d). Clozapine showed moderately greater benefit in reducing suicide attempts and need for urgent intervention for perceived emerging suicide risk, although it did not lower suicide risk per se.²⁴ Another study associated olanzapine with a 2.3-fold lower risk of suicidal behavior, compared with haloperidol.²⁵

 

Comparing two potentially effective agents may have limited the observed difference between clozapine and olanzapine.²⁴ Nevertheless, previous (largely uncontrolled) comparisons with other treatment options indicate substantially lower risks of both suicides and attempts with clozapine.²² In December 2002, the FDA approved a unique indication for clozapine: to reduce the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Treatment recommendation. Risks of suicide and other causes of premature death are high in patients with chronic psychotic disorders, underlining the importance of appropriate longterm care. Clozapine has shown benefit in reducing risk of suicidal behaviors. When clozapine is otherwise a plausible option, this additional potential benefit can be considered when selecting therapy for individual patients.

Related resources

• American Psychiatric Association. Suicide-prevention practice guidelines. Washington, DC: American Psychiatric Press, 2003 (in press).
• American Foundation for Suicide Prevention. http://www.afsp.org
• American Association of Suicidology. www.suicidology.org
• National Institute of Mental Health (NIMH)/Suicide.

Drug brand names

• Clozapine • Clozaril
• Carbamazepine • Tegretol
• Divalproex • Depakote
• Haloperidol • Haldol
• Lithium carbonate • Eskalith, Lithobid, others
• Olanzapine • Zyprexa

Disclosure

Dr. Baldessarini has received research grants from Molecular Insight Pharmaceuticals, Eli Lilly and Co., Janssen Pharmaceutica, Protarga Inc., and Solvay Pharmaceuticals, and is a consultant to Auritec Laboratories, Molecular Insight Pharmaceuticals, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutica, and Protarga Inc.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

Stage of change	Patient behavior
Precontemplation	No intention to change behavior in the foreseeable future; little or no awareness of problems
Contemplation	Aware that a problem exists; seriously thinking about overcoming it but no commitment to take action
Preparation	Intends to take action within the next month; has tried unsuccessfully to take action in the past year
Action	Modifies behavior, experiences, or environment to overcome problems
Maintenance	Works to prevent relapse and consolidate gains attained during action stage; for addictive behaviors, maintenance extends indefinitely from 6 months after the initial action
Source: Prochaska JO. Transtheoretical model: Stages of Change. Cancer Prevention Research Center, University of Rhode Island. http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

 

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

Phase	Therapeutic goals
Engagement	Build an alliance Attract patient to treatment program
Persuasion	Convince engaged patient to accept longer-term, abstinence-based treatment
Active treatment	Help patient develop attitudes and techniques essential to maintain sobriety
Relapse prevention	Help patient maintain gains made in active treatment and cope with lapses/relapses should they occur

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

 

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

Stage of change	Patient behavior
Precontemplation	No intention to change behavior in the foreseeable future; little or no awareness of problems
Contemplation	Aware that a problem exists; seriously thinking about overcoming it but no commitment to take action
Preparation	Intends to take action within the next month; has tried unsuccessfully to take action in the past year
Action	Modifies behavior, experiences, or environment to overcome problems
Maintenance	Works to prevent relapse and consolidate gains attained during action stage; for addictive behaviors, maintenance extends indefinitely from 6 months after the initial action
Source: Prochaska JO. Transtheoretical model: Stages of Change. Cancer Prevention Research Center, University of Rhode Island. http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

 

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

Phase	Therapeutic goals
Engagement	Build an alliance Attract patient to treatment program
Persuasion	Convince engaged patient to accept longer-term, abstinence-based treatment
Active treatment	Help patient develop attitudes and techniques essential to maintain sobriety
Relapse prevention	Help patient maintain gains made in active treatment and cope with lapses/relapses should they occur

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

 

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:

• appreciate this population’s heterogeneity
• adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
• be empathic rather than confrontational
• realize that treatment often proceeds in stages—not on a smooth, linear path
• recognize the importance of medication compliance.

ASSESSMENT

Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:

Box

• diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
• severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
• causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
• level of motivation for treatment and their treatment goals.

Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.

A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.

Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.

Our research³ and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.⁴

Stages of Change model. The Stages of Change model^5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.^7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),⁵ people generally make behavioral changes in stages defined by their level of willingness to make these changes.

When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.

Table 1

5 stages of change: The transtheoretical model of behavior change

Stage of change	Patient behavior
Precontemplation	No intention to change behavior in the foreseeable future; little or no awareness of problems
Contemplation	Aware that a problem exists; seriously thinking about overcoming it but no commitment to take action
Preparation	Intends to take action within the next month; has tried unsuccessfully to take action in the past year
Action	Modifies behavior, experiences, or environment to overcome problems
Maintenance	Works to prevent relapse and consolidate gains attained during action stage; for addictive behaviors, maintenance extends indefinitely from 6 months after the initial action
Source: Prochaska JO. Transtheoretical model: Stages of Change. Cancer Prevention Research Center, University of Rhode Island. http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm

It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.

 

WHICH DISORDER IS TREATED FIRST?

Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.

Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.

Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).

One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.

Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.^{9 11} Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:

• focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
• providing intense case management
• stressing the importance of medication compliance.¹²

COUNSELING PRINCIPLES

As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.

Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”

As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.

Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.

Table 2

4 phases in treating the dually diagnosed patient

Phase	Therapeutic goals
Engagement	Build an alliance Attract patient to treatment program
Persuasion	Convince engaged patient to accept longer-term, abstinence-based treatment
Active treatment	Help patient develop attitudes and techniques essential to maintain sobriety
Relapse prevention	Help patient maintain gains made in active treatment and cope with lapses/relapses should they occur

To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).

PHASES OF TREATMENT

Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).¹³ Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.

Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.

Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.

Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.

Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.¹⁴ Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.

Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.

Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.

 

ADJUNCTIVE TREATMENTS

Self-help groups. Ask whether the patient has attended self-help groups for addiction or psychiatric illness. If so, then ask, “What did you think of the meetings? What did you like and dislike?”

Self-help groups such as Alcoholics Anonymous (AA) or the Manic-Depressive and Depressive Association (MDDA) can help enormously in the recovery process. These groups are free, readily available, and can offer patients a support network. Although many dual-diagnosis patients are reluctant to attend self-help groups, they may benefit from the support, role modeling, practical advice, and structure that these meetings offer.

Drug therapy for the dual-diagnosis patient focuses on the psychiatric disorder and is usually combined with psychosocial approaches. There is little evidence that one medication is more effective than others for these patients.

Because medication compliance is key to their effective treatment, be sure to ask patients at each visit, “Have you been taking your medication as prescribed?” Because dual-diagnosis patients have been shown to take more or less medication than prescribed,¹⁵ asking how much medication they are taking can be revealing.

Related resources

• American Academy of Addiction Psychiatry www.aaap.org
• National Institute on Drug Abuse www.nida.nih.gov
• National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov

Disclosure

Dr. Manwani receives research support from Abbott Laboratories.

Dr. Weiss is a speaker for Abbott Laboratories and Eli Lilly and Co.

Acknowledgment

Supported by grants K0200326, DA09400, and DA15968 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

Disorder	Weighted mean prevalence among abuse victims	Lifetime prevalence among general population
Alcohol abuse/dependence 4	19%	5 to 8%
Depression 4	48%	10% to 21%
Drug abuse disorder 4	9%	5% to 6%
Posttraumatic stress disorder 4	64%	1% to 12%
Suicidality 4	18% (ideation and attempts)	Ideation 1-16% Attempts <1-4%
	% of abused sample	% of non-abused sample
Anxiety symptoms 5	26%	8%
Generalized anxiety Disorder 6	10%	4%
Panic disorder 6	13%	<1%

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

 

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

1. In general, how would you describe your relationship?
□ a lot of tension	□ some tension	□ no tension
2. Do you and your partner work out arguments with:
□ great difficulty	□ some difficulty	□ no difficulty
Answers are scored on a 1-to-3 scale, with 1 meaning “a lot of tension” or “great difficulty.” A score of 1 on either question indicates possible domestic abuse/violence.
Source: Reference 14

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

 

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

Disorder	Weighted mean prevalence among abuse victims	Lifetime prevalence among general population
Alcohol abuse/dependence 4	19%	5 to 8%
Depression 4	48%	10% to 21%
Drug abuse disorder 4	9%	5% to 6%
Posttraumatic stress disorder 4	64%	1% to 12%
Suicidality 4	18% (ideation and attempts)	Ideation 1-16% Attempts <1-4%
	% of abused sample	% of non-abused sample
Anxiety symptoms 5	26%	8%
Generalized anxiety Disorder 6	10%	4%
Panic disorder 6	13%	<1%

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

 

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

1. In general, how would you describe your relationship?
□ a lot of tension	□ some tension	□ no tension
2. Do you and your partner work out arguments with:
□ great difficulty	□ some difficulty	□ no difficulty
Answers are scored on a 1-to-3 scale, with 1 meaning “a lot of tension” or “great difficulty.” A score of 1 on either question indicates possible domestic abuse/violence.
Source: Reference 14

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

 

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come,⁷ and possibly saving the patient’s life.

This article will discuss ways to:

• detect signs of abuse
• determine whether a victim is in danger
• share information about crisis resources
• help those who are considering leaving an abusive partner to make a safety plan.

Box 1

CASE REPORT: TWO YEARS OF HURT

Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.

Table 1

Psychiatric disorders in victims of domestic abuse/violence

Disorder	Weighted mean prevalence among abuse victims	Lifetime prevalence among general population
Alcohol abuse/dependence 4	19%	5 to 8%
Depression 4	48%	10% to 21%
Drug abuse disorder 4	9%	5% to 6%
Posttraumatic stress disorder 4	64%	1% to 12%
Suicidality 4	18% (ideation and attempts)	Ideation 1-16% Attempts <1-4%
	% of abused sample	% of non-abused sample
Anxiety symptoms 5	26%	8%
Generalized anxiety Disorder 6	10%	4%
Panic disorder 6	13%	<1%

She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.

When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.

Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.

The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.

SCREENING FOR ABUSE

The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence.^8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources.¹¹

Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.

Prevention and treatment guidelines for physicians^9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.¹¹

Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.

WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).¹⁴

WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse.¹⁴ It includes the two WAST-short questions, plus five questions about whether:

• arguments with an intimate partner ever diminish the patient’s self-esteem
• such arguments ever result in kicking or hitting
• the patient ever feels frightened by the partner’s words or actions
• the patient has ever been physically or emotionally abused by his or her partner.

Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.

HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:

• Hurt you physically?
• Insult you or talk down to you?
• Threaten you with harm?
• Scream or curse at you?”

 

Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse.¹⁵

Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:

• “Do you live alone?”
• “Do you have a significant other?”
• “How is your relationship going?”
• “Is your partner supportive?”
• “What happens when you and your partner disagree?”

Table 2

Woman Abuse Screening Tool-Short version

1. In general, how would you describe your relationship?
□ a lot of tension	□ some tension	□ no tension
2. Do you and your partner work out arguments with:
□ great difficulty	□ some difficulty	□ no difficulty
Answers are scored on a 1-to-3 scale, with 1 meaning “a lot of tension” or “great difficulty.” A score of 1 on either question indicates possible domestic abuse/violence.
Source: Reference 14

Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.

Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon.¹⁶ In these states, clinicians should disclose their reporting obligation at the start of the patient interview.

Box 2

Box 3

WHEN A PATIENT CONFIRMS ABUSE

Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”

Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.

Assess the danger to the patient (Box 2).¹⁷

Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.

Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.

DEVELOPING A SAFETY PLAN

Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.

Start by asking the patient:

• “If you leave home, where will you go?
• Is there an alternative if you cannot stay where you planned?
• Do you have an emergency bag?” (Box 3) ¹⁷

Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.

Instruct the patient to:

• Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
• Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
• Learn the local domestic violence hotline number.¹⁷

 

IF A PATIENT DENIES ABUSE

If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.

Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.

Related resources

• National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
• National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
• American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
• American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org

Drug brand names

• Fluoxetine • Prozac
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

CASE REPORT: I have a gun

Mr. V, age 77, appears depressed and anxious during his appointment at a mental hygiene clinic. He reports insomnia, concentration trouble, and anhedonia. He tells the psychiatrist he keeps a loaded gun at home and is not sure he can control his suicidal impulses.

The patient is Caucasian and has a history of heart failure, pulmonary disease, and type 2 diabetes. His wife died 18 months ago. He lives alone, but his sister lives nearby. He recently received a right hip replacement, which required 3 months of rehabilitation in a nursing home to recover from surgical complications. He still has trouble walking.

As in Mr. V’s case, treating older patients referred for psychiatric care often involves evaluating suicide risk. His age, race, gender, depressed mood, recent bereavement, and medical ailments place him in the population at highest risk of suicide (Box, Table 1).^1-8

Box

This article describes an age-based psychiatric workup of the suicidal older patient, including factors to consider when screening for depressive symptoms, prescribing drug therapy, and determining the need for hospitalization.

AGE-BASED CLINICAL WORKUP

For older patients who report suicidal ideation, an age-appropriate workup—using clinical interviews and screening instruments—is essential. The clinical interview can build rapport and gather information about the patient’s suicidal plan or intent. Based on our experience, we recommend the following 6-step screening interview, summarized in Table 2.

1. Ask about a specific plan. Does the patient have the means readily available to carry out this plan? What is the timeline (imminent versus vaguely futuristic)? Does the patient report having control over this plan?
2. Gather a suicide history. Has the patient attempted suicide before? By what means? Is there a family history of suicide? If yes, by what means did this family member commit suicide, and how was the patient affected?
3. Assess social status. How isolated is the patient? Have there been recent changes in his or her social circle, such as loss of a spouse? Can the patient identify at least one person who would be negatively affected by the suicide?
4. Assess medical health. Does the patient suffer from chronic pain? Does the patient have a recently diagnosed medical condition? Has a longstanding medical condition become more debilitating? Does the patient report feeling hopeless about impending medical difficulties? Has he or she been keeping regularly scheduled medical appointments with outpatient clinicians?
5. Assess mental health. Does the patient meet DSM-IV criteria for depression or schizophrenia, which are associated with high suicide risk? Does he or she report being hopeless or helpless? Is the suicidal ideation ego dystonic?
6. Ascertain clinical signs of suicidal intent. Has the patient:

Table 1

Suicide risk with mental and physical illness, by patient age

Risk factors	Young (21 to 34 yrs)	Middle-aged (35 to 54 yrs)	Young-old (55 to 74 yrs)	Elderly (77+ yrs)
Psychiatric disorders	•	•	•	•
Mood disorders		○	•	•
Alcohol abuse	○	•	○
Primary psychoses	•	○
Personality disorders	○
Physical ailments			•	•
• Significant risk factor ○ Potential risk factor
Source: Compiled from information in references 4-8.

CASE REPORT continued: Some telling signs

Mr. V’s laboratory screening reveals slightly elevated serum glucose and mild anemia. An ECG reveals a type I heart block, but all other lab results are unremarkable. His sister reports he recently gave away his dog, which he and his wife had owned for many years. He has also mentioned a desire to revise his will when speaking to other family members. Hospital records indicate he has missed numerous medical appointments over the past 4 months.

 

SCREENING INSTRUMENTS

Psychological assessments can often buttress the clinical interview findings. Several measurements are well-suited for detecting suicidal risk and concomitant depression (Table 3).

Beck SSI-C. The Beck Scale for Suicide Ideation – Current (SSI-C) assesses a patient’s preparation and motivation to commit suicide.⁹ This short (19-item) self-report measure asks patients to rate their wish to die, desire to attempt suicide, duration (and frequency) of suicidal thoughts, sense of control over suicide, and deterrents they face. The SSI-C helps to measure or monitor suicidality and is reliable and valid for psychiatric outpatients.⁹

BDI-II. The Beck Depression Inventory—recently revised in a second edition (BDI-II)¹⁰—can be useful because depression is one of the strongest risk factors for elder suicide. The 21-item BDI-II—a psychometrically sound, self-report instrument—asks about general symptoms of depression and gauges their severity. It can be applied to diverse patient populations and ages¹¹ and is appropriate for older patients who are also being treated medically.

Beck Hopelessness Scale. Hopelessness has been recognized as a possible harbinger of suicide.¹² One study showed that depression became a clinically meaningful suicide predictor only when accompanied by hopelessness.¹³

A score of 10 or more on the Beck Hopelessness Scale identified 91% of patients in one study who eventually committed suicide. The hopelessness patients expressed on this scale more strongly differentiated between those who did or did not commit suicide than did their scores on the BDI or SSI-C.¹⁴

Table 2

6-step clinical interview with an older suicidal patient

Determine plan and specify means Gather suicide history (personal and family history) Determine level of social support Evaluate medical health Evaluate mental health Determine presence of suicide warning signs:
Neglect of personal care Intentional self-starvation Recent writing or changing of a will Giving away material possessions Relinquishing responsibilities, such as pets or positions of authority
Source: Adapted from the Cincinnati Veterans Affairs Medical Center general psychological suicide assessment

HRSD-R. The revised Hamilton Rating Scale for Depression (HRSD-R) documents patients’ levels of mood disturbance and suicidality. One item in this 21-item, clinician-administered instrument specifically asks about the patient’s level of suicidality in the past week. The scale has well-documented reliability and validity and is appropriate for psychiatric populations.¹⁵

CASE REPORT continued: Alarming findings

Along with the clinical interview, Mr. V. is screened with the Beck Hopelessness Scale and Beck Depression Inventory-II. These instruments are chosen because they are easy to administer, and patients can readily comprehend the questions—even when under duress. Mr. V’s results reveal moderate depression and severe hopelessness.

INPATIENT VS. OUTPATIENT CARE

Older patients are often referred to a psychiatrist because of vague suicidal ideation, but they may also present in an acute crisis—with immediate plans for suicide and readily accessible means. The first concern for their safety is to ensure they are not left alone.

Patient interview. First, listen empathetically and ask detailed questions, especially ones that remind patients of their daily connections and responsibilities. For instance, ask, “Do you have children who would be affected by your decision?” Address patients’ immediate needs, such as hunger, thirst, or pain.¹⁶ Work on building a therapeutic alliance before asking questions that may appear trivial to agitated patients (such as tasks assessing cognitive abilities).

Avoid arguing with patients, and refrain from offering advice or sermonizing. Allow them to describe their emotions, and communicate that you understand their concerns. Discuss how they can expect to receive treatment to ease their discomfort. Inform them that mental health specialists can treat them and monitor their progress.

Hospitalization. Begin discussing treatment options and broach the notion of hospital admission if necessary. One way to foster an alliance is to frame inpatient care as a way of helping them recover from their crisis in a safe environment.

To ensure patient safety, it is best to err on the side of admission. Admitting the suicidal patient not only guarantees strict supervision but also allows time for necessary psychological assessment. Hospitalization may also allow family members to remove any weapons or hazardous conditions from the patient’s home.

Including the family in problem-solving is especially important when managing older suicidal patients. For patients who are isolated from family or friends, recovery may depend on improving their support network.

Table 3

Comparing screening instruments for suicide risk

Measure	Description	Time (minutes)
Beck Depression Inventory (BDI)	21-item, self-administered; identifies depressive symptoms in past week	10
Beck Hopelessness Scale (BHS)	20-item, self-administered; measures hopelessness, fatalism, and pessimism in past week	5
Beck Scale for Suicide Ideation-Current (SSI-C)	19-item, self-administered; gauges suicidal intention	10
Hamilton Rating Scale for Depression-revised (HRSD-R)	21-item, clinician-administered; rates depressive symptoms in past week	25

Outpatient care. Not all acutely suicidal older patients require hospital admission. They may be safely managed as outpatients if they:

 

• have strong social support
• are not isolated
• have no access to firearms or other dangerous weapons.

Safety can be enhanced by having family members take responsibility for the senior’s well-being and by asking the patient to contract for safety. A safety contract may include:

• verbal confirmation—and ideally a written statement—that the patient will not commit suicide within a specified period
• a list of people the patient will contact when feeling suicidal
• steps being taken to monitor the patient’s welfare.

Finally, schedule follow-up appointments soon after discharge to certify patients are being closely monitored. To encourage outpatient medication adherence, build strong alliances with family members and ask patients to bring in their pill bottles during follow-up appointments.

CASE REPORT continued: Observation begins

The staff is clearly concerned about Mr. V’s suicide risk and requests that he voluntarily admit himself to the VA hospital. This decision is based on his level of isolation, the lethality of his suicide plan, access to a weapon, and the depression and hopelessness revealed by his screening tests. He reluctantly agrees and is admitted to the inpatient psychiatric unit for observation and treatment by a geriatric internist and a geriatric psychiatrist.

DRUG THERAPY FOR SUICIDALITY

For patients with mild depressive symptoms, psychotherapy may be sufficient to manage depression associated with suicidality. However, those with moderate-to-severe depression require both drug treatment and psychotherapy.

Drug selection depends upon the underlying psychiatric illness. If the older patient is experiencing a depressive disorder, a selective serotonin reuptake inhibitor (SSRI) or another antidepressant could serve as first-line treatment (Table 4). These medications are safe for suicidal patients because they are not fatal in overdose.

Administration. Because age-related changes in pharmacokinetics and spharmacodynamics can slow medication clearance, reduced dosages usually achieve a therapeutic effect and minimize the risk of side effects in geriatric patients.

Antidepressants commonly used for older patients are shown in Table 4. Excepting citalopram and escitalopram, these dosages are lower than usual. We start healthy older patients on one-half the usual dosage and those who are medically ill or have neurodegenerative disorders on one-third to one-fourth the usual dosage. We also titrate more slowly to reduce the risk of side effects.

Table 4

Antidepressants commonly used to treat geriatric depression

Medication	Recommended dosage (mg/d)
SSRIs
Citalopram	20 to 40
Escitalopram	10 to 20
Fluoxetine	10 to 40
Paroxetine	10 to 40
Sertraline	25 to 150
Others
Bupropion	100 to 400
Mirtazapine	15 to 45
Venlafaxine	75 to 225

As in younger patients, the most common side effects of SSRIs in older patients include GI difficulties, overactivation, and sexual dysfunction. Paroxetine’s potential for anticholinergic effects may be a concern for some older patients.

Drug-drug interactions are of great concern when treating older patients, who take an average of six to nine medications per day.¹⁷ Compared with other SSRIs, fluoxetine and paroxetine, are more likely to inhibit cytochrome P-450 enzymes 2D6 and 3A4. They could thus increase blood levels of drugs taken concomitantly that are substrates of 2D6 or 3A4.

Antidepressant side effects can sometimes be used to advantage. For example, mirtazapine’s sedating property at lower dosages could help older patients with insomnia.

CASE REPORT concluded: Finding support

Mr. V is started on an SSRI antidepressant. He also receives supportive and milieu therapy and coping skills training. During his hospitalization, Mr. V contracts for safety and allows his sister to remove the handgun from his home.

Upon discharge, Mr. V is referred to a day treatment program that operates 3 to 5 days a week and offers case management, group therapy, and individual psychotherapy. The program helps him meet other older patients and allows him to discuss his life’s accomplishments and losses with others his age. His sister is an integral part of the program, and he maintains close contact with her.

Mr. V reports vague and occasional suicidal ideation, with no specific plan or intent. He and his sister note that his medical condition improved soon after his psychiatric condition stabilized.

Related resources

• Surgeon General’s Call to Action to Prevent Suicide. www.mental-health.org/suicideprevention/calltoaction.pdf
• Centers for Disease Control and Prevention. National Center for Injury Prevention and Control.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

Drs. Montross reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Mohamed is a speaker and consultant to Forest Laboratories and Eli Lilly and Co.

Dr. Kasckow receives research support from, is a consultant to, and is a speaker for Forest Laboratories, Eli Lilly and Co., Pfizer Inc., and Janssen Pharmaceutica.

 

Dr. Zisook is a consultant to GlaxoSmithKline and a speaker for GlaxoSmithKline, Wyeth Pharmaceuticals, Pfizer Inc., Forest Laboratories, and Bristol-Myers Squibb Co.

CASE REPORT: I have a gun

Mr. V, age 77, appears depressed and anxious during his appointment at a mental hygiene clinic. He reports insomnia, concentration trouble, and anhedonia. He tells the psychiatrist he keeps a loaded gun at home and is not sure he can control his suicidal impulses.

The patient is Caucasian and has a history of heart failure, pulmonary disease, and type 2 diabetes. His wife died 18 months ago. He lives alone, but his sister lives nearby. He recently received a right hip replacement, which required 3 months of rehabilitation in a nursing home to recover from surgical complications. He still has trouble walking.

As in Mr. V’s case, treating older patients referred for psychiatric care often involves evaluating suicide risk. His age, race, gender, depressed mood, recent bereavement, and medical ailments place him in the population at highest risk of suicide (Box, Table 1).^1-8

Box

This article describes an age-based psychiatric workup of the suicidal older patient, including factors to consider when screening for depressive symptoms, prescribing drug therapy, and determining the need for hospitalization.

AGE-BASED CLINICAL WORKUP

For older patients who report suicidal ideation, an age-appropriate workup—using clinical interviews and screening instruments—is essential. The clinical interview can build rapport and gather information about the patient’s suicidal plan or intent. Based on our experience, we recommend the following 6-step screening interview, summarized in Table 2.

1. Ask about a specific plan. Does the patient have the means readily available to carry out this plan? What is the timeline (imminent versus vaguely futuristic)? Does the patient report having control over this plan?
2. Gather a suicide history. Has the patient attempted suicide before? By what means? Is there a family history of suicide? If yes, by what means did this family member commit suicide, and how was the patient affected?
3. Assess social status. How isolated is the patient? Have there been recent changes in his or her social circle, such as loss of a spouse? Can the patient identify at least one person who would be negatively affected by the suicide?
4. Assess medical health. Does the patient suffer from chronic pain? Does the patient have a recently diagnosed medical condition? Has a longstanding medical condition become more debilitating? Does the patient report feeling hopeless about impending medical difficulties? Has he or she been keeping regularly scheduled medical appointments with outpatient clinicians?
5. Assess mental health. Does the patient meet DSM-IV criteria for depression or schizophrenia, which are associated with high suicide risk? Does he or she report being hopeless or helpless? Is the suicidal ideation ego dystonic?
6. Ascertain clinical signs of suicidal intent. Has the patient:

Table 1

Suicide risk with mental and physical illness, by patient age

Risk factors	Young (21 to 34 yrs)	Middle-aged (35 to 54 yrs)	Young-old (55 to 74 yrs)	Elderly (77+ yrs)
Psychiatric disorders	•	•	•	•
Mood disorders		○	•	•
Alcohol abuse	○	•	○
Primary psychoses	•	○
Personality disorders	○
Physical ailments			•	•
• Significant risk factor ○ Potential risk factor
Source: Compiled from information in references 4-8.

CASE REPORT continued: Some telling signs

Mr. V’s laboratory screening reveals slightly elevated serum glucose and mild anemia. An ECG reveals a type I heart block, but all other lab results are unremarkable. His sister reports he recently gave away his dog, which he and his wife had owned for many years. He has also mentioned a desire to revise his will when speaking to other family members. Hospital records indicate he has missed numerous medical appointments over the past 4 months.

 

SCREENING INSTRUMENTS

Psychological assessments can often buttress the clinical interview findings. Several measurements are well-suited for detecting suicidal risk and concomitant depression (Table 3).

Beck SSI-C. The Beck Scale for Suicide Ideation – Current (SSI-C) assesses a patient’s preparation and motivation to commit suicide.⁹ This short (19-item) self-report measure asks patients to rate their wish to die, desire to attempt suicide, duration (and frequency) of suicidal thoughts, sense of control over suicide, and deterrents they face. The SSI-C helps to measure or monitor suicidality and is reliable and valid for psychiatric outpatients.⁹

BDI-II. The Beck Depression Inventory—recently revised in a second edition (BDI-II)¹⁰—can be useful because depression is one of the strongest risk factors for elder suicide. The 21-item BDI-II—a psychometrically sound, self-report instrument—asks about general symptoms of depression and gauges their severity. It can be applied to diverse patient populations and ages¹¹ and is appropriate for older patients who are also being treated medically.

Beck Hopelessness Scale. Hopelessness has been recognized as a possible harbinger of suicide.¹² One study showed that depression became a clinically meaningful suicide predictor only when accompanied by hopelessness.¹³

A score of 10 or more on the Beck Hopelessness Scale identified 91% of patients in one study who eventually committed suicide. The hopelessness patients expressed on this scale more strongly differentiated between those who did or did not commit suicide than did their scores on the BDI or SSI-C.¹⁴

Table 2

6-step clinical interview with an older suicidal patient

Determine plan and specify means Gather suicide history (personal and family history) Determine level of social support Evaluate medical health Evaluate mental health Determine presence of suicide warning signs:
Neglect of personal care Intentional self-starvation Recent writing or changing of a will Giving away material possessions Relinquishing responsibilities, such as pets or positions of authority
Source: Adapted from the Cincinnati Veterans Affairs Medical Center general psychological suicide assessment

HRSD-R. The revised Hamilton Rating Scale for Depression (HRSD-R) documents patients’ levels of mood disturbance and suicidality. One item in this 21-item, clinician-administered instrument specifically asks about the patient’s level of suicidality in the past week. The scale has well-documented reliability and validity and is appropriate for psychiatric populations.¹⁵

CASE REPORT continued: Alarming findings

Along with the clinical interview, Mr. V. is screened with the Beck Hopelessness Scale and Beck Depression Inventory-II. These instruments are chosen because they are easy to administer, and patients can readily comprehend the questions—even when under duress. Mr. V’s results reveal moderate depression and severe hopelessness.

INPATIENT VS. OUTPATIENT CARE

Older patients are often referred to a psychiatrist because of vague suicidal ideation, but they may also present in an acute crisis—with immediate plans for suicide and readily accessible means. The first concern for their safety is to ensure they are not left alone.

Patient interview. First, listen empathetically and ask detailed questions, especially ones that remind patients of their daily connections and responsibilities. For instance, ask, “Do you have children who would be affected by your decision?” Address patients’ immediate needs, such as hunger, thirst, or pain.¹⁶ Work on building a therapeutic alliance before asking questions that may appear trivial to agitated patients (such as tasks assessing cognitive abilities).

Avoid arguing with patients, and refrain from offering advice or sermonizing. Allow them to describe their emotions, and communicate that you understand their concerns. Discuss how they can expect to receive treatment to ease their discomfort. Inform them that mental health specialists can treat them and monitor their progress.

Hospitalization. Begin discussing treatment options and broach the notion of hospital admission if necessary. One way to foster an alliance is to frame inpatient care as a way of helping them recover from their crisis in a safe environment.

To ensure patient safety, it is best to err on the side of admission. Admitting the suicidal patient not only guarantees strict supervision but also allows time for necessary psychological assessment. Hospitalization may also allow family members to remove any weapons or hazardous conditions from the patient’s home.

Including the family in problem-solving is especially important when managing older suicidal patients. For patients who are isolated from family or friends, recovery may depend on improving their support network.

Table 3

Comparing screening instruments for suicide risk

Measure	Description	Time (minutes)
Beck Depression Inventory (BDI)	21-item, self-administered; identifies depressive symptoms in past week	10
Beck Hopelessness Scale (BHS)	20-item, self-administered; measures hopelessness, fatalism, and pessimism in past week	5
Beck Scale for Suicide Ideation-Current (SSI-C)	19-item, self-administered; gauges suicidal intention	10
Hamilton Rating Scale for Depression-revised (HRSD-R)	21-item, clinician-administered; rates depressive symptoms in past week	25

Outpatient care. Not all acutely suicidal older patients require hospital admission. They may be safely managed as outpatients if they:

 

• have strong social support
• are not isolated
• have no access to firearms or other dangerous weapons.

Safety can be enhanced by having family members take responsibility for the senior’s well-being and by asking the patient to contract for safety. A safety contract may include:

• verbal confirmation—and ideally a written statement—that the patient will not commit suicide within a specified period
• a list of people the patient will contact when feeling suicidal
• steps being taken to monitor the patient’s welfare.

Finally, schedule follow-up appointments soon after discharge to certify patients are being closely monitored. To encourage outpatient medication adherence, build strong alliances with family members and ask patients to bring in their pill bottles during follow-up appointments.

CASE REPORT continued: Observation begins

The staff is clearly concerned about Mr. V’s suicide risk and requests that he voluntarily admit himself to the VA hospital. This decision is based on his level of isolation, the lethality of his suicide plan, access to a weapon, and the depression and hopelessness revealed by his screening tests. He reluctantly agrees and is admitted to the inpatient psychiatric unit for observation and treatment by a geriatric internist and a geriatric psychiatrist.

DRUG THERAPY FOR SUICIDALITY

For patients with mild depressive symptoms, psychotherapy may be sufficient to manage depression associated with suicidality. However, those with moderate-to-severe depression require both drug treatment and psychotherapy.

Drug selection depends upon the underlying psychiatric illness. If the older patient is experiencing a depressive disorder, a selective serotonin reuptake inhibitor (SSRI) or another antidepressant could serve as first-line treatment (Table 4). These medications are safe for suicidal patients because they are not fatal in overdose.

Administration. Because age-related changes in pharmacokinetics and spharmacodynamics can slow medication clearance, reduced dosages usually achieve a therapeutic effect and minimize the risk of side effects in geriatric patients.

Antidepressants commonly used for older patients are shown in Table 4. Excepting citalopram and escitalopram, these dosages are lower than usual. We start healthy older patients on one-half the usual dosage and those who are medically ill or have neurodegenerative disorders on one-third to one-fourth the usual dosage. We also titrate more slowly to reduce the risk of side effects.

Table 4

Antidepressants commonly used to treat geriatric depression

Medication	Recommended dosage (mg/d)
SSRIs
Citalopram	20 to 40
Escitalopram	10 to 20
Fluoxetine	10 to 40
Paroxetine	10 to 40
Sertraline	25 to 150
Others
Bupropion	100 to 400
Mirtazapine	15 to 45
Venlafaxine	75 to 225

As in younger patients, the most common side effects of SSRIs in older patients include GI difficulties, overactivation, and sexual dysfunction. Paroxetine’s potential for anticholinergic effects may be a concern for some older patients.

Drug-drug interactions are of great concern when treating older patients, who take an average of six to nine medications per day.¹⁷ Compared with other SSRIs, fluoxetine and paroxetine, are more likely to inhibit cytochrome P-450 enzymes 2D6 and 3A4. They could thus increase blood levels of drugs taken concomitantly that are substrates of 2D6 or 3A4.

Antidepressant side effects can sometimes be used to advantage. For example, mirtazapine’s sedating property at lower dosages could help older patients with insomnia.

CASE REPORT concluded: Finding support

Mr. V is started on an SSRI antidepressant. He also receives supportive and milieu therapy and coping skills training. During his hospitalization, Mr. V contracts for safety and allows his sister to remove the handgun from his home.

Upon discharge, Mr. V is referred to a day treatment program that operates 3 to 5 days a week and offers case management, group therapy, and individual psychotherapy. The program helps him meet other older patients and allows him to discuss his life’s accomplishments and losses with others his age. His sister is an integral part of the program, and he maintains close contact with her.

Mr. V reports vague and occasional suicidal ideation, with no specific plan or intent. He and his sister note that his medical condition improved soon after his psychiatric condition stabilized.

Related resources

• Surgeon General’s Call to Action to Prevent Suicide. www.mental-health.org/suicideprevention/calltoaction.pdf
• Centers for Disease Control and Prevention. National Center for Injury Prevention and Control.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

Drs. Montross reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Mohamed is a speaker and consultant to Forest Laboratories and Eli Lilly and Co.

Dr. Kasckow receives research support from, is a consultant to, and is a speaker for Forest Laboratories, Eli Lilly and Co., Pfizer Inc., and Janssen Pharmaceutica.

 

Dr. Zisook is a consultant to GlaxoSmithKline and a speaker for GlaxoSmithKline, Wyeth Pharmaceuticals, Pfizer Inc., Forest Laboratories, and Bristol-Myers Squibb Co.