50 154 310 314 The efficacy of antidepressants may be assessed by their

50 154 310 314 the efficacy of antidepressants may be

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50, 154, 310-314 The efficacy of antidepressants may be assessed by their discontinuation. For adults, there is strong evidence that stopping antidepressants increases suicide risk. 38, 39, 310, 315-317 Likewise, antide- pressant non-adherence is associated with suicide attempts. 37, 38, 214, 315, 316, 318-320 Busch and Fawcett make an important point based on case studies of patients that have died by suicide while hospitalized. Similar outpatient investigations led them to the same conclusion.
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Continuity of Care for Suicide Prevention and Research 48 Fawcett finds that there is a profile of patient attributes that characterizes inpatients that are at high risk for suicide. High “psychic anxiety,” profound sleep disturbance, rapidly fluctuating clinical course, and inability to experience pleasure are all on the list. 146, 148, 151, 280, 281 Busch and Fawcett may well have identified a subset of patients that are at high risk for suicide for which there may be an indication for using emergency psychopharmacology to prevent suicide attempts and sui- cide. These hypotheses are important because medications are rapidly effective for anxiety and sleep as well as the agitation associated with a fluctuating clinical course. 176 These hypotheses have not been tested. If they prove to be true, the results have many implications for the way po- tentially suicidal inpatients and outpatients are treated and managed. Before describing a path forward, one more piece of background information needs to be restated. Without question, suicide attempts and suicide acts are life and death situations potentially. This realization is critical to accepting the proposal for using emergency psychopharmacology for sui- cide prevention because any pharmaceutical used may have most serious adverse effects including death by intentional overdose or from infrequent or rare physiologic actions inherent to a particu- lar pharmaceutical. Accordingly, the use of pharmaceuticals for suicide prevention must weigh the consequences of doing nothing pharmacologically and relying solely on all other means for sui- cide prevention. Surely, suicide prevention requires as many effective tools as can be mobilized. Where to start? Inpatient units are among the safest places to begin research of the sort to be sug- gested. The various hypotheses suggested by Busch and Fawcett mentioned above can be evalu- ated by randomized methods. For many, suicide risk is associated with a discrete time interval during which psychopharmacology may augment other anti-suicide interventions. One obvious experiment is similar to the trial comparing clozapine to olanzapine. In the proposed similarly de- signed trial, patient participants could be randomized to one group that receives short-term lithium plus treatment as usual or to the control condition that receives only treatment as usual. Suicide behaviors could be assessed as 3, 6, and 12 months. This sort of model, randomized controlled trial can be applied with other pharmaceuticals thought to have significant anti-suicide properties.
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