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ObjectivesRestricting access to lethal means is an effective suicide prevention strategy. However, there is little discussion in the literature about the potential contribution of prescribing practices on discharge from inpatient psychiatric care (which has been established as a high-risk period for suicide) to suicide deaths by overdose of prescribed medication. This study aimed to assess the quantity, toxicity and potential lethality of psychotropic medication being prescribed on discharge from psychiatric care to those with and without indices of suicidality.MethodsPatient demographic, clinical and prescription data were collected from 50 randomly selected charts following discharge from inpatient psychiatric care. Psychotropic medications (dose × duration) on discharge were converted to their equivalent doses of neuroleptics, antidepressants and anxiolytics to rate toxicity and potential lethality, using the Maudsley Prescribing Guidelines. Mood stabilizing medications were also documented.Results39% of prescriptions analysed contained toxic and potentially fatal doses of either neuroleptic or antidepressant equivalent medication.ConclusionsPatient discharge from inpatient psychiatric care presents a golden opportunity to moderate access to potentially fatal psychotropic medication. Iatrogenic provision of lethal means for suicide during a period of increased risk and in a group at increased suicide risk may impact suicide prevention efforts and requires further in-depth research. Current prescribing practices may be a missed opportunity to intervene in this regard.

AbstractBehavioural and interpersonal difficulties arising during the course of cognitive psychotherapy are common and they provide unique opportunities to assess and modify patients' beliefs and assumptions. A breakdown in the therapeutic relationship may be on a continuum from a simple misunderstanding to a more chronic and complex problem. It may act as a potent vehicle for change in the patient, but may also precipitate change in the therapist who is also part of that relationship which can influence treatment outcome.

The prolactin response to dl-fenfluramine (an indirect central serotonin agonist) challenge has been used to assess serotonergic function and appears to be blunted in depressed patients. We used this method to determine whether the serotonergic deficit in depressed patients is corrected by treatment with paroxetine. Prior to treatment with paroxetine sixteen depressed patients received a placebo challenge followed by a dl-fenfluramine challenge the next day. The same two challenges were repeated after treatment. Prolactin baseline levels were measured before pill administration, and then hourly for 5 hours. Fenfluramine/norfenfluramine levels were assayed at each time point after drug administration. Treatment with paroxetine significantly increased the baseline prolactin level independently of treatment response but positively correlated with paroxetine dose. We found that pre-treatment prolactin response to dl-fenfluramine challenge did not predict clinical response to paroxetine, nor did the prolactin response change significantly after treatment. There was no significant difference in the post-treatment prolactin response between treatment responders and treatment non-responders. We found evidence of increased prolactin levels that may reflect effects of paroxetine in enhancing serotonin levels. Acute release of serotonin as measured by the prolactin response to fenfluramine is not altered by paroxetine treatment.

Background: Serotonin abnormalities have been reported in the brain of suicide victims. Evidence of a serotonin deficiency in suicide attempters is less consistent. We hypothesized that a serotonin deficiency may be present in suicide attempters whose attempt behavior more closely approximates completed suicide. Method: Sixty-seven (67) drug-free depressed inpatients (46 suicide attempters, 21 nonattempters) underwent research clinical assessments and a lumbar puncture. Cerebrospinal fluid (CSF) monoamine metabolites were assayed. Degree of medical damage and intent of the most recent suicide attempt were rated. Results: CSF amine metabolites did not differentiate suicide attempters as a group from nonattempters. However, reduced serotonergic activity, as indicated by lower levels of CSF 5-hydroxyindoleacetic acid (5-HIAA) was associated with a history of planned suicide attempts and with suicide attempts that resulted in greater medical damage. Other monoamine metabolites did not correlate with seriousness of suicidal behavior, except for low CSF homovanillic acid and higher medical damage. No correlation was found with violent method. Conclusions: Planned and more medically damaging suicide attempts appear to be associated specifically with low serotonergic activity and, therefore, resemble completed suicide both behaviorally and biochemically. It remains to be determined whether low levels of CSF 5-HIAA can predict greater medical damage in future suicide attempts. © American College of Neuropsychopharmacology

We found a 38% lower maximal prolactin response to an oral challenge dose of 60 mg of dl-fenfluramine relative to placebo in younger (<30 years) depressed inpatients compared with the response in age-matched healthy controls (p < .03). Severity of depression did not correlate with prolactin response. Prolactin responses in older depressed patients (30 years) did not differ from older controls. Younger depressed patients differed from older depressed patients in terms of earlier age of onset of first lifetime episode of major depression, greater degree of suicidal intent during a recent suicide attempt, double the level of hopelessness on admission to hospital, and a higher rate of comorbid borderline personality disorder. A blunted prolactin response to fenfluramine may be interpreted as evidence for reduced serotonergic function in younger depressed patients and may underlie their observed greater suicidality and hopelessness.Neuropsychopharmacology (1995) 13 53–64.

Serotonergic system abnormalities have been implicated in major depression, suicide, violence, alcoholism, and other psychopathologies. The prolactin response to fenfluramine has been widely used as a neuroendocrine probe to study brain serotonin responsivity. We have extended this methodology by using the positron emission tomography (PET) 18F-fluorodeoxyglucose (18FDG) method to examine the fenfluramine-induced changes in regional cerebral glucose metabolism (rCMRglu), an indicator of changes in regional neuronal activity. We report results on 16 healthy controls, each of whom underwent two PET studies. One group of six subjects had a placebo on day 1 and a single 60 mg oral dose of fenfluramine on day 2. The second group, of 10 subjects, was tested on two consecutive occasions without drug or placebo. Data were analyzed for significant rCMRgluchanges on day 2 vs day 1 using the statistical parametric mapping method (p< 0.01). Subjects who did not receive drugs showed no statistically significant areas of rCMRgluincrease or decrease on day 2 versus day 1. In contrast, the group that received fenfluramine showed significant fenfluramine-induced responses. Areas of rCMRgluincreases involved mainly the left prefrontal and left temperoparietal cortex. Within the prefrontal cortex, two major areas of rCMRgluincrease included, first, an area centered on the anterior cingulate and, second, an area in the lateral prefrontal cortex involving principally the inferior, middle, and superior frontal gyri. Some decreases in rCMRgluwere observed, principally in the right hemisphere. This PET-fenfluramine paradigm is a potentially useful method for studying abnormalities of serotonin function in the prefrontal cortex.

Suicide is a major public health issue of global concern. It is the leading cause of death in young Irish men, marking suicide and suicidal behaviour as important topics for clinical epidemiology and public health research. Ireland has a statutory obligation from the “Reach Out” policy document to “systematically plan research into suicidal behaviour to address deficits in our knowledge” (pp. 50). Suicide is undoubtedly a complex phenomenon and therefore one which requires advanced methods of investigation and innovative approaches to research the factors underpinning suicide in modern Ireland, the development and evaluation of prevention strategies and the informing of evidence-based policy.