Why does treatment for depression increase the risk of suicide?
Whether you are bipolar or suffer from major depressive disorder – when you start taking medication for depression, your risk of suicide actually goes up for a short period of time.
The risk of suicide in depression
Every time an advertisement for a medication for depressive disorder or bipolar depression comes on the television, one thing that seems to stick out is the warning that states “May increase the risk of suicide“. This is often an arguing point for people who are opposed to psychiatric medications. If it is supposed to improve your mood, why does the risk of suicide go up? Shouldn’t the opposite be true?
How do antidepressants work?
Antidepressant medications work by increasing the activity of neurotransmitters in the mood centers of the brain. Nerve cell signals are transmitted by the release of chemicals known as neurotransmitters. These include naturally occurring chemicals such as serotonin, norepinephrine and dopamine. The neurotransmitter is released from one cell which signals the next cell to react. The same cell then “gathers up” the neurotransmitter to be used again later.
Most antidepressants specifically work by blocking the “reuptake” of neurotransmitters so that they are in the synapses or spaces between the nerve cells for a longer period of time. This increases the likelihood that the neurotransmitter will send a “happy” signal to the next cell – sooner.
Why do antidepressants increase the risk of suicide?
The problem with depression and how long it takes to recover is twofold, because depression involves both mood and energy levels. In a person with depression, the mood state is lowered because there are often not enough neurotransmitters available. This leads to the mental effects of depression causing sadness and an inability to enjoy normal activities. There is also a corresponding drop in energy levels making the victim lethargic and sleepy.
When antidepressants are prescribed, most healthcare practitioners make it pretty clear that the mood state will not really begin to get noticeably better for at least 2 to 3 weeks. What is not always made clear is that energy levels actually begin to improve before the mood level is increased.
Once this person with low mood level and low energy level begins to take antidepressant medication, their energy levels go up fairly quickly. The mood level, however, stays depressed – sad and unable to see the light at the end of the tunnel.
If patients had been thinking of suicide as part of their depression, they may not have had the energy to make actual plans or to carry them out. Once their energy levels are boosted – they may find themselves still having the same thoughts, but this time – able to act.
Are the newer medications worse?
This increased risk of suicide is not new, despite what the media has portrayed. It is not specific to a certain medication or even a certain kind of medication. It is a fact, a well-known risk that has existed since the beginnings of treatment of depression.
Our medications, today, are really much less dangerous than medications of old. Thirty years ago, your choices for the treatment of depression included only tricyclics such as Elavil and Tofranil or MAO inhibitors such as Parnate. Both of these medication types carried a lot of very debilitating side effects (dry mouth, constipation, excessive sweating, dizziness, and food intolerances) as well as the increased risk of suicide. While they were effective, they were also quite dangerous in the event of an overdose – possibly resulting in death.
We now have more advanced medications – the SSRIs or Serotonin specific reuptake inhibitors, Norepinephrine reuptake inhibitors (NRIs) and newer MAO inhibitors that have much fewer side effects and are less likely to result in a serious overdose – but they have not been able to eliminate the actual risk of suicide. This is inherent in the treatment of depression because the energy improves before the mood.
With older medications, the psychiatrist would often only prescribe a few days’ worth of medication at a time because the old medications could be dangerous if too many were taken and lead to overdose by someone trying to commit suicide. This often meant that the patient was seen once a week or more often during the first month.
Now that overdose is not such a risk, physicians often prescribe an entire months’ worth of meds at once, and no one keeps track of the patient during this dangerous period – giving them plenty of time to plan and act. Generally the newer medications cannot be used as a suicide tool but it does not stop patients from finding other tools.
What can help decrease the risk?
The solution is to know your patient – know your friends, know your family. If you have a friend or relative who has been depressed and is placed on medication, be aware.Check on them frequently. Drag them around to social activities, out to eat, to outdoor events. Note any changes or patterns that indicate they may be considering suicide. Help them through the funk. You may get on their nerves, but you may also save their life.
A little effort and toleration of irritating friends is way better than going to a funeral and wishing you had done something.