Pharmacotherapy in the prevention of suicidal behavior

Prevention or reduction of suicide remains a serious challenge for the medical community. Psychotherapeutic and psychosocial interventions have not been shown to reduce the incidence of suicide attempts and analytic psychotherapy has been shown to increase suicidal behavior. The efficacy of pharmacotherapy in reducing suicide attempts in patients with a history of repeated suicidal behavior has been shown with low doses of the neuroleptic agent flupenthixol compared with placebo. Supporting findings have been reported with trifluoperazine. There is evidence to suggest that some antidepressants may not be neutral in their effect on suicidal behavior. Maprotiline, for example, was associated with an increase in suicide attempts compared with placebo in a large long-term treatment study despite its significant efficacy in preventing relapse of depression. Differential lethality indices taken from large community studies support the notion that noradrenergic drugs such as maprotiline, desipramine, and nortriptyline are associated with a higher than expected incidence of death from overdose, and the suicide-provoking potential may relate to some noradrenergic property. The studies of serotonergic antidepressants do not suggest that they are suicide-provoking agents; rather they appear to be neutral or protective. Prospective prophylactic studies are needed to test the ability of potential treatments for the reduction of suicidal behavior.