For providers steeped in the use of evidence-based psychotherapies, it is important to keep in mind the relief from suicidal ideation that can be achieved through the use of combination therapy (psychotherapy plus pharmacotherapy). For patients experiencing suicidal ideation with intent, it is especially critical to alert patients to the option of psychiatric medications, and to support their decision to pursue pharmacotherapy in conjunction with psychotherapy.
A subset of patients afflicted by mental health issues do not “buy in” to psychotherapy and may be open to pursuing a trial of psychotropic medication. Similarly, some individuals find mental health treatment in the form of pharmacotherapy to be less stigmatizing than treatment via psychotherapy. Research has suggested, the stigma associated with mental health treatment-seeking may be a particularly salient phenomenon among current and former members of the military.
It should also be noted that some disorders are simply treated more effectively with pharmacotherapy. With the exception of the psychotic disorders, there is perhaps no other cluster of disorders in the DSM-IV-TR more frequently treated via pharmacotherapy than bipolar-spectrum disorders. Relative to other disorders, there is less evidence for the efficacy of psychotherapy alone in treating these illnesses.
Bipolar I and II disorders are two of the DSM-IV-TR diagnoses in which we see suicidal behavior most frequently (Harris & Barraclough, 1997). It has been estimated that the lifetime prevalence of suicidal ideation and/or attempts among bipolar patients ranges from 33% to 80% (Lopez et al., 2001; Valtonen et al., 2005). Given the prevalence of suicidal ideation and behavior in bipolar-spectrum disorders, and the important role of psychotropic medications in treating the symptoms of these illnesses, a greater understanding of the role of various medications in reducing suicide risk in this population is needed.
Bipolar disorders are often treated with mood stabilizers, atypical antipsychotics, or both. Yet the role of mood stabilizers versus atypical antipsychotic medications has been understudied. A study by Ahearn et al. (2012), sought to test the hypothesis that the use of atypical antipsychotics in combination with lithium (a mood stabilizer) or divalproex(an antidepressant) may confer additional protection from suicide among bipolarpatients seeking treatment in the VA system.
The medical records of over 1300 VA patients having made suicide attempts over a 6-year period between 1999 and 2004were examined.Inclusion criteria were: 1) at least one outpatient diagnosis of bipolar disorder type 1 or 2 and 2) at least one prescription for lithium, divalproex, or both during the study period. Exclusion criteria included any diagnosis of schizophrenia, schizoaffective disorder, dementia, or any cognitive disorder. The average lifetime number of manic or depressive episodes was 5.02. The mean age of onset since first bipolar diagnosis was 35.24 years. The mean time elapsed since age of first onset was 18.52 years.
Divalproex was the most commonly prescribed medication in this study, a finding consistent with prior studies in the general population which point to an increase in the rates of divalproex prescriptions and a decrease in the rates of lithium prescriptions over the past two decades (Shulman et al., 2003). Seventy-seven percent of patients filled a divalproex prescription during the six-year period; 57% filled at least one prescription of antipsychotics, and 42% filled at least one prescription of lithium. Although fewer patients used lithium, those who did spent longer on their medication (an average of 29.6 months, versus 24.0 months on divalproex and 18.7 months on antipsychotics).
Close to 60% of suicide attempts occurred when patients were on neither divalproex, nor lithium, nor atypical antipsychotics. Importantly, close to 90% of patients spent an average of 45 months during this six-year period on none of these three medications. Though correlational and retrospective in nature, these findings suggest that treatment via one or more of these medications may confer protection from suicide attempts. These findings also send a message regarding the importance of promoting medication adherence, a role which can be filled by psychotherapists in addition to physicians and nurse practitioners.
This study supported the protective effect of both lithium and divalproex with respect to suicide attempts. The suicide rate for those on lithium alone was 7.7/10,000 months of exposure. The rate for those on divalproex alone was 7.0/10,000 months of exposure, and the rate for those on combined treatment (lithium plus divalproex) was 6.3/10,000 months of exposure.
In this study, patients prescribed only an atypical antipsychotic had a high suicide attempt rate (26.2 attempts per 10,000 months of exposure). In an analysis controlling for duration of illness and age of onset (in combination, considered a proxy for illness severity), a significance increase in the odds for suicide attempts was observed for those taking antipsychotics versus those who were not. No such pattern was observed for those prescribed lithium or divalproex.
Interestingly, those on atypical psychotics alone had a higher suicide rate than those who were on an atypical antipsychotic in combination with either lithium or divalproex. These findings are suggestive of a protective effect of both lithium and divalproex and a potential negative effect of atypical antipsychotics.
A Role For Psychotherapists:
One of the primary findings of Ahearn et al. (2012) was that atypical antipsychotics may confer risk for suicide attempts. As educated consumers of the literature and advocates for our patients, we can share this finding with our prescribing colleagues, as well as with our patients and their families.
A secondary finding was that medication adherence more broadly may play a central role in conferring protection from suicide attempts. Therapists can play an important role in supporting adherence to prescribed medication regimens with our bipolar patients and their families. Establishment and maintenance of a strong therapeutic relationship may be an important variable in allowing therapists to accomplish this (Zeber et al., 2008).
Ahearn, E.P., Chen, P., Hertzberg, M., Cornette, M.M., Suvalsky, L., Cooley-Olson, D., Swanlund, J. Eickhoff, J., Beck, T. and Krahn, D. (2013). Suicide attempts in veterans with bipolar disorder during treatment with lithium, divalproex, and atypical antipsychotics, Journal of Affective Disorders, 145 (1) 77-82.
Dr. Cornette is a clinical psychologist and subject matter expert on suicide working at the CDP HQ. She has developed the CDP’s two-day workshop on suicide and is the coordinator for the one-week civilian training program.