5 Tips: Identifying & monitoring patients on drugs that may increase suicide risk

Suicide is a global public health issue with devastating impacts on individuals, families and communities. Worldwide, almost one million people die by suicide every year, including 4,000 Canadians.(1,2) Even more individuals have thoughts of suicide and make attempts.(2) Deaths by suicide can be prevented. Pharmacists can play an important role in early recognition and intervention, particularly as it relates to medications that may increase suicide risk. The following five tips summarize some of the actions that pharmacists can take. 1. Identify medications that may increase risk of suicidal ideation Pharmacists are knowledgeable about which medications may increase the risk of suicidal ideation, through reviews of product monographs, Health Canada warnings and published literature. Elevated risk of suicide has been noted with both psychotropic and nonpsychotropic medications. While association with suicide ideation does not equal causation, examples of potentially problematic drugs include antidepressants, varenicline, isotretinoin, antiepileptic drugs, stimulants, efavirenz, glucocorticoids, fluoroquinolones, and alpha- and beta-interferons.(3-5) This list is not exhaustive and does not infer that use of these medications is contraindicated, even in patients with pre-existing mental illness. For example, varenicline has demonstrated to be both safe and effective in patients with clinically stable psychotic, anxiety and mood disorders.(6) Rather, a comprehensive assessment should be performed to determine the appropriateness of therapy, particularly in the context of the patient’s other risk factors for self-harm.(7) If alternatives are indicated, safe and available, pharmacists can recommend these to the prescriber. Patients should be involved in medication selection through a shared decision-making process. Medication reviews at the community pharmacy (or upon admission and discharge from hospital) are opportune times to identify these medications and provide patients with information regarding their associated risks. It is also helpful to educate patients on how they and their loved ones can monitor for changes in thoughts and behaviours, and disclose them to facilitate early intervention. 2. Observe for warning signs of self-harm Pharmacists working with patients in community and ambulatory practice settings provide care to patients longitudinally. As such, they are trusted and privy to knowledge of the patient’s baseline status, their typical demeanour, and self-care ability (e.g., as evidenced by their hygiene or attendance at the pharmacy for refills). Pharmacists are also in a unique position to notice patients who may be purchasing or stockpiling large quantities of medication. In addition to a patient vocalizing that they have thoughts of self-harm or feelings of hopelessness, other warning signs are listed in Table 1.(8,9) Pharmacists should inform patients of any associations with self-harm upon initiation of a new medication known to carry this risk. If there are other risk factors for suicide (e.g., trauma, significant loss, substance use), pharmacists should schedule a phone, virtual or in-person follow-up with these patients. The conversation can centre around any changes in thoughts or behaviours, as listed in Table 1. Although suicidal thoughts and attempts have been spontaneously reported at various treatment stages, it may be particularly valuable to check in with patients at treatment initiation, during dose changes and upon medication discontinuation.(10) In addition to the patient and their loved ones, other members of the healthcare team should be engaged so that they too can monitor for these signs and symptoms. 3. Learn how to assess patients for suicide risk Suicide risk assessment (see reference 12 for a 5-step evaluation process) involves identifying factors that may increase or decrease a patient’s risk of suicide. This is done in order to determine an overall level of risk and to develop a care plan focused on patient safety, addressing modifiable risks and protective factors.(11,12) As a result of societal stigma and lack of formal training, suicide may be an uncomfortable and challenging topic of discussion between pharmacists and patients.(13) It is important to note that talking about suicide does not increase the likelihood that an individual will attempt suicide. Breaking from this misconception and communicating with compassion and empathy can help establish a trusting relationship with the patient. In fact, acknowledging and talking about suicide may reduce rather than increase suicidal ideation, as it lifts individuals from isolation, demonstrates that someone cares, and may benefit long-term mental health.(14,15) Pharmacists can also take a Mental Health First Aid course (https://www.mhfa.ca/), now available virtually, to further develop skills and confidence in helping individuals experiencing a mental health issue.(16) 4. Provide individualized support for patients at elevated risk of suicide Pharmacists can provide more individualized support by identifying patient-specific warning signs, risk and protective factors, and tailoring interventions to these factors.(13) This may include engaging the patient’s chosen family members, a trusted friend and/or a crisis line. Patients who are part of communities and groups that are oppressed and marginalized may benefit most from interventions designed for them specifically, as they are frequently designed and delivered by peers (see Table 2 resources).(17,18) 5. Report suicidal ideation as an adverse drug reaction Side effects, including thoughts of self-harm or suicide, should be reported to Health Canada.(19) This is particularly crucial when they are unexpected or related to medications that have recently entered the Canadian market. While adverse drug reaction reports cannot determine incidence or prevalence, they can signal potential safety issues, identify previously unknown or rare side effects, and lead to changes such as product monograph modifications and safety warnings from federal regulatory agencies. Summary Pharmacists can take tangible actions to decrease suicide risk, particularly in patients taking medications known to be associated with increased suicidal thoughts. They can be prepared to support patients in their moments of greatest need by taking a continuing education course or reviewing existing toolkits and resources, along with clearly communicating and collaborating with the patient, their prescriber and loved ones. Avery Loi is a pharmacy resident at University Health Network in Toronto, ON. Maria Zhang (Maria.Zhang@camh.ca) is a clinician educator, jointly at the Centre for Addiction and Mental Health and the Leslie Dan Faculty of Pharmacy in Toronto, ON. Read more on suicide prevention. References 1. Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016;387:1227-39. 2. Public Health Agency of Canada. Suicide in Canada: key statistics. 2016. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/suicide-canada-key-statistics-infographic/pub-eng.pdf (accessed January 29, 2021). 3. Gorton HC, Webb RT, Kapur N, et al. Non-psychotropic medication and risk of suicide or attempted suicide: a systematic review. BMJ Open 2016;6:e009074. 4. Koch J, Ward S, Martin B, et al. A review of suicidality in nonpsychotropic medications. Mental Health Clinician 2015;5:224-36. 5. Rogers D, Pies R. General medical drugs associated with depression. Psychiatry (Edgmont) 2008;5(12):28-41. 6. Evins AE, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with psychotic, anxiety, and mood disorders in the EAGLES trial. J Clin Psychopharmacol 2019:39(2):108-16. 7. Government of Canada. Suicide: risks and prevention. September 9, 2016. https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-risks-prevention.html (accessed April 28, 2021). 8. Government of Canada. Preventing suicide: warning signs and how to help. https://www.canada.ca/en/public-health/services/suicide-prevention/warning-signs.html (accessed February 1, 2021). 9. National Institute of Mental Health. Warning signs of suicide. OM 19-4316; 2019. https://www.nimh.nih.gov/health/publications/warning-signs-of-suicide/index.shtml (accessed January 29, 2021). 10. Government of Canada. ADHD drugs may increase risk of suicidal thoughts and behaviours in some people; benefits still outweigh risks. March 30, 2015. https://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2015/52759a-eng.php (accessed April 28, 2021). 11. Bucago C, Cheung H, Zhang M. Suicide risk assessment and the role of the community pharmacist Pharmacy Connection 2019. https://pharmacyconnection.ca/suicide-risk-assessment-and-the-role-of-the-community-pharmacist-fall-2019/ (accessed January 29, 2021). 12. Substance Abuse and Mental Health Services Administration. Evaluation and Triage card : Safe-T Card. 2009. https://sprc.org/resources-programs/suicide-assessment-five-step-evaluation-and-triage-safe-t-pocket-card (accessed January 29, 2021). 13. Centre for Suicide Prevention. How do I talk to someone thinking about suicide? 2020. https://www.youtube.com/watch?v=pF_lxq6fuMk&feature=emb_logo&ab_channel=CentreforSuicidePrevention (accessed January 29, 2021). 14. Canadian Mental Health Association. Preventing suicide. February 27, 2016. https://cmha.ca/documents/preventing-suicide (accessed March 4, 2021). 15. Dazzi T, Gribble R, Wessely S, et al. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychol Med 2014;44:3361–3. http://www.ncbi.nlm.nih.gov/pubmed/24998511 (accessed January 29, 2021). 16. Mental Health Commission of Canada. Mental health first aid. https://www.mhfa.ca/ (accessed January 29, 2021). 17. Centre for Suicide Prevention. Toolkit: Indigenous suicide prevention. 2013. Available at https://www.suicideinfo.ca/resource/indigenous-suicide-prevention/ (accessed January 29, 2021). 18. Centre for Suicide Prevention. Suicide Prevention toolkit: Sexual minorities and suicide. https://www.suicideinfo.ca/wp-content/uploads/2018/09/CSP_Toolkit-sexual-minorities_web.pdf (accessed January 29, 2021). 19. Government of Canada. Report a side effect. https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/adverse-reaction-reporting.html (accessed January 29, 2021). Read more on suicide prevention during COVID-19.

5 Tips: Identifying & monitoring patients on drugs that may increase suicide risk

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