October 2023 Newsletter: Suicide Prevention, Managing Explosive Behavior in Youth, and Perinatal Treatment of Bipolar Disorder

In this newsletter, we are focusing on an essential aspect of suicide prevention: pharmacologic strategies. This comes in the wake of last month’s observance of World Suicide Prevention Day.

We also discuss strategies for managing explosive behavior in youth, key points from a presentation on perinatal treatment of bipolar disorder, and our practical research summaries of adult, child, and adolescent psychiatry (Quick Takes and CAP Smart Takes).

Suicide Prevention

On September 10, the world observed Suicide Prevention Day under the theme “Creating Hope Through Action.” Current estimates suggest an alarming rate of over 700,000 suicides each year globally. This day served as a poignant reminder to persist in our call to action. It underscored the fact that our actions have the power to foster hope and bolster prevention efforts.

Facts about suicide:

It is the fourth leading cause of death among young individuals aged 15–29.
Women exhibit a higher tendency to attempt suicide; men are more likely to successfully complete the act.
Groups in vulnerable situations experience an uneven impact of suicide.
The COVID-19 pandemic has significantly amplified many risk factors associated with suicide.
The highest rate of suicide occurs in persons 75 years and older.

Facts about suicide in children and adolescents:

In younger children, suicide attempts are often impulsive and associated with feelings of sadness, confusion, and anger.
In adolescents, suicide attempts may be associated with feelings of stress, self-doubt, and pressure to succeed.
For each completed suicide, there are several thousand attempts.

Pharmacologic approaches for suicide prevention:

Lithium:
- It can significantly lower the risk and rate of suicide as well as suicide attempts among patients diagnosed with affective disorders (e.g., bipolar and unipolar depression).
- The effectiveness of lithium might be associated with a reduction in aggression and impulsivity.
- Use lithium for long-term improvement rather than as a short-term antisuicide agent.
- Regularly monitor lithium levels, renal function, thyroid function, and other metabolic side effects.
- Although there is not a universally defined dose for lithium, some research suggests that even very low doses could be effective. Other studies recommend maintaining a steady-state dose with a lithium concentration between 0.6 mEq/L–0.8 mEq/L.
Clozapine:
- It is FDA approved for recurrent suicidal behavior in patients with schizophrenia.
- It is underutilized due to its side effects and lack of management knowledge.
- Consider using clozapine in patients with schizophrenia or schizoaffective disorder with an increased suicide risk.
Ketamine:
- It induces a rapid reduction of depressive symptoms and suicidal ideation in adults.
- The therapeutic process consists of multiple ketamine infusions.
- Some research indicates a 50% reduction in the severity of suicidal thoughts after 10 infusions.
- However, the effects may not be sustained beyond a 6-week period.
- Recommended dosing strategy: 0.5 mg/kg IV over 40 minutes
- Frequency of dosing:
  - Initially: From 1-3 times/week
  - Maintenance: Weekly to every 6 weeks
- It should be noted that insurance companies might not cover this treatment.
Esketamine:
- It is FDA approved for treatment-resistant depression and MDD with suicidal thoughts and actions.
- It has a very rapid response (i.e., within hours), including suicidality.
- Administration is intranasal and must be supervised.
- It must take place in a clinical setting.
- The recommended dosing schedule is as follows:
  - Dose is 28 mg–84 mg
  - Induction phase: Twice weekly for a duration of 4 weeks
  - Maintenance phase: Once weekly or biweekly, as required
Antidepressants:
- These are used to address depression and anxiety.
- Suicidality is greatly reduced by the use of antidepressants.
- Suicide and self-harm rates tend to be higher when antidepressants are stopped.
- Children and adolescents might experience suicidal thoughts in the early phases of treatment.
  - Mitigate this risk by education, safety planning, and close monitoring.

Managing Explosive Behavior in Youth With David Rosenberg, M.D.

In this interview, Dr. David Rosenberg highlights practical considerations regarding the evaluation of children and adolescents with explosive behavior, such as the need to rule out medical conditions and trauma-related disorders. He also reviews essential management strategies for this population, including medication selection and titration, family engagement, and risk management, among others.

Interview highlights include the following:

In initiating medication for patients with explosive behavior, it is always best to start low and go slow. The estimated length of time for assessing whether an initial trial is beneficial is 2–4 weeks.
Clozapine may be an option for patients with persistent violence but must be used with caution and ideally after a consultation with another trusted colleague.

Learn more and earn 0.75 CME credits here.

Perinatal Treatment of Bipolar Disorder

In this video lecture, Dr. Vivien Burt thoroughly explores the complexities of the perinatal treatment of bipolar disorder, detailing the challenges and repercussions of discontinuing mood stabilizers during pregnancy. In a careful analysis, Dr. Burt explores the potential hazards associated with the use of lithium, valproate, and carbamazepine in the context of pregnancy. Furthermore, she provides an enlightening review of the guiding principles for treating bipolar disorder during pregnancy.

Guiding Principles for Treating Bipolar Disorder During Pregnancy

Pregnant women with moderate-to-severe bipolar illness should continue mood stabilizers and other psychiatric medication.
Lithium and lamotrigine are reasonable treatment choices for bipolar illness in pregnancy.
Lithium is a first choice for pregnant women with bipolar disorder.
Lamotrigine is thought to be better at preventing depression than mania.
Atypical antipsychotics do not appear to be teratogenic.
Treatment of bipolar disorder in pregnancy is decided best on a case-by-case basis.

Learn more and earn 1 CME credit here.

Quick Takes: Research, Digested

Use of NSAIDs for Delirium Risk Reduction

The causes of delirium are complex and involve factors such as neuronal aging, oxidative stress, neuroendocrine dysregulation, and neuroinflammation.
NSAIDs may play a role in mitigating delirium risk, especially among patients without dementia. Learn more.

Listen to or read the full volume, and earn 0.5 CME credits here.

CAP Smart Takes: Research, Digested

A systematic review of randomized controlled trials of lithium found it superior to placebo but less effective than antipsychotics in pediatric bipolar manic/mixed episodes.
Lithium was found safe and effective when used for pediatric bipolar and conduct disorders; however, common side effects included nausea and headache. Learn more.