03. Risk for Suicide Attempts and Suicide Associated With Benzodiazepines

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Your patient calls between visits; a devastating event has occurred, rendering him incapable of diverting his thoughts from the tragedy. These intrusive reflections disrupt his sleep. In such instances, many physicians might advocate a brief regimen of benzodiazepines. Would the potential elevation in suicide risk due to disinhibition concern you?

Greetings, I am Paul Zarkowski from the Psychopharmacology Institute.

Past epidemiologic research implies a heightened suicide risk among individuals consuming benzodiazepines. However, these studies present interpretative challenges as individuals prescribed benzodiazepines are already at an elevated suicide risk due to their medical indications alone. A recent French study endeavors to eliminate these confounding variables, examining benzodiazepines’ impact on suicide risk. This innovative study employs a design wherein subjects serve as their own controls. It juxtaposes the month preceding a suicidal act with the months 60–90 days prior. Unrelated factors maintain consistent prevalence in the months before the suicide, whereas a risk-increasing factor manifests more frequently right before the act. The researchers identified 111,500 individuals who attempted suicide and 12,312 who completed suicide between 2013–16, each having received at least 1 benzodiazepine prescription within the preceding 120 days.

Prescriptions of benzodiazepines were significantly more common in the month before the suicidal act, with an odds ratio ranging from 2.77 to 1.44, contingent upon the group. The highest odds ratio, 2.77, was observed among patients with no psychiatric history—defined as an absence of psychotropic medication, disability, or hospitalizations—in the previous year. This same demographic was also 1.88 times more likely to obtain a benzodiazepine in the month preceding their suicide. For individuals with psychiatric medication, disability, or hospitalization history within the last year, the likelihood of receiving benzodiazepines was 1.74 times higher before an attempt and 1.45 times before a completed suicide.

Through individual comparisons, the French scholars succeeded in sidestepping numerous confounding factors common in suicide studies, including psychiatric diagnoses, substance use, social isolation, familial challenges, or genetic predisposition to suicide. They contend these elements would likely remain stable during the brief 120-day research period. However, other analyses have underscored a transient spike in suicide risk following detrimental life developments, such as a dire medical diagnosis or social status alteration. It raises the possibility that the same recent catastrophic occurrence prompting the benzodiazepine prescription may also have intensified the suicide risk.

To accommodate this hypothesis, the researchers adjusted their findings for benzodiazepines by contrasting them with outcomes from an alternative nonbenzodiazepine—specifically, cyamemazine, the most frequently prescribed antipsychotic in France, renowned for its sedative and anxiolytic characteristics. The corrected findings remained substantially consistent, revealing a markedly elevated threat of a suicidal act post–benzodiazepine prescription, with variances between 1.66 and 2.15 depending on the group. However, the odds ratio for completed suicide among those without recent psychiatric history was indeterminable due to insufficient suicide instances in the cyamemazine-exposed cohort.

Significantly, this methodology parallels that adopted by a Swedish team investigating the correlation between SSRIs and suicide. Rather than employing a suicidal act as the index event, they utilized the initiation of an SSRI regimen, recording suicidal activities before and subsequent to this event. Their discovery: The apex of suicide attempt risk was the month before commencing SSRI, and all following months showed a reduced occurrence of suicide attempts across all ages.

In conclusion, although benzodiazepines remain a vital component in anxiety management, this study underscores the imperative of meticulous patient monitoring following indications for benzodiazepine prescriptions. This consideration becomes especially pertinent when patients contact us amidst visits, recounting life-altering incidents, prior to the authorization of a benzodiazepine.

Abstract

Risk of Suicide Attempt and Suicide Associated With Benzodiazepine: A Nationwide Case Crossover Study

Marie Tournier, Anne Bénard-Laribière, Fabrice Jollant, Emilie Hucteau, Papa-Yatma Diop, Ana Jarne-Munoz, Antoine Pariente, Emmanuel Oger, Julien Bezin

Background: Previous studies that found an association between benzodiazepines and suicidal behaviours were confounded by indication bias.

Aims: To limit this bias, a case crossover study (CCO) was conducted to estimate the risk of suicide attempt and suicide associated with benzodiazepines.

Method: Patients ≥16 years, with hospitalised suicide attempt or suicide between 2013 and 2016, and at least one benzodiazepine dispensing within the 120 days before their act were selected in the nationwide French reimbursement healthcare system databases (SNDS). For each patient, frequency of benzodiazepine dispensing was compared between a risk period (days -30 to -1 before the event) and two matched reference periods (days -120 to -91, and -90 to -61).

Results: A total of 111,550 individuals who attempted suicide and 12,312 suicide victims were included, of who, respectively, 77,474 and 7958 had recent psychiatric history. Benzodiazepine dispensing appeared higher in the 30-day risk period than in reference ones. The comparison yielded adjusted odds ratios of 1.74 for hospitalised suicide attempt (95% confidence interval 1.69-1.78) and 1.45 for suicide (1.34-1.57) in individuals with recent psychiatric history, and of 2.77 (2.69-2.86) and 1.80 (1.65-1.97) for individuals without.

Conclusion: This nationwide study supports an association between recent benzodiazepine use and both suicide attempt and suicide. These results strengthen the need for screening for suicidal risk carefully before initiation and during treatment when prescribing benzodiazepines.

Reference

Tournier, M., Bénard-Laribière, A., Jollant, F., Hucteau, E., Diop, P. Y., Jarne-Munoz, A., Pariente, A., Oger, E., & Bezin, J. (2023).

Risk of suicide attempt and suicide associated with benzodiazepine: A nationwide case crossover study

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Acta Psychiatrica Scandinavica, 148

(3), 233–241.