XI Congresso della Società Italiana di Psicopatologia Psichiatria ...

cificità e complessità diversi da quelli con cui abitualmente
interagisce: come le problematiche collegate alle sindromi
maladattative ed ai traumi di restrizione, le necessità
di affrontare terapie specialistiche integrate con i colleghi
di altre branche, i rischi dell’autolesionismo e dell’esposizione
all’altrui violenza senza dimenticare le tossicodipendenze
e le difficoltà delle patologie a doppia diagnosi.
La dimensione carceraria fa sì che si concentrino nello spa-
Suicide as a treatable condition
201
SIMPOSI TEMATICI
zio-tempo anche esigenze punitivo-penali e le esigenze rieducative.
Le barriere fisiche diventano facilmente barriere
di competenza e di comprensione, cosicché da una parte c’è
il rischio di frammentare e parcellizzare i progetti terapeutici,
dall’altra sono presenti continue interferenze degli organi
legali di controllo e di disciplina a cui anche i medici devono
sottostare, con un’ambiguità di fondo che fa slittare i
rapporti dell’area sanitaria continuamente dalla custodia alla
cura, dalla repressione all’aiuto.
25 FEBBRAIO 2005 - ORE 16.00-17.30
SALA CAVALIERI 1
S92 - Suicide: a medical perspective
R.J. Baldessarini
Professor of Psychiatry & Neuroscience, Harvard Medical
School, Boston, Massachusetts
Introduction: only recently has mortality associated with
major psychiatric disorders become an explicit topic of therapeutic
research interest, stimulated recently by concerns
about possibly increased suicidal risk during treatment with
antidepressants.
Methods: the presenter and his collaborators undertook a
series of meta-analyses to summarize published and original
data pertaining to rates of suicides and attempts and to ratings
of suicidal thinking during various treatments.
Results: clozapine is the only treatment to have regulatory
approval for reducing suicidal risk (in schizophrenia patients).
Evidence is abundant and consistent that long-term
treatment of bipolar disorder patients with lithium is associated
with reductions in rates of suicides (S) and attempts
(A) by about 80%, with decreases in the S/A ratio (a proposed
“lethality index”) as well as in ratings of suicidal
thinking. Lithium may be more effectively antisuicidal
than other mood-stabilizers, and may have such benefits in
nonbipolar depression. Evidence concerning antidepressants
and suicidal risk, though abundant, is complex and
largely inconclusive, with both minor increases and decreases
reported; however, trial duration is relatively short
and may be unbalanced between treatment arms. Reported
short-term increases in suicidal thoughts and attempts
among juveniles treated with SRI antidepressants vs.
placebo raise special concerns, given inconsistent evidence
of clinical efficacy of antidepressants in juvenile depression
and risks of unrecognized juvenile bipolar disorder.
There is growing evidence that suicidal thinking decreases
more with antidepressants than placebo, evidently
paralleling overall clinical improvement but suggesting
that the pharmacology of suicidal thinking and behviors
may differ.
Conclusions: major psychiatric disorders are associated
with increased mortality, particularly due to suicide. Evidence
of beneficial effects of psychotropic treatments on
suicidal risk is emerging, and is particularly strong for lithi-
MODERATORI
L. Tondo, G. Isacsson
um. Debate over possibly increased suicidal risk in some antidepressant-treated
patients encourages reconsideration of
clinical practices regarding the care of potentially suicidal
patients. Ethical and feasible therapeutic studies are urgently
required to clarify potential benefits/risks regarding causes
of excess mortality (including accidents, complications
of substance abuse and comorbid medical disorders, as well
as suicide) among the growing treatment options in contemporary
psychiatry.
Antidepressant drugs and suicide,
consequences for prevention
G. Isacsson
Division of Psychiatry, Karolinska Institute, Stockholm
SSRIs have repeatedly been accused of increasing the risk
of suicide in depressed individuals. Based on interpretations
of adverse events in clinical trials of paroxetine for
depressed children, even authorities have warned for SS-
RIs. On the other hand, research has demonstrated decreased
suicide rates correlated to the increased use of SS-
RIs, also in children 1 2 . Depression is the foremost risk
factor for suicide, and the advent of SSRIs has allowed for
a better treatment of depression. SSRIs constitute about
80% of the use of antidepressants in all age groups in
Sweden. It must therefore urgently be clarified if SSRIs
possess some hidden suicide inducing property. We
analysed all 14,857 suicides in Sweden 1992-2000 that
were subjected to forensic toxicological screening 3 . We
compared the detections of different antidepressants
among the suicides with those in a control group of
26,422 deaths by accident or natural causes. When compared
to the average of all antidepressants, the Odds Ratios
indicated highly significant underrisks for the SSRIs,
average risks for tricyclics, and overrisks for venlafaxine
and mirtazapine. These results does not support a suicide
inducing effect of SSRIs. The implications of the findings
are that suicide preventive efforts in all age groups should
focus on the treatment of the underlying illness, depression,
and that SSRIs constitute a safe and effective tool
for this.