Shortly after she was diagnosed with psoriatic arthritis, Sarah Lawrence was prescribed Otezla (apremilast). In less than two months after beginning the drug treatment, she says, she started experiencing suicidal ideation. “The thoughts were so intense and so different from my normal thought process, I knew something was horribly wrong.”
Neither she nor anyone in her family has a history of mental illness or suicide. Once she stopped using the drug, it took only a few days for the suicidal thoughts to dissipate. She considers herself lucky in that she was able to recognize the thoughts as a drug side effect.
“My experience with Otezla surprised me, because I had no history of depression or suicidal ideation,” she adds. “If others taking this drug suffer from existing mental health issues, I could see how the side effect might be overwhelming and potentially life-threatening. That I realized what was happening and got support as the thoughts were clearing likely saved my life.”
Suicide rates have been increasing for nearly two decades, and debates have popped up about how certain drugs — like antidepressants or even antiepileptics — might affect your risk for it, either up or down. With some conditions, it’s difficult to tease apart the effects of the treatment from the underlying effects of illness. In other cases, like when 11-year-old Nicholas suffered from depression and anxiety after taking Singulair, an allergy medication, patients may be shocked to learn that a drug they thought was treating something totally unrelated to their brains could have mood-altering effects.
In a study, Robert Gibbons, PhD, a biostatistician at the University of Chicago and his team used sophisticated statistical analyses to determine which of 922 drugs were associated with an increased or decreased risk of suicide. They found that 10 were linked to a greater suicide risk, and 44 with a lesser one. Some of the findings were surprising, for example, says Gibbons. One is that the popular vitamin folic acid appeared to lower the risk of suicidal ideation.
“It can be difficult to differentiate whether it is the medication or other chronic mental health issues that may be causing suicidal thoughts,” says Brian Wind, PhD, a clinical psychologist at JourneyPure, an addiction treatment center. “Health professionals will typically adjust the dosage or prescribe another medication if they assess that the medication consumed is potentially a cause for suicidal thoughts.”
Researchers who studied sleeping medications suggest that patients ask family members to be extra vigilant, by monitoring their loved ones for sleep walking or changes in behavior during the first week or so of taking a new drug. “These medications can have a rare paradoxical effect [similar to] alcohol, where people start behaving completely out of character,” says W. Vaughn McCall, MD, MS, a psychiatry professor in the Medical College of Georgia at Augusta University in a press release. “Instead of calming, they [the drugs] may hyperstimulate. Instead of being relaxed, patients become fearful. So it goes the opposite way. We don’t know why, and we can’t pick these people out in advance.”
Antidepressants come with a black box warning about the threat of suicide. The warning has been controversial since the FDA added it in 2004, a year after Kim Wictzak tells MedShadow that Zoloft — an antidepressant prescribed to treat her husband’s insomnia — instead led to his death by suicide.
For obvious reasons, this factor can be troubling to patients and families struggling with depression. While it’s a real danger for some patients, the study shows that, overall, the drugs were associated with a lower risk of suicide. “A large number of medications used to treat mental health disorders (depression, bipolar disorder, psychosis) were associated with decreased risk of suicidal behavior providing reassurance to clinicians and patients about the effectiveness and safety of these drugs in suicidal patients,” Gibbons tells MedShadow.
The drugs associated with an added risk for depression and suicidal thoughts are:
- Fioricet (Butalbital/acetaminophen/caffeine)
- Vicodin (Acetaminophen/Hydrocodone/Bitartrate)
- Codeine Phosphate/Promethazine Hydrochloride
- Cyclobenzaprine Hydrochloride
- Promethazine Hydrochloride
The drugs associated with a lower risk for depression and suicidal ideation are:
- Acamprosate Calcium
- Amlodipine Besylate
- Benztropine Mesylate
- Bupropion Hydrochloride
- Buspirone Hydrochloride
- Citalopram Hydrobromide
- Clonidine Hydrochloride
- Divalproex Sodium
- Doxepin Hydrochloride
- Duloxetine Hydrochloride
- Escitalopram Oxalate
- Fluoxetine Hydrochloride
- Folic Acid
- Guanfacine Hydrochloride
- Hydroxyzine Hydrochloride
- Hydroxyzine Pamoate
- Lithium Carbonate
- Lurasidone Hydrochloride
- Pantoprazole Sodium
- Prazosin Hydrochloride
- Propranolol Hydrochloride
- Quetiapine Fumarate
- Sertraline Hydrochloride
- Trazodone Hydrochloride
- Venlafaxine Hydrochloride
- Ziprasidone Hydrochloride
JourneyPure’s Wind emphasizes that it’s important to pay attention to how you feel within the first week or two after starting a new treatment. “Sometimes there may be an adjustment period, where the patient feels constantly fatigued or brain fog after starting on a new course of medication; effects should subside within the first two weeks,” says Wind.
Another study suggests that it’s more than just which drugs you’re taking — but how many — that could influence your tendency toward depression. The study, published in JAMA, reports that 15% of adults who simultaneously used three or more medications that listed depression or suicidal ideation as possible adverse effects experienced depression compared to 7% of those taking just one medication and 9% of those using two of the drugs. The study did not cover those on antidepressants.
The most commonly used drugs that list depression as a potential adverse effect, according to the JAMA study, were antihypertensives (blood pressure-lowering drugs), proton-pump inhibitors (like Omeprazole for acid reflux), analgesics and hormonal contraceptives. More often than not, if a patient was prescribed a combination of drugs with the potential to cause depression, that mixture included antihypertensives and proton-pump inhibitors.
Suicidal thoughts should never be ignored.
If you or someone you know is thinking about suicide, immediately call the confidential toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week, in English and Spanish.