What do we know about the effectiveness of drug therapies used in the treatment PD suicidal behavior? Dr. Robert Cardish sums it up.

In the June 2007 issue of the Canadian Journal of Psychiatry, Dr. Robert Cardish, a supervisory faculty member at Mount Sinai Psychotherapy Institute, examines the existing literature for information on the efficacy of pharmacotherapies in PD suicidality.

Although Cardish found an absence of studies specifically evaluating the treatment of suicidality associated with personality disorders, several studies evaluated the efficacy of pharmacotherapy for symptom clusters closely associated with suicidal behavior. Some degree of efficacy was found to exist in using drug therapy for acute treatment of:

• transient psychotic episodes
• flashbacks and dissociations
• affective dysregulation
• impulsivity
• anger and hostility

Personality Disorder and Suicidality

Among the personality disorders, suicidal behavior is particularly associated with Borderline and Antisocial PD. There is also evidence that PDs are more prevalent among individuals who do commit suicide. Psychological autopsy studies of those who commit suicide typically show a high proportion of victims to have had a PD diagnosis, usually BPD (Cheng 1997, Black 2004). Longitudinal studies of inpatients diagnosed with BPD have found suicide rates of approximately 10% (Paris 2002).

Although those with APD are known to attempt suicide, these attempts rarely result in death (Garvey 1980). There have been no studies of the rate of suicide of those with APD, but nonnatural mortality (death from suicide, accidents, and homicide) is higher in this group (Repo-Tiihonen 2001). Criminal offenders diagnosed with a personality disorder have a 5-year suicide rate of 3%; however, the research did not specify the type of PD (Kullgren 1998).

Drug Therapy for PD-Related Suicidal Behavior

No Direct Studies

The main obstacle to drawing strong conclusions regarding drug therapy for suicidality in PDs is that there are no studies directly evaluating the efficacy of psychopharmacological agents in suicidal PD patients. Therefore, Cardish based his assessments on literature relating to specific PD symptom clusters frequently associated with suicidal behavior.

Medication May Help…Sometimes

Medication should not be considered first-line treatment in working with PD patients. Cardish found evidence that pharmaceuticals may sometimes be useful in helping patients cope with specific symptom clusters, particularly during periods of acute crisis. In these instances, medications should be adjunctive to other therapeutic approaches.

Cardish’s Conclusions

Based on his evaluation of existing research, Cardish cautiously makes the following general observations with respect to the evidence for use of the following drugs or classes of drug for treatment of suicide-related symptoms in PD patients:

Affective instability, depression anger, and impulsivity: SSRIs may reduce symptoms of in some patients.

Suicidal feelings, anger or hostility, and impulsive aggression: Neuroleptics may be tried to lower proneness to act on these feelings**.

Cluster B disorders for affective instability and impulsive aggression: Mood stabilizers (divalproex and carbamazepine) and anticonvulsants (topiramate and lamotrigine) may be tried, but patient must be monitored for bone marrow suppression and changes in liver enzymes**.

Self-mutilation: Naltrexone, clonidine and omega-3 fatty acids may be tried on a case-by-case basis**.

Nonrapid-cycling bipolar disorder: Lithium, highly lethal in overdose, may be unsuitable with this high-risk population, and if used, must be carefully monitored**.

**Cardish considers the evidence for efficacy to be weak and/or equivocal.

Additional PD Treatment Information

There are several good websites with reliable information on treatment options for personality disorders, including MentalHelp.net and Psychology Prof Online. Also see the Suite101.com article series on Personality Disorders, Antisocial PD and Borderline PD.

It must be kept in mind that psychopharmacological treatment programs are designed by medical mental health professionals on a case-by-case basis. This Sute101 article is a summary of one academic review of existing research. It is not meant to be used for self-diagnosis or in place of psychiatric care.

Sources

Black D. et al. (2004) Suicidal behaviour in borderline personality disorder: prevalence, risk factors, prediction and prevention. J Personal Disord, 18.

Cardish, R. J. (2007) Psychopharmacologic Management of Suicidality in Personality Disorders. Canadian Journal of Psychiatry, 52, 6.

Cheng A., Mann A., Chan K.(1997) Personality disorder and suicide-a case-control study. Br J Psychiatry.170.

Garvey M., Spoden F. (1980) Suicide attempts in antisocial personality disorder. Compr Psychiatry, 21.

Kullgren G., Tengstrom A., Grann M. (1998) Suicide among personality-disordered offenders: a follow-up study of 1943 male criminal offenders. Soc Psychiatry Psychiatr Epidemiol, 33.

Paris J. (2002) Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv, 53.

Repo-Tiihonen E., Virkkunen M., Tiihonen J. (2001) Mortality of antisocial male criminals. J Forensic Psychiatry, 12.