Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly?
BMC Geriatrics
Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly? Anders Carlsten*†1 and Margda Waern†2
0 Department of psychiatry and neurochemistry, Sahlgrenska Academy at Gothenburg University , Gothenburg , Sweden
1 Social Medicine, Department of Public Health and Community Medicine, Sahlgrenska Academy at Gothenburg University and Nordic School of Public Health , Gothenburg , Sweden
Background: While antidepressant-induced suicidality is a concern in younger age groups, there is mounting evidence that these drugs may reduce suicidality in the elderly. Regarding a possible association between other types of psychoactive drugs and suicide, results are inconclusive. Sedatives and hypnotics are widely prescribed to elderly persons with symptoms of depression, anxiety, and sleep disturbance. The aim of this case-control study was to determine whether specific types of psychoactive drugs were associated with suicide risk in late life, after controlling for appropriate indications. Methods: The study area included the city of Gothenburg and two adjacent counties (total 65+ population 210 703 at the start of the study). A case controlled study of elderly (65+) suicides was performed and close informants for 85 suicide cases (46 men, 39 women mean age 75 years) were interviewed by a psychiatrist. A population based comparison group (n = 153) was created and interviewed face-to-face. Primary care and psychiatric records were reviewed for both suicide cases and comparison subjects. All available information was used to determine past-month mental disorders in accordance with DSM-IV. Results: Antidepressants, antipsychotics, sedatives and hypnotics were associated with increased suicide risk in the crude analysis. After adjustment for affective and anxiety disorders neither antidepressants in general nor SSRIs showed an association with suicide. Antipsychotics had no association with suicide after adjustment for psychotic disorders. Sedative treatment was associated with an almost fourteen-fold increase of suicide risk in the crude analyses and remained an independent risk factor for suicide even after adjustment for any DSM-IV disorder. Having a current prescription for a hypnotic was associated with a four-fold increase in suicide risk in the adjusted model. Conclusion: Sedatives and hypnotics were both associated with increased risk for suicide after adjustment for appropriate indications. Given the extremely high prescription rates, a careful evaluation of the suicide risk should always precede prescribing a sedative or hypnotic to an elderly individual.
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Background
The use of psychotropic drugs among the elderly is high
[1-3] and health risks associated with these drugs are a
topic of public health concern. Increased risk for fall
accidents [4,5], adverse drug reactions [6], drug related
morbidity [7] and unfavourable interactions with other
medication [8] have been emphasized in the literature.
While the induction of suicidality is a concern in younger
age groups [9], there is increasing evidence that
antidepressants may be beneficial in the prevention of suicide
late in life [10-15]. Regarding a possible association
between other types of psychoactive drugs (sedatives,
hypnotics, antipsychotics) and suicide, results are
inconclusive [16-18]. Sedatives and hypnotics are widely
prescribed to elderly persons with symptoms of
depression, anxiety, and sleep disturbance. They are regularly
detected in post-mortem analyses of elderly suicide
victims, and often implicated in lethal overdoses in Sweden
[19].
The elderly consume more psychotropics than any other
age group in Sweden [20]. There have been substantial
changes in the sales of psychotropic drugs to persons aged
65 and above over the last fifteen years. While sales of
antipsychotics (Figure 1a) and sedatives (Figure 1b)
decreased by almost 50% during this time period, sales of
hypnotics remained extremely high (Figure 1c). Sales rates
are particularly high in the older elderly, with Defined
Daily Dosages (DDD)/1000 inhabitants and day as high
as 165 in women and 120 in men (Figure 1c). SSRIs were
introduced in Sweden in 1990 and antidepressant sales
have seen a near five-fold increase since that time (Figure
1d.)
Given the high psychotropic prescription rates and the
high suicide rates in this age group it would be
appropriate to examine whether different types of psychotropic
drugs are associated with increased suicide risk. When
testing for a possible association, it is important to rule
out confounding by indication. However, studies that
include detailed evaluation of psychiatric symptoms in
elderly suicides and population-based controls are
lacking. The aim of the current study was thus to determine
whether different types of psychotropic drugs were
associated with increased risk of suicide in persons aged 65 years
and above after adjustment for appropriate indications.
Methods
One hundred consecutive (...truncated)