Relationship Between Antidepressants and Suicidal Risk in Adults

This paper provides a critical analysis of the relationship between antidepressants and suicidal risk in adults. It explores the theories surrounding the issue and highlights their prevalence in contemporary nursing.

Running head: CONTEMPORARY MENTAL HEALTH
Name of the Student
Name of the University
Author Note

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Introduction:
This paper will provide critical analysis of the relationships between antidepressant and suicidal
risk in adults. The explored the theories surroundings the issue and highlight their prevalence in
contemporary nursing. Suicidal behaviors take over millions of individuals every year DSM V refer to
suicide as symptoms of some psychiatric disorder which is considered as the psychiatric emergency
(Shain 2016). The risk of suicide and suicidal behavior takes over more than a million individuals every
year worldwide. The non-fatal suicidal behavior is estimated to 25 to 50% times more common (Shain
2016). The world health organization reported that the annual report on the suicide rate is approximately
13 per 100000 individuals. In 2017, there are 6213 suicides in the United Kingdom and the republic in
Ireland. In the UK, men are three times as likely to commit suicide and at higher risk of committing
suicide compared to women (Pitman et al. 2017). An array of research suggested that although
antidepressants are widely prescribed for decreasing the symptoms of depression and risk of suicide,
selective serotonin reuptake inhibitor may induce worse suicidal thoughts in vulnerable patients (Haw and
Hawton 2015). In the United Kingdom, the average of 16 suicides per day observed in countries where 4
to 5 deaths were observed as a result of consuming antidepressant (Haw and Hawton 2015). In June
2005, as discussed by González et al. (2016), the adolescents and adult aged in-between 18 to 25 years
experienced who were consuming specific serotonin inhibitors are more prone to suicidal thoughts. The
significance of this issues is that while antidepressants are given to reduce the suicidal thoughts, a
significant number of antidepressants increase the suicidal thoughts which reported 11,225 out of 856,493
(1.3%) teens and adults taking SSRIs in 2017 (Haw and Hawton 2015 ) . The health professionals are
guided by DSM 5 to ask the client regarding their past suicide attempts to diagnosis the disorder (Haw
and Hawton 2015 ) . Moreover, previously suicide was reserved to the diagnosed of borderline disorder
and major depressive but after conducting in-depth research the researchers uncovered the fact that
suicide attempt and risk of suicide can be facilitated by consumption of specific antidepressants
(McCormick, Murray and McNew 2015). This topic is important in contemporary nursing since it is a

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unique challenge to nursing care. The contemporary mental health professionals are peer workers who
once suffered from mental illness and experienced similar kind of emotional turmoil which is experienced
by many clients (O'Connor and Kirtley 2018). Many clients who consumed that certain serotonin
inhibitors are exhibit suicidal behavior or at high risk of committing suicide (O'Connor and Kirtley 2018).
After gaining an understanding of how anti-depressants and suicide risk is highly correlated,
contemporary mental health professionals would be able to understand the feelings of clients along with
their needs and able to improve the strategies to promote the wellbeing of the health professionals
(BriggsSlater and Bowley 2017).
Discussion:
While antidepressants are widely prescribed for reducing the symptoms of depression and anxiety
and suicidal risk, there are some antidepressants drugs, especially some selective serotonin inhibitors
facilitate the risk of suicides in vulnerable patients. As discussed by there are a certain level of selective
serotonin reuptake inhibits such as paroxetine and citalopram and others were contraindicated in adults
and adolescents due to increased risk of suicide. As discussed by Serafini et al. (2017), selective
serotonin reuptake inhibitors are a class of drugs which target serotonin inhibitors. While the exact
mechanism of the drug is unknown, this drug provided to the patients with bipolar, major depressive
disorder and anxiety to ease the symptoms of depression by increasing the level of serotonin in the brain
(Amita et al. 2015). The chemical name of serotonin is 5-hydroxytryptamine which is a
neurotransmitter responsible is for the feeling of happiness and wellbeing. It is used for transmitting nerve
cells and active in constricting smooth muscles. Moreover, as the precursor of melatonin, it helps in the
regulation of the biological sleep cycle as well as an internal clock (Rayan 2017). As discussed by
Gałecki et al. (2016), it plays a crucial role in appetite, emotions, cognitive, motor, and autonomic
functions. In depression and anxiety, the level of serotonin become extremely low which further affects
the mood, motor functions, blood clotting, bowel functions, and bone density (Biernacka et al. 2015).
Hence, when antidepressants, especially selective serotonin reuptake inhibitors are administrated by

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health professionals, they believed to increase the extracellular level of serotonin by limiting the
reabsorption or reuptake into the presynaptic cells, increasing the level of serotonin in synaptic cleft
available for binding to the receptor such as postsynaptic receptor which is a membrane protein activated
in presence of neurotransmitters (Biernacka et al. 2015). It is called selective because it seems to
primarily affect serotonin and also have selectivity for other monoamine transporters, exhibiting weak
affinity for the norepinephrine and dopamine transporters (McCormick, Murray and McNew 2015).
The role of selective serotonin reuptake inhibitors in inducing suicidal ideation:
Suicidal ideation or suicidal thoughts are thoughts of committing suicide. While the underlying
reason behind the high risk of committing suicide can be many factors, FDA reported that the vulnerable
population with severe mental illness can be subjected to the risk of committing suicide. Taking an insight
into the situation, the considerate number of literature documented that it induces the risk of suicide,
especially in children and adolescents’ (Aghakhan et al. 2016). The person who experienced suicidal
thoughts or at higher risk of committing suicide, may feel trapped, have frequent mood swings. As
discussed by Aghakhan et al. (2016), ICD-10 cm codes are an assessment tool which is designed by world
health organization where suicidal ideation is fallen under R45.851 diagnosis index (Molero et al. 2016).
It was observed that with the lower dose of the antidepressant , adults and adolescents are more prone to
the situation Although the exact mechanism of how selective serotonin reuptake inhibitors facilities the
risk of suicide, FDA ( food and drug administration ) suggested that how selective serotonin reuptake
inhibitors such as do not show activity on depression for a couple of weeks. It shows action by
worsening the symptoms first then improving it. During the first month of treatment with SSRI, the
symptoms of depression rapidly worsen since facilitate a greater degree of psychomotor retardation in
patients by increasing the reuptake initially before reducing the symptoms of depression or anxiety
(Molero et al. 2016). Psychomotor systems are the systems where movements and thinking are combined
which include balance and coordination. While a greater degree of psychomotor retardation induced in an
older population, it is a common symptom of depression (Hicks et al. 2016). Serotonin reuptake inhibitors

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induce the psychological symptoms by inducing psychomotor retardation using the mechanism discussed
above. It is important to mention that emergencies phenomenon plays a crucial role in the inducing
suicidal thoughts (Rahikainen et al. 2016). In depression, individuals have a high level of negative
thoughts but left with no energy to perform the cat of self-injury or self-harm. During the early phase of
treatment of SSRI, the patient’s energy is boosted by the medication. Positive changes in mood are a
time-consuming and prolonged process. In this interval, the lacked energy restored in the patients which
further facilitate the act of self-injury or self-harm, highlighting the restoring energy increases the risk of
committing suicide in vulnerable patients. Similar kinds of the study conducted by Aghakhan et al.
(2016), suggested that selective serotonin reuptake inhibitors produce behavioral toxicity where the
medications induce the behavioral activation in patients such as irritability, anxiety, agitation insomnia
followed by the high risk of committing suicide. Interestingly, a study by Molero et al. (2016), suggested
that SSRI also induce akathisia which is defined as psychomotor restlessness. It can be separated into
subjective such as inner restlessness and desire of continuously, and knee nodding while sitting which
further can elevate sudden negative thought process , subjective vulnerable patients to high risk of
suicide. After gaining an understanding of how these drugs are able to facilitate the risk of committing
suicide, FDA restricted the frequent use of antidepressants and limited it to certain illness where only
certain drugs can be applied with strictly recommended doses (Coon et al. 2016). FDA published a black
box warning that in children or adolescents, the treatment with antidepressants such as SSRI may pose a
risk of violence, aggression, mania, behavioral changes, suicidal ideation and risk of homicide ( Locher et
al. 2016) Although SSRI is not considered an addictive drug, stopping the sudden consumption of
Selective serotonin reuptake inhibitors or missing dose of it can induce sudden side effects such as
dizziness, lethargy, and uneasiness (Fischer, Jocham and Ullsperger 2015). Hence, it is crucial to
implement other non-pharmacological interventions to withdraw from consumption of the medication and
reduction of risk of committing suicide.
The struggle of contemporary mental health nurses to resolve the issue:

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While contemporary mental health nurses focused on the recovery of the patients by
implementing their lived experience to create an environment, a considerate number of contemporary
mental health nurses are struggled to provide care to the vulnerable patient with a high risk of committing
suicide Fischer, Jocham and Ullsperger 2015). An array of literature highlighted that there are a number
of reasons behind these struggles experienced by nurses which further reflected through discrepancies in
care or compromised quality of care (Fischer, Jocham and Ullsperger 2015). As front line health
professionals, nurses are heavily relying on non-pharmacological interventions such as creating safe
environments, engaging in therapeutic relationships by effective communication with family members
and patients, implementing the lived experience to ease their suffering. Consequently, patients and their
family members feel comfortable, empowered, and confident with a high level of self-esteem (Strawn,
Mills and Croarkin 2019).. Taking an insight of the current situation, the first reason behind challenges
faced by these mental health nurses which hinder them from providing the best care is that while
contemporary nursing based on evidence-based practice, a considerate number of nurses are unaware of
the actual cause of suicide ideation. As discussed by McCormick et al. (2016), since committing suicide
or suicidal thoughts are common for vulnerable patients with mental illness like anxiety and depression,
mental health nurses lack the skills and knowledge to treat the patients who are already consuming
antidepressants. The significant numbers of nurses are confused about the symptoms of suicide because
of antidepressants with symptoms of suicide because of depression (Fekadu et al. 2016). Consequently,
they feel helpless and lost while providing care to patients with a high risk of committing suicide or
suicidal ideation. Consequently, they become impaired to integrate specific nursing theories which are a
crucial recovery of patients with mental illness (McCormick, Murray and McNew 2015). One such
theory is Barker's Tidal Model of Mental Health Recovery which is a middle range mental health theory
which focuses on helping patients in recovery by creating their own voyage of discovery (Davidson et al.
2015). Phil bakers defined the tidal model as a philosophical approach to the discover the wellbeing of
mental health and it provides an opportunity to the mental health nurses for helping mentally ill patients
in reclaiming their personal story of mental distress, negative thoughts, emotional turmoil. It provides the

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opportunity to the patients use own language, metaphors and personal stories for expressing their journey
towards recovery which further facilitates the feeling of being empowered, confident and safe. However,
because of inability to the identification of early signs of suicides because of prescribed selective
serotonin reuptake inhibitors, nurses are not able to apply this theory into practice which further creates a
discrepancy in care and recovery journey (McCormick, Murray and McNew 2015). Consequently, the
nurses become avoidant and dismissive of clients. Another identified struggle of mental health nurses is
that a considerate number of clients are not clear about the role of mental health which made it difficult
for nurses to provide the accurate care since patients are not corporative enough to reveal their vulnerable
thoughts (McCormick, Murray and McNew 2015). Because of a lack of extensive research and the nature
of the illness, it is difficult to negotiate the boundaries of care. A considerate number of mental health
nurses are not able to maintain cultural competencies while providing care for the patients coming from
diverse culture. The prime reason behind it is that culture has a strong influence on the health, though
process and actions. People who are at high risk of suicides because of the consumption of SSRI have
negative thoughts which are solely influenced by the cultural values and patients coming from different
cultures have different negative thoughts and thoughts of self-harm influenced by cultural values.
Consequently, culturally incompetent contemporary mental health nurses are unable to meet special
cultural needs which further facilitate ethical dilemma and disrespecting dignity. Contemporary mental
nurses are subjected to high risk of psychological experience such as because of coming in direct contact
with the patients who are having suicidal thoughts (Strawn, Mills and Croarkin 2019). Consequently,
nursing professionals tend to treat them badly, not warming enough to reduce suicidal thoughts in
patients. Hence, in order to provide safe and responsive care to the adults and assisting them in faster
recovery, nurses need to adapt the accurate skills to gain the understanding of the issue and assots them to
cope up with the situation.
Possible changes or solutions:

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There are diverse ranges of solutions available for reducing the risk of suicide in adults who are
consuming selective serotonin reuptake inhibitors. In the current context, mental health nurses must gain
a depth understanding of how SSRI increases the risk of developing suicidal thoughts or a high risk of
self-harm (BriggsSlater and Bowley 2017). More resources are required to available for contemporary
mental health nurses to conduct extensive researchers regarding how SSRI can induce suicide ideation.
This would help mental health nurses to identify early signs of the suicide or risk of subjected to suicidal
thoughts and focus on the non-pharmacological interventions to reduce the depression in order to reduce
the use of antidepressants. In order to reduce the high risk of committing suicide in adults, nurses must
incorporate replacement therapies instead of anti-depressants (Papathanasiou et al. 2015). Clinicians
play a massive role in reducing risk since clinicians should be aware of the fact that prescribing the SSRI
may induce suicidal risk and hence there is a need for early follow up and encourage support as well as
supervision of patients and family members, especially early phase of treatment since as discussed
above in early stages the medications increase psychological problems in individuals. The nurses are
required to offer greater psychological support. As discussed by () Cognitive behavioral therapy is the
most suitable nonpharmacological therapy to reduce the risk of committing suicide. Cognitive behavioral
therapy is short term therapy which helps people find new ways to behave properly by changing their
thought process. Consequently, changing the thought process of vulnerable patients would help to reduce
the tendency of committing suicide or eliminating the negative thoughts which further help to reduce
stress, deal with negative feelings such as grief, improving emotion regulations. However, since cognitive
behavior therapy rearranges the thought process it may have a negative impact on patients. Hence, it is
required to recommend according to the risk of suicide. Moreover, to improve the wellbeing of the
patient's nurses are required to implement Barker’s Tidal Model of Mental Health Recovery in the
practice for supporting patients to reclaim their story of emotional distress. The nurses are required to
involve family members of depressive patients who are highly prone to commit suicide in order to gain an
understanding of previous suicide attempt so that appropriate interventions can be designed according to
it. The nurses are required to be empathetic, compassionate and kin while engaging these patients in the

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early stage of treatment to provide a safe and comfortable environment for effective communications and
therapeutic relationships.
As discussed above, because of the confusing nature of mental health conditions nurses experienced an
array of difficulties which reduces the quality of care. To resolve these issues, nurses are required to
involve themselves in the training as well as workshops so that they can work with these vulnerable
clients (BriggsSlater and Bowley 2017). The mental health nurses are required to involve themselves in
the motivational interviews and dialectical behavioral therapy with help of peer workers to reduce their
stress and increase their compliance in order to provide accurate care to the patients. The mental health
nurses are required to develop cultural competencies in order to identify the special need of the patients
according to their cultural practice in order to avoid ethical dilemma and breaching the dignity of the
patients (Fokuo et al. 2017). In the current context, clinical supervision would be helpful for the mental
health nurses in order to work with the client. The support from clinical supervisors and proper staff
would be appropriate to reduce professional burn out of nurses (Liu et al. 2017). The nurses are required
to involve themselves debriefing reflective practice which is crucial for identifying the weakness practice.
Highly skilled specialist nurses are required to implement in professional practice.
Conclusion:
Thus it can be concluded that antidepressants are widely prescribed for reducing the symptoms of
depression and anxiety and suicidal risk, there are some antidepressants drugs, especially some selective
serotonin inhibitors facilitate the risk of suicides in vulnerable patients. In was observed that in patients,
anti-depressants, especially SSRI increases the extracellular level of serotonin by limiting the
reabsorption or reuptake into the presynaptic cells. however, it was observed that during the first month of
treatment with SSRI, the symptoms of depression rapidly worsen since facilitate a greater degree of
psychomotor retardation in patients by increasing the reuptake initially before reducing the symptoms of
depression or anxiety which further increases the risk of committing suicide. A significant number of
mental health nurses are struggled to provide care to the vulnerable patient with a high risk of committing

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suicide because of role confusion, inability to understand the early signs clearly, cultural incompetence
and high level of psychological distress they are subjected to. To reduce the risk of suicide in adults, the
nurses are required to provide psychological support such as replacing SSRI with alternative therapies. In
order to provide safe and responsive care nurses must provide with training, clinical supervision and
debriefing to enhance their practice of providing care to vulnerable patients.

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References:
Aghakhani, K., Soltani, S., Farhidnia, N. and Fallah, F., 2017. Successful Suicide in a Child: Depression-
Related or Paroxetine-Induced?. International Journal of Medical Toxicology and Forensic Medicine, 6(4
(Autumn)), pp.242-246.
Amitai, M., Chen, A., Weizman, A. and Apter, A., 2015. SSRI-induced activation syndrome in children
and adolescents—what is next?. Current Treatment Options in Psychiatry, 2(1), pp.28-37.
Biernacka, J.M., Sangkuhl, K., Jenkins, G., Whaley, R.M., Barman, P., Batzler, A., Altman, R.B., Arolt,
V., Brockmöller, J., Chen, C.H. and Domschke, K., 2015. The International SSRI Pharmacogenomics
Consortium (ISPC): a genome-wide association study of antidepressant treatment response. Translational
psychiatry, 5(4), p.e553.
Briggs, S., Slater, T. and Bowley, J., 2017. Practitioners' experiences of adolescent suicidal behaviour in
peer groups. Journal of psychiatric and mental health nursing, 24(5), pp.293-301.
Coon, E.A., Ahlskog, J.E., Silber, M.H., Fealey, R.D., Benarroch, E.E., Sandroni, P., Mandrekar, J.N.,
Low, P.A. and Singer, W., 2018. Do selective serotonin reuptake inhibitors improve survival in multiple
system atrophy?. Parkinsonism & related disorders, 48, pp.51-53.
Davidson, J.E., Zisook, S., Kirby, B., DeMichele, G. and Norcross, W., 2018. Suicide prevention: a healer
education and referral program for nurses. Journal of nursing administration, 48(2), pp.85-92.
Fekadu, A., Medhin, G., Selamu, M., Shiferaw, T., Hailemariam, M., Rathod, S.D., Jordans, M., Teferra,
S., Lund, C., Breuer, E. and Prince, M., 2016. Non-fatal suicidal behaviour in rural Ethiopia: a cross-
sectional facility-and population-based study. BMC psychiatry, 16(1), p.75.
Fischer, A.G., Jocham, G. and Ullsperger, M., 2015. Dual serotonergic signals: a key to understanding
paradoxical effects?. Trends in cognitive sciences, 19(1), pp.21-26.

11
CONTEMPORARY MENTAL HEALTH
Fokuo, J.K., Goldrick, V., Rossetti, J., Wahlstrom, C., Kocurek, C., Larson, J. and Corrigan, P., 2017.
Decreasing the stigma of mental illness through a student-nurse mentoring program: a qualitative
study. Community mental health journal, 53(3), pp.257-265.
Gałecki, P., Mossakowska-Wojcik, J. and Talarowska, M., 2018. The anti-inflammatory mechanism of
antidepressants–SSRIs, SNRIs. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 80,
pp.291-294.
González, R.A., Igoumenou, A., Kallis, C. and Coid, J.W., 2016. Borderline personality disorder and
violence in the UK population: categorical and dimensional trait assessment. BMC psychiatry, 16(1),
p.180.
Haw, C. and Hawton, K., 2015. Suicide is a complex behaviour in which mental disorder usually plays a
central role. Australian & New Zealand Journal of Psychiatry, 49(1), pp.13-15.
Hicks, J.K., Bishop, J.R., Sangkuhl, K., Müller, D.J., Ji, Y., Leckband, S.G., Leeder, J.S., Graham, R.L.,
Chiulli, D.L., LLerena, A. and Skaar, T.C., 2015. Clinical Pharmacogenetics Implementation Consortium
(CPIC) guideline for CYP2D6 and CYP2C19 genotypes and dosing of selective serotonin reuptake
inhibitors. Clinical Pharmacology & Therapeutics, 98(2), pp.127-134.
Liu, N.H., Daumit, G.L., Dua, T., Aquila, R., Charlson, F., Cuijpers, P., Druss, B., Dudek, K., Freeman,
M., Fujii, C. and Gaebel, W., 2017. Excess mortality in persons with severe mental disorders: a multilevel
intervention framework and priorities for clinical practice, policy and research agendas. World
psychiatry, 16(1), pp.30-40.
Locher, C., Koechlin, H., Zion, S.R., Werner, C., Pine, D.S., Kirsch, I., Kessler, R.C. and Kossowsky, J.,
2017. Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake
inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic
review and meta-analysis. Jama Psychiatry, 74(10), pp.1011-1020.

12
CONTEMPORARY MENTAL HEALTH
McCormick, U., Murray, B. and McNew, B., 2015. Diagnosis and treatment of patients with bipolar
disorder: A review for advanced practice nurses. Journal of the American Association of Nurse
Practitioners, 27(9), pp.530-542.
McCormick, U., Murray, B. and McNew, B., 2015. Diagnosis and treatment of patients with bipolar
disorder: A review for advanced practice nurses. Journal of the American Association of Nurse
Practitioners, 27(9), pp.530-542.
Molero, Y., Lichtenstein, P., Zetterqvist, J., Gumpert, C.H. and Fazel, S., 2015. Selective serotonin
reuptake inhibitors and violent crime: a cohort study. PLoS medicine, 12(9), p.e1001875.
Näslund, J., Hieronymus, F., Lisinski, A., Nilsson, S. and Eriksson, E., 2018. Effects of selective
serotonin reuptake inhibitors on rating-scale-assessed suicidality in adults with depression. The British
Journal of Psychiatry, 212(3), pp.148-154.
O'Connor, R.C. and Kirtley, O.J., 2018. The integrated motivational–volitional model of suicidal
behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754),
p.20170268.
Papathanasiou, I.V., Tsaras, K., Neroliatsiou, A. and Roupa, A., 2015. Stress: Concepts, theoretical
models and nursing interventions. American Journal of Nursing Science, 4(2-1), pp.45-50.
Pitman, A., Nesse, H., Morant, N., Azorina, V., Stevenson, F., King, M. and Osborn, D., 2017. Attitudes
to suicide following the suicide of a friend or relative: A qualitative study of the views of 429 young
bereaved adults in the UK. BMC psychiatry, 17(1), p.400.
Rahikainen, A.L., Vauhkonen, P., Pett, H., Palo, J.U., Haukka, J., Ojanperä, I., Niemi, M. and Sajantila,
A., 2019. Completed suicides of citalopram users—the role of CYP genotypes and adverse drug
interactions. International journal of legal medicine, 133(2), pp.353-363.

13
CONTEMPORARY MENTAL HEALTH
Rayan, A., 2017. Suicide Risk Assessment and Management for Adults with Major Depressive
Disorder. Health, 4(6), pp.63-70.
Serafini, G., Solano, P. and Amore, M., 2016. Antidepressant Medications and Suicide Risk: What Was
the Impact of FDA Warning?. In Melatonin, Neuroprotective Agents and Antidepressant Therapy (pp.
477-499). Springer, New Delhi.
Shain, B., 2016. Suicide and suicide attempts in adolescents. Pediatrics, 138(1), p.e20161420.
Strawn, J.R., Mills, J.A. and Croarkin, P.E., 2019. Switching Selective Serotonin Reuptake Inhibitors in
Adolescents with Selective Serotonin Reuptake Inhibitor-Resistant Major Depressive Disorder: Balancing
Tolerability and Efficacy. Journal of child and adolescent psychopharmacology.