Adherence to psychotropic medication in completed suicide in Sweden 2006–2013: a forensic-toxicological matched case-control study

Abstract

Objective To investigate the influence of adherence to psychotropic medications upon the risk of completed suicide by comparing person-level prescriptions and postmortem toxicological findings among complete-suicide cases and non-suicide controls in Sweden 2006-2013. Methods Using national registries with full coverage on dispensed prescriptions, results of medico-legal autopsies, causes of death, and diagnoses from inpatient care, estimated continuous drug use for 30 commonly prescribed psychotropic medications was compared with forensic-toxicological findings. Subjects who had died by suicide (cases) were matched (1:2) with subjects who had died of other causes (controls) for age, sex, and year of death. Odds ratios were calculated using logistic regression to estimate the risk of completed suicide conferred by partial adherence and non-adherence to pharmacotherapy. Adjustments were made for previous inpatient care and the ratio of initiated and discontinued dispensed prescriptions, a measure of the continued need of treatment preceding death. Results In 5294 suicide cases and 9879 non-suicide controls, after adjusting for the dispensation ratio and other covariates, partial adherence and non-adherence to antipsychotics were associated with 6.7-fold and 12.4-fold risks of completed suicide, respectively, whereas corresponding risk estimates for antidepressant treatment were not statistically significant and corresponding risk increases for incomplete adherence to antidepressant treatment were lower (1.6-fold and 1.5-fold, respectively) and lacked statistical significance. Conclusion After adjustment for the need of treatment, biochemically verified incomplete adherence to antipsychotic pharmacotherapy was associated with markedly increased risks of completed suicide.

Suicidal Behavior and Its Relationship with Postmortem Forensic Toxicological Findings

“…According to the data obtained from the National Institute of Statistics (INE) in Spain, the number of suicides is higher in men than in women. These data correlate with those of the present study and those carried out in recent years in Spain [38] and Europe [21,[56][57][58].…”

“…The associations between psychotropic medications and the risk of suicide are a recurring topic of discussion [18,19]. Antipsychotic agents appear to have protective effects in both non-fatal suicides and complete suicidal acts, but the possible anti-suicide or pro-suicide properties of antidepressants remain inconclusive [20][21][22][23]. Nevertheless, it was observed that people treated with medications were 9.6 times more likely to attempt suicide during the hours they were intoxicated [24].…”

Antipsychotic Treatment Failure: A Systematic Review on Risk Factors and Interventions for Treatment Adherence in Psychosis

“…In this regard, one could wonder if the routine blood level monitoring for antipsychotics may thus contribute to its superior effectiveness in previously non-responsive patients (Patteet et al, 2012 ). Moreover, non-adherence has been significantly associated with poorer clinical outcome, including greater risk of hospitalization, longer duration of hospitalization (Higashi et al, 2013 ; Olivares et al, 2013 ), and greater risk of suicide (Leucht and Heres, 2006 ; Llorca, 2008 ; Forsman et al, 2019 ). In addition, partial and total medication non-adherence are strongly associated with psychotic relapse as non-adherent patients with schizophrenia having a 5-fold increase in risk of relapse (Robinson et al, 1999 ; Caseiro et al, 2012 ).…”

Psychiatry in the Digital Age: A Blessing or a Curse?

“…Thus, non-adherence to antipsychotic medication has been shown to be associated with a higher rate of psychiatric and medical hospitalizations in patients with schizophrenia [130]. Biochemically verified non-adherence to antipsychotic medication was reported to be associated with an increased risk of completed suicide [131]. In the USA in 2016, the estimated cost of drug-related morbidity and mortality resulting from non-optimized pharmacotherapy, including medication non-adherence, was USD 528 billion [132].…”