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Re: tricyclics and suicide

Posted by Elizabeth on November 3, 1999, at 11:57:14

In reply to Re: tricyclics and suicide, posted by saint james on November 1, 1999, at 18:40:20

> > Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.

This is well said, and I have to balance the risks of prescribing vs. the risks of not prescribing. There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression"), the patient's current level of suicidal ideation and history of suicide attempts, the level of social support available to the patient, etc. As Saint James points out below, you can also write for just a week at a time if the patient is "high-risk."

> One months supply of a TCA generally is not enough to kill someone. Doc make this call often, so the write scripts for the smallest amount of time in those that might try suicide.

This is sort of an oversimplification...because people metabolize tricyclics at widely varying rates (in particular, somewhere around 10% of Caucasians (less in other ethnic groups) are deficient in an enzyme involved in TCA metabolism), the lethal dose varies a lot as well. A month's supply at a starting dose probably wouldn't be lethal for a normal metabolizer, but it could be for a poor metabolizer.




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