Might That Medrol Dosepak Trigger a Suicide?
Abstract & Commentary
By Joseph E. Scherger, MD, MPH
Dr. Scherger reports no financial relationships relevant to this field of study.
Synopsis: Adults treated with glucocorticoids in a primary care setting have a five-fold increase in suicide or suicidal behavior and other severe neuropsychiatric disorders. The risk is highest with first-time use of these medications.
Source: Fardet L, et al. Suicidal behavior and severe neuropsychiatric disorders following glucocorticoid therapy in primary care. Am J Psychiatry 2012;169:491-497.
IN THIS COHORT STUDY FROM THE UNITED KINGDOM, FARDET ET AL REVIEWED medical records from 424 general practices from 1990 until 2008 for incidence rates of neuropsychiatric disorders following glucocorticoid therapy. There were 786,868 courses of oral glucocorticoids prescribed for 372,696 patients. The medications included prednisolone, prednisone, dexamethasone, triamcinolone, betamethasone, methylprednisolone, and deflazacort, all given orally. Neuropsychiatric disorders identified included depression, mania, delirium, panic disorder, and suicidal behavior.
A neuropsychiatric disorder was considered to be associated with the use of glucocorticoids if it occurred after initiating therapy and the patient did not have that diagnosis within the preceding 6 months. The treatment group was compared with two other groups: a random sample of other patients who did not receive glucocorticoids, and a random sample of others with the same underlying neuropsychiatric conditions who did not receive glucocorticoids.
Among the groups, matching was done within the same practice and stratified by age and sex. Adjustments were made for potential confounding variables including age, sex, past history of glucocorticoid use, past history of any neuropsychiatric disorder, daily dose of glucocorticoids, and underlying medical disease.
The incidence rate for any neuropsychiatric disorder in the treatment group was 16 per 100 person years overall. The incidence rate was 22 for the first course of corticosteroid, 14 for the second course, and 12 for the third and later courses. The risk of suicide or suicide attempt was increased approximately five-fold (hazard ratio [HR] = 5.3; 95% confidence interval, 3.8-7.3) and was more likely in younger patients. The increase in risk by individual disorder was most marked for delirium (HR = 6.4; 5.9-6.8) and mania (HR = 5.7; 5.1-6.6), especially in older men. Other significant increases were shown for depression and panic disorder. Larger daily doses and prior history of neuropsychiatric disorders were associated with a greater risk for all of these outcomes.
The authors conclude that glucocorticoids increase the risk of suicidal behavior and neuropsychiatric disorders. Educating patients and their families about these adverse events and increasing primary care physicians’ awareness about their occurrence should facilitate early monitoring.
Commentary
Every time I give a short course of glucocorticoids in my practice — something I do not do as often as other physicians in my area — I hope that I am not causing an asceptic necrosis of the hip. I fear this because I have seen it in my practice. We are all aware that some patients given these steroids have mental health side effects. This study is a wake-up call that these mental health side effects may be serious and life-threatening in some patients.
Every time we prescribe a medication, a risk-benefit calculation takes place in our reflection. Large epidemiologic studies like this may help us avoid a disaster that otherwise is only likely to occur once in our practice lifetime.
Adults treated with glucocorticoids in a primary care setting have a five-fold increase in suicide or suicidal behavior and other severe neuropsychiatric disorders. The risk is highest with first-time use of these medications.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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