Preventing Suicidal Behavior in ADHD

Individuals with attention-deficit/hyperactivity disorder (ADHD) have an elevated risk for suicidal behaviors. Stimulant medications are helpful in treating the core symptoms of ADHD; non-stimulant medications are also available to treat this disorder. Do these medications influence the risk of suicide attempts?

Zheng Chang and colleagues recently published the results of a large study addressing this question in the journal Biological Psychiatry. These investigators analyzed de-identified information from databases containing U.S. employer-sponsored commercial health insurance claims between 2005 and 2014. Specifically, they reviewed inpatient, outpatient, and filled prescription claims from 146 million individuals representing about 49% of the U.S. population.

From this information, they identified a group of about 3.8 million individuals with a diagnosis of ADHD. They were also able to ascertain months when an individual had an emergency room visit, ambulance ride, or inpatient hospitalization associated with a suicide attempt and correlate that information with periods when these individuals filled prescriptions for stimulant or non-stimulant medications for ADHD.

The results of the study were clear. During months when individuals filled prescriptions for ADHD medications, there was a 31-39% lower risk of a suicide attempt compared with months without a filled ADHD medication prescription. This effect was seen for all age groups ranging from children to middle-aged individuals. It was also seen for individuals with or without a history of depression or substance use disorder. Interestingly, the lower risk was only associated with stimulant medications for ADHD (e.g., methylphenidate and amphetamines); no statistically significant effect on suicide attempts was observed during months when individuals were prescribed atomoxetine, a non-stimulant medication.

The mechanisms underlying the anti-suicidal effects of stimulants in patients with ADHD cannot be determined from this type of data. Although both stimulant and non-stimulant medications can be effective in treating ADHD symptoms, it is interesting that only the stimulants were associated with lowered risks of suicide attempts.

Although stimulants are first-line treatments for ADHD, they are also drugs with abuse potential. Similarly, ketamine has abuse potential, and yet, when used appropriately, it has powerful antidepressant effects. This may also be true of psychedelics and cannabinoids such as marijuana. Perhaps it is not surprising that drugs with powerful influences on brain activity can have beneficial or deleterious effects depending on how they are used.

This column was written by Eugene Rubin M.D., Ph.D., and Charles Zorumski M.D.