suicide. The prescription of a psychotropic agent is itself a marker for suicidal risk and it is important to consider its lethality in prescribing for patients with mental disorders. Furthermore, there is a marked gradient in toxicity among antidepressants (Cassidy and Henry, 1987; Kapur et al., 1992). In a study conducted in the United Kingdom, desipramine was reported to have over twice the death rate by overdose per 1,000,000 prescriptions compared to amitriptyline, imipramine, or nortriptyline, and 9 times the death rate by overdose of mianserin (Cassidy and Henry, 1987). In data from the United States, the toxicity of different antidepressants was examined using two different databases—the Association of Poison Control Centers (APCC) and the Drug Abuse and Early Warning Network (DAWN) (Kapur et al., 1992). In the APCC database the rate of overdose was adjusted for prescription volume based on the National Prescription Audit. Both APCC and DAWN databases revealed that desipramine had a higher risk for suicide attempt and greater fatality given an overdose than either amitriptyline or imipramine. The DAWN analysis also demonstrated that the three tricyclic antidepressants had between a 2.5 and 8.5 greater risk of death due to overdose than fluoxetine. Therefore, alteration in prescription practices to favor SSRIs over TCAs might result in a decline in deaths by overdose of antidepressants.
Suicide and suicide attempt are markedly increased in patients with epilepsy (Brent, 1986; Hawton et al., 1980; Mackay, 1979; Matthews and Barabas, 1981; Sillanpaa, 1973). While interictal psychopathology related to epilepsy seems to be an important risk factor for suicidal behavior (Mendez et al., 1989), phenobarbital may be an iatrogenic cause of depression and suicidal behavior in epilepsy (Brent, 1986; Brent et al., 1990; Brent et al., 1987a; Ferrari et al., 1983). One naturalistic study suggested that exposure to phenobarbital caused about a 4-fold risk for depression, which was most likely to occur if there was a family history of depression and very unlikely to occur in the absence of a family history of depression (Brent et al., 1987a). Phenobarbital is no longer a first-line anticonvulsant in the United States, but because of its overall safety and cost, it still is used quite commonly in developing countries. Screening for a family history of depression may help to avoid the iatrogenic difficulties associated with this medication.
Availability of high buildings or bridges provides another means for suicide. In New York City, suicide by jumping was highest in Manhattan, and lowest in Staten Island, the two extremes for access to buildings of 7 stories or higher (Marzuk et al., 1992). In another study in New York, 81 percent of all suicides jumped from their own residences (Fischer et al.,