Methylphenidate and suicidal ideation: Report of two cases.

Stimulant prescriptions are routinely used to treat Attention Deficit Hyperactivity Disorder. Reports of psychiatric symptoms that have occurred include euphoria, delirium, confusion, toxic psychosis, and hallucinations. Here, authors report two cases of Attention Deficit Hyperactivity Disorder who were prescribed methylphenidate. Both children developed suicidal ideation that abated after discontinuing the drug. There were no depressive symptoms reported along with it, and the ideation could not be explained on the basis of impulsivity either.

INTRODUCTION

Prescription stimulants are often used to treat Attention Deficit Hyperactivity Disorder (ADHD). Drugs like methylphenidate (MPH), dextroamphetamine, and dextroamphetamine-amphetamine help people with ADHD feel more focused. Methylphenidate has become the most preferred drug prescribed by physicians for initial treatment of ADHD. Usual doses ranges from 10 to 60 mg/day depending on the age and the response of the child.[12]

MPH increases dopamine (DA) by blocking dopamine transporters (DATs) and adenosine monophosphatase c (AMP) by releasing DA from the nerve terminal using the DAT as carriers.[3]

Reports of psychiatric symptoms that occur include euphoria, delirium, confusion, toxic psychosis, and hallucinations. Such symptoms should not be unexpected as methylphenidate's pharmacologic effects are “basically the same as those of amphetamines.” Cases of psychosis with methylphenidate abuse have been reported when the drug is used in “runs,” similar to amphetamine abuse.[4] There are limited data in the literature regarding the psychiatric side effects of methylphenidate when it is abused. Most of the data are found in case reports. Side effects reported are similar to the psychiatric side effects of amphetamines. Psychiatric symptoms of extreme anger with threats of aggressive behavior may occur in methylphenidate abuse. When high doses are taken, delirium, aggressiveness, panic states, and hallucinations have been observed. Violence, agitation, and depression with suicidal ideation have also been reported in previous studies.[45]

Here authors report two cases where the suicidal ideation developed in male children in whom treatment with Methylphenidate was initiated for ADHD.

CASE REPORTS

Case 1

An 8-year-old male child, attending the Child Guidance Clinic at our institute was diagnosed as a case of ADHD, combined type as per DSM-IV TR by the consultant Psychiatrist. The patient had marked hyperactivity at school, home, and in social settings. The child reportedly also had impulsivity and poor concentration as was apparent from history, observation, and mental status examination. The patient had average Intelligent Quotient, but due to hyperactivity and inattention, he was not performing well in academics. He also had behavioral problems at home.

The patient was prescribed methylphenidate immediate release at the dose of 5 mg per day. Parents reported after a week as was scheduled. They mentioned that during the initial 2 days, the child reported suicidal ideation. In the evening when all family members were sitting and talking, the child said without any context (in vernacular language) on the first day “I wish to commit suicide” and on the second day he said “don't cremate me if I die”. During these two days, he was interacting well, playing adequately and his biological functioning was normal. Also there were no other behavioral problems or any other unusual behavior. No other side effects of methylphenidate were reported by the parents.

Parents were alarmed by child's utterances and stopped methylphenidate after 2 days and thereafter no suicidal ideation was expressed by the child. Following this, atomoxetine was prescribed, no side effects have been observed since then and the patient has been coming to child guidance clinic regularly. The case had no family history of mental illness or suicide.

Case 2

H, a 7-year-old child, was diagnosed with ADHD, combined type as per DSM-IV TR by the consultant Psychiatrist. There was evidence of hyperactivity in multiple social settings as reported by parents. In school he was unable to sit at one place, and would disturb his class mates. He would lose his note books and other articles of stationery frequently. His handwriting was untidy and note books had many frivolous mistakes. Teachers reported poor concentration in class and his inability to perform as per his potential. He was not able to maintain peer relationships and had frequent fights with them. He was prescribed 10 mg of methylphenidate once daily. Parents reported after 2 weeks to the child guidance clinic. They had stopped giving the drug after 12 days. They reported that when he was given the drug on a holiday, he seemed energetic and did more activities than usual. He would not obey his parents. In the afternoon he went to lie on the bed and threw six to seven quilts over himself and said “I want to die”. During this time he interacted less and appeared restless. He started slapping himself and tried to tie a garden hose around his neck. There was impairment in sleep onset for one night. There was no history of similar behavior in the past. There was no other apparent cause for the behavior like psychosocial stress or any medical problem. There was complete resolution of the symptoms by next morning. The drug was stopped immediately and no recurrence was reported.

Both the case reports are written from the descriptive clinical notes and experience of the treating clinician in routine clinical practice. However, no structured scales could be applied to assess for behavior or any affective symptoms.

DISCUSSION

Depressed mood or affective symptoms may occur as an adverse effect during MPH treatment, and impulsivity may result in attempted suicide even in ADHD children without depression. Although there is a “modest association” between ADHD and suicide, primarily in patients with comorbidities such as conduct or major mood disorder.[4] Although review data provides reassurance of the safety of methylphenidate, several unexpected or uncommon Adverse Drug Reactions (hepatomegaly, suicidal ideation, weight gain, or drug interactions) were identified by intensive pharmaco-surveillance monitoring program. Results show that an intensive pharmaco-surveillance monitoring program that involves pharmacovigilance centers and clinicians can improve the collection of information on drug safety in children.[4]

In our report, both the cases had combined type of ADHD, manifesting hyperactivity, impulsivity and impaired attention. In the first case, on treatment with 5 mg of methylphenidate, the child developed suicidal ideation, which abated, once methylphenidate was discontinued. The behavior reported was only at the level of expression of thought and there were no behavioral components of the expressed suicidal ideation. However, this behavior was quite strange for child's usual self. This produced a great deal of distress in the parents. The resulting behavior was apparent after 2 days of initiation of the drug which reflects the urgent need to look further into it as the first follow-up after prescription is usually a week.

In both cases side effects appeared beyond the duration of peak drug level. The first patient was given immediate release formulation in the morning which has a half-life of approximately 2 hours. However, in the literature, the psychological side effects are reported to occur beyond peak drug levels. The pharmacokinetic profile of MPH is such that various other side effects such as insomnia, decreased appetite and nausea have been described even after 12 hours of last intake of the drug and it is not eliminated from the body until after 48 hours.[6]

In the second case, the same happened with 10 mg of methylphenidate and the symptoms resolved after 12 hours of the last dose and never reappeared after the discontinuation of methylphenidate. This case had developed some behavioral symptoms which could be taken as affective and suicidal ideas can be a part of this brief affective disorder that also subsided within 12 hours. These symptoms can also be understood as behavioral component of suicidal ideas. Parents' main concern was suicidal ideas and related behavior.

In previous literature, similar findings were reported. In the two case reports, the subjects were taking methylphenidate for ADHD, Combined subtype and in both cases, the patients attempted suicide with the overdose of methylphenidate itself.[7] In another study[8] the parents were asked to fill out the common and uncommon adverse drug reactions with Methylphenidate and it was found that parents reported suicidal ideation as a less common adverse drug reaction. Further, a few case reports are available which document psychotic symptoms with methylphenidate use along with suicidal ideation.[5]

In previous literature reporting suicidal ideation due to methylphenidate taken for ADHD, it has been offered as an explanation that this ideation could be due to the impulsivity as a natural part of the ADHD illness or it could be secondary to the depressed mood caused due to methylphenidate use. Our patient had ADHD, combined subtype, and he had features of impulsivity as well. However, on detailed history from the patient and parents, there were no similar complaints in the past nor was any history suggestive of depressed mood in the past or after initiation of methylphenidate. This suicidal ideation disappeared completely in our patient after discontinuation of the drug. There was no significant behavioral manifestation of suicidal ideas in the first case and it was a transient phenomena. In comparison to previous literature, the suicidal ideation in our patients was not secondary to any depressive symptomatology nor could it be explained on the basis of impulsivity alone which is inherent in the disorder itself. This suggests that suicidal ideation can occur as an isolated side effect of MPH.

In view of the current findings and existing literature, clinicians need to be alert to the adverse effects of methylphenidate during examination of every case. Equally important is ensuring that the patients' parents and teachers of the patients are appropriately educated regarding potential adverse effects of methylphenidate.