In March 2018 the EMA announced stronger measures aimed at avoiding the exposure of babies to valproate medicines in the womb. Under the new restrictions, valproate medicines are contraindicated in bipolar disorder during pregnancy because of the high risk of congenital malformations and developmental problems in the child. Valproate medicines must not be used in female patients of childbearing potential unless there is a pregnancy prevention programme in place and certain conditions are met. These include:
an assessment of the patient’s potential for becoming pregnant
pregnancy tests before starting and during treatment as needed
counselling about the risks of valproate treatment and the need for effective contraception throughout treatment
a review of ongoing treatment by a specialist at least annually
a risk acknowledgement form that patients and prescribers will go through at each such annual review to confirm that appropriate advice has been given and understood.
The EMA said the new measures were put in place because of evidence suggesting that information on the risks of valproate use in pregnancy was still not getting through to women despite earlier steps aimed at ensuring this.See Management: approach See Management: treatment algorithm
Suicide is the thirteenth leading cause of death worldwide, with about 1 million deaths every year due to self-inflicted violence.
In people aged 15 to 44 years, self-inflicted injury is the fourth leading cause of death and the sixth leading cause of ill health and disability worldwide, making suicide a significant public health concern.
There are 5 components to suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts.
Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting suicidal behaviour (includes death by suicide, suicide attempt, and suicidal ideation). Suicide risk management is an ongoing process in the treatment of a person who has a mental disorder.
Key risk factors for suicide include previous suicide attempt, current suicidal plan or ideation, and history of mental illness (most commonly major depressive disorder and substance abuse).
Effective treatment of mental disorder plays an important role in suicide prevention. Other important prevention strategies are suicide risk screening in primary care, mental health education for primary care physicians and gatekeepers, means restriction, and media interventions. Numerous popular community-based interventions (such as school programmes and community suicide awareness activities) have not demonstrated benefit in suicide rate reduction and there are concerns that some may not be safe.
Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting suicidal behaviour. Suicidal behaviour includes death by suicide, suicide attempt, suicide plan, and suicidal ideation. The literature also sometimes includes non-suicidal self-harm as a component of suicidal behaviour. There are 5 key components to suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts.
Department of Psychiatry
Sun Life Financial Chair in Adolescent Mental Health
IWK Health Centre and Dalhousie University
WHO Collaborating Center for Mental Health Training and Policy
SK has received research grants from various foundations and national granting agencies (none from either the pharmaceutical nor psychotherapy industries) to support some of his academic work. He is employed by a university and hospital, and sees patients who sometimes present with a suicide attempt. He has also co-authored a textbook on suicide risk assessment and management, published in 2007 and the second edition in 2012.
Dr Stan Kutcher would like to gratefully acknowledge Dr Magdalena Szumilas, a previous contributor to this monograph. MS is an author of a reference cited in this topic.
Professor of Psychiatry and Mental Health
Departamento de Saude Mental
Faculdade de Ciencias Medicas
Universidade Nova de Lisboa
RG declares that he has no competing interests.
Assistant Clinical Professor of Psychiatry
University of California
SR declares that he has no competing interests.
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