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Q: increased suicidal ideation in ambien(zolpidem) users ( Answered,   3 Comments )
Subject: increased suicidal ideation in ambien(zolpidem) users
Category: Health > Medicine
Asked by: elizabethfaiella-ga
List Price: $150.00
Posted: 08 Mar 2006 03:35 PST
Expires: 07 Apr 2006 04:35 PDT
Question ID: 704875
I represent a family whose father committed suicide after taking
ambien for three weeks.. a totally unexpected act in a man with no
history of mental illness, but suffering his first bout of stress
related depression(loss of job) for which he was prescribed
Ambien(alone). I need medical literature.. not anectdotal internet
stories on the worsening of depression/ and or suicidal ideation
caused by giving ambien to a depressed patient( strictly warned about
by the manufacturer of ambien in PDR)I stress that journals,
texts,clinical trials,or other authoritative  sources will be the only
things I can use.... Thanks Elizabeth Faiella

Request for Question Clarification by umiat-ga on 08 Mar 2006 22:52 PST
Hello, elizabeth!

 I hate to admit it, but I have found virtually nothing in the medical
literature relative to an increase in depression, increase in suicidal
ideation or attempted suicide in conjunction with Ambien (Zolpidem).
Conversely, most literature mentions that Zolpidem can actually help
with depression in conjunction with it's use for sleep disturbances. I
have searched several databases quite thoroughly over more than four
hours and come up empty, except for a few journal references citing
case where Zolpidem was a factor (but not necessarily the cause) of
death as a result of suicide. I have included them below for your
review in case they are at all helpful. I have also included any
abstracts which touch on issues with Zolpidem which might offer some
help - if even remotely.


"Acute zolpidem overdose--report of two cases." Gock SB, Wong SH,
Nuwayhid N, Venuti SE, Kelley PD, Teggatz JR, Jentzen JM.  J Anal
Toxicol. 1999 Oct;23(6):559-62.

"This report describes two cases of acute zolpidem overdose. The
decedent in the first case was a 36-year-old female found dead in bed
in her secured home. She had a history of psychiatric illness,
including paranoid disorder, depression with panic episodes, and
post-traumatic stress disorder. She was treated with risperidone and
sertraline. Nine months prior to her death, the decedent was also
prescribed zolpidem (Ambien). The postmortem examination revealed
white foam within the larynx and upper trachea, which is indicative of
pulmonary edema. Toxicological analyses of the urine showed the
presence of caffeine, risperidone, and zolpidem. Subsequent
quantitation of postmortem iliac serum revealed 5.6 microg/L of
9-hydroxyrisperidone and the following zolpidem concentrations: blood
(subclavian), 4.5 mg/L; blood (iliac), 7.7 mg/L; vitreous humor, 1.6
mg/L; bile, 8.9 mg/L; urine, 1.2 mg/L; liver, 22.6 mg/kg; and gastric
contents, 42 mg.

"The second case involved a 58-year old female, also found dead in
bed, with white foam around her mouth. The decedent had a 25-year
history of hypertension and mental illness--manic depression and
schizophrenia. She was medicated with carbamazepine, naproxen,
risperidone, and zolpidem. The postmortem examination revealed
cardiomegaly, pulmonary edema, hepatomegaly, mild coronary
atherosclerosis, and no signs of trauma. Toxicological analyses of the
urine showed the presence of zolpidem and carbamazepine and
metabolite. Zolpidem concentrations were as follows: blood (iliac),
1.6 mg/L; vitreous humor, 0.52 mg/L; bile, 2.6 mg/L; liver, 12 mg/kg;
and gastric contents, 0.9 mg. The zolpidem blood concentrations of
these cases are consistent with those of the previously published
fatalities. The blood/vitreous humor ratios of zolpidem were 2.81
(subclavian) and 4.81 (iliac) in the first case and 3.08 (iliac) in
the second case. These ratios, along with the sampling times of blood
and vitreous humor for both cases, are not conclusive to indicate a
definitive presence or absence of postmortem drug redistribution of
zolpidem. The cause of death for both cases was determined to be acute
zolpidem overdose, and manner of death was suicide."


In the following case, death is not attributed solely to overdose.

"A fatality involving zolpidem." Lichtenwalner M, Tully R. J Anal
Toxicol. 1997 Nov-Dec;21(7):567-9.

"An elderly woman residing in an independent-living retirement
community was found dead in the bathtub. She had a history of
depression and was prescribed Ambien (generic name zolpidem) for the
treatment of insomnia. Two empty prescription bottles of Ambien were
found; both were for 10-mg tablets with a total quantity of 60. A
postmortem examination was conducted, and blood, urine, and gastric
contents were submitted for toxicology screening. The cause of death
was drowning. The only remarkable toxicology finding was zolpidem.
Quantitative analysis by gas chromatography-mass spectrometry
determined the following concentrations of zolpidem: blood, 7.9
micrograms/mL and urine, 4.1 micrograms/mL. A total of 7 mg unabsorbed
zolpidem was found in the gastric contents. Our findings report the
highest blood concentration of zolpidem reported to date and
corroborate other studies that imply that death due solely to
overdosage of zolpidem is an unlikely occurrence."


Another connection between Zolpiden and suicide, though other
medications are also in the picture. Note that the depressed patient
was prescribed Zolpiden - and then attempted suicide with Zolpiden and
another medication.

From "Suicidal Ideation With IFN- and Ribavirin in a Patient With Hepatitis C 
Karin Ademmer, M.D., Manfred Beutel, M.D., Reinhard Bretzel, M.D.,
Jens Clemens, M.D., and Christian Reimer, M.D.  Psychosomatics
42:365-367, August 2001.


"Besides weekly psychoanalytically oriented psychotherapy, Mr. A. was
started on trimipramine (75 mg/day), St. John's wort (900 mg), and

*** zolpidem (10 mg at night), **** 

2 months after starting the antiviral therapy. Therapeutic blood
levels of the antidepressants were not monitored. This treatment did
not improve Mr. A.'s symptoms, and he began having suicidal ideation
("it would be better for his family if he were not alive.") At this
stage, 4 months after starting treatment for his hepatitis C
infection, Mr. A. was admitted to our psychosomatic ward.

"Eight days after admission, Mr. A. attempted suicide with
trimipramine (3,000 mg) and zolpidem (2,000 mg) on the ward, after
which he was discovered unconscious in his room. His vital signs were
stable. It was difficult to understand his abrupt suicide attempt at
this stage because there had been no clinical evidence of
deterioration of depressive symptoms."


Another death where Zolpidem was involved, but was not the cause:

"Fatality caused by a combined trimipramine-citalopram intoxication."
Musshoff F, Schmidt P, Madea B. Forensic Sci Int. 1999 Dec


Just a one sentence snippet:

"The role of benzodiazepines in elderly suicides." Carlsten A, Waern
M, Holmgren P, Allebeck P.  Scand J Public Health. 2003;31(3):224-8.

* Note the one line in this abstract that might be if interest:

 "The annual fatality ratios for the newer benzodiazepine-like
hypnotics zopiclone and zolpidem appear to be on the rise."


Possibly relevant:

"Zolpidem-induced psychosis." Markowitz JS, Brewerton TD. Ann Clin
Psychiatry. 1996 Jun;8(2):89-91.


You might want to continue to follow this particular PubMed search
string just in case anything else stands out:


Let me know if any of these citations are useful as an answer to your
question - or whether there is another angle I might pursue that could
be of additional help to your case.


Request for Question Clarification by pafalafa-ga on 15 Mar 2006 18:01 PST

I read this article today and remembered your question here at Google Answers:
Bizarre events linked to sleeping pills in US 

I thought this would be of interest to you and the family.  You may
want to contact the researchers involved in this work.

Let me know if I can be of assistance,


Request for Question Clarification by pafalafa-ga on 01 Apr 2006 18:23 PST

I came across some data that may be of interest, as it's formal and
credible, though may not hit the nail on the head in terms of suicidal

Zolpidem abuse was tracked methodically in the mid-1990s.  There were
generally about 5,000 ER overdose cases every year involving
zolpidem,and about 75% of these were deemed suicide attempts.

Of course, the use of the drug as a means of suicide is a very
different thing from the drug evoking suicidial thoughts.  However,
the two are certainly not unrelated, either.

Let us know if anything mentioned above, by any of the researchers, is
useful enough to warrant further digging.

Thanks...and good luck,

Subject: Re: increased suicidal ideation in ambien(zolpidem) users
Answered By: pafalafa-ga on 02 Apr 2006 08:51 PDT

Hello again.

As noted in some of the earlier comments, there is a limited
literature on zolpidem and its direct influence on suicidal ideation.

However, there is considerable literature -- particularly case reports
-- of zolpidem's infrequent but well-documented psychotropic side
effects, which include hallucinations, psychosis, and depression. 
These certainly seem an indication of a medicine powerful enough to
induce an altered state of thinking in some patients, and one that
could possibly contribute to suicidal thoughts.

I have listed the relevant literature below.  I've presented first the
papers that, to my mind, seem to have the most relevance to your
question.  These are followed by a longer list of papers of secondary
importance, but still worth a look.

I trust this information is just what you needed.  But before rating
this answer, please let me know if there's anything else I can do for
you.  Just post a Request for Clarification, and I'm at your service.

Best of luck to you and your clients.



[this strikes me as the most quantitative overview available]
Seeing things with zolpidem

...Zolpidem (Stilnox) was marketed in Australia in late 2000 for the
short term treatment of insomnia. It is structurally unrelated to the
benzodiazepines, but has a similar pharmacological action. In 2001,
ADRAC received 72 reports describing 170 reactions in association with
zolpidem as shown in Table 1.

...Of these 72 reports, 56 described one or more neurological or
psychiatric reactions, especially visual hallucinations, confusion,
depression and amnesia. Most reactions occurred with a daily dose of
10 mg and 70% occurred after the first dose. Most of the 15 reports of
hallucinations occurred within a few hours, often soon after the drug
was taken. Half of the reports of amnesia described a total loss of
memory for events immediately after the drug was taken, although two
described poor memory in subsequent days. The onset of confusion and
depression was sometimes apparent within hours of taking the drug but
in most cases occurred the following day.

...Prescribers should be alert to the fact that zolpidem may be
associated with distressing neurological or psychiatric reactions.

[NOTE that Table 1 shows that hallucinations were the most common
adverse reaction, but depression was fairly common as well]

Adverse Reaction          Number of Occurrences
Visual hallucinations       15
Depression                   7


[the Veterans Administration has published a cautionary study on the
use of information for the study author is
Zolpidem prescribing and adverse drug reactions in hospitalized
general medicine patients at a Veterans Affairs hospital.
Mahoney JE, Webb MJ, Gray SL.
Section of Geriatrics, Department of Medicine, University of Wisconsin
School of Medicine, Madison, Wisconsin

...Zolpidem is prescribed for sleep disruption in hospitalized
patients, but data on the incidence of adverse drug reactions (ADRs)
are based largely on outpatient studies.

...CONCLUSIONS: In this case series in medical inpatients, there was a
high frequency of ADRs, particularly CNS ADRs, associated with
zolpidem use. Zolpidem should be used cautiously in the hospital


[this article explicitly mentions ideation]
Encephale. 2004 Mar-Apr;30(2):153-5
Dependence on zolpidem: a report of two cases

Boulanger-Rostowsky L, Fayet H, Benmoussa N, Ferrandi J.

EPSDM, Service du Docteur Talgorn, Secteur 51G02, 56, avenue du
General Sarrail, 51022 Chalons-en-Champagne cedex, France patient presents an epileptic seizure whereas the other display
a severe psychiatric complication such a psychosis. In the literature,
withdrawal was accompanied by confusion, suicidal ideas, nausea,
vomiting, sweat, tremors, tachycardia and insomnia rebound.


[zolpidem is finding increasing use in suicide attempts...though not
conclusive as to ideation, there is at least a suggestion of a
relationship, particularly when considered in the context of other
Forensic Sci Int. 2004 Jun 30;143(1):53-9.

Fatal intoxications in a Swedish forensic autopsy material during 1992-2002
Jonsson A, Holmgren P, Ahlner J.
Department of Clinical Pharmacology, University Hospital, S-581 85
Linkoping, Sweden.

...The aim of the present study was to describe the current pattern of
substances detected in fatal intoxications in Sweden.

...The drugs with high proportions of cases with toxic concentrations
detected were propoxyphene, amitriptyline, zolpidem, carisoprodol,
alprazolam, thioridazine, methadone and ketobemidone.

...All suicides, uncertain cases and accidents where the cause of
death were fatal intoxications


[ psychotropic reactions may be dose-dependent ]
Ann Pharmacother. 2001 Dec;35(12):1562-4
Brodeur MR, Stirling AL.
College of Pharmacy and Allied Health Professions, St. John's
University, New York, NY

Delirium associated with zolpidem.

...CONCLUSIONS: This case, along with previous reports, warrants the
cautious use of zolpidem. Clinicians should be aware that a majority
of these reactions occur in women. It appears that the reactions are
concentration dependent, therefore, dosage reductions should be made
in elderly patients and those with hepatic insufficiency.


[Strong cautions about zolpidem-induced psychosis go back more than a decade]
Ann Clin Psychiatry. 1996 Jun;8(2):89-91
Markowitz JS, Brewerton TD.
Department of Psychiatry and Behavioral Sciences, Medical University
of South Carolina, Charleston 29425-0810

Zolpidem-induced psychosis.

...There are several case reports of zolpidem causing psychotic
reactions in patients with no history of psychosis. We report two
additional cases in which zolpidem was implicated in psychotic
reactions characterized by auditory and visual hallucinations as well
as delusional thinking.

...Zolpidem should be used at the lowest effective dose for the least
amount of time as necessary.

...In patients manifesting new-onset or unexplained psychotic
symptoms, zolpidem use should be considered in the differential


[This is a tangential study, but it is an FDA docket document prepared
by the US Drug Enforcement Administration, and documents the
prevelance with which zolpidem is showing up in suicide attempts,
similar to what is being seen in the Scandanavian studies}:


Drug Enforcement Administration 


...3.1 Zolpidem is abused, diverted and trafficked in the United States.

...3.2. From 1994-1998, the DAWN system has documented a total of 21,860
estimated episodes. The number of estimated episodes increased in 1994 and
1995 and has remained relatively stable from 1996-1998:1422 in 1994; 3918
in 1995, 5444 in 1996; 5453 in 1997 and 5623 in 1998. When normalized
with total annual zolpidem prescriptions (IMS data), the numbers of estimated
DAWN episodes are 62 per 100,000 prescriptions in 1997 and 56 per 100,000
in 1998.

...Zolpidem is taken orally...either in an attempt to commit suicide (75%)
or for its other psychological effects... The typical DAWN episode
involved a white (880/0), female... within the age ranges of 35-45 years
(30%), 25-34 years old (25%). These episodes most often involved an
overdose (910/0) or other unexpected response (30/0). The DAWN reports
found zolpidem used alone on 33% of occasions. When used in combination,
zolpidem was most often taken with alcohol (440/0), or other benzodiazepines
(40%). Large numbers of hospital emergency episodes were reported in
twenty-two US cities.


This site has a host of relevant articles...a search on [ zolpidem and
adverse ] turned up 69 listings.  Here are the most relevant:

Zolpidem: Delirium with mania in an elderly patient: case report 
Source: Reactions, Volume 1, Number 1000, 2004-05-08, pp. 14-15(2)

Zolpidem: Visual hallucinations: case report 
Source: Reactions, Volume 1, Number 961, 2003, pp. 16-16(1)

Zolpidem abuse: Euphoria and hyperactivity: case report 
Source: Reactions, Volume 1, Number 954, 2003, pp. 16-16(1)

Zolpidem: Delirium and hallucinations: case report 
Source: Reactions, Volume 1, Number 912, 2002, pp. 11-11(1)

Zolpidem: Delirium in an elderly patient: case report 
Source: Reactions, Volume 1, Number 893, 2002, pp. 16-16(1)
Publisher:Adis International

Zolpidem: Nightmares, delirium and hallucinations: 3 case reports 
Source: Reactions, Volume 1, Number 793, 2000, pp. 12-12(1)

Zolpidem: Psychosis in an elderly patient: case report 
Source: Reactions, Volume 1, Number 653, 1997, pp. 12-12(1)

Zolpidem: Visual hallucinations and amnesia: 2 case reports 
Source: Reactions, Volume 1, Number 611, 1996, pp. 12-12(1)

Zolpidem: Psychosis: 2 case reports 
Source: Reactions, Volume 1, Number 613, 1996, pp. 12-12(1)

Zolpidem: Amnesia: 2 case reports 
Source: Reactions, Volume 1, Number 614, 1996, pp. 12-12(1)

Zolpidem: Sensory distortions: case report 
Source: Reactions, Volume 1, Number 543, 1995, pp. 12-12(1)

Zolpidem: Psychotic disorders in a patient with anorexia: case report 
Source: Reactions, Volume 1, Number 466, 1993, pp. 12-12(1)

Zolpidem: Amnesic psychotic effects: 2 case reports 
Source: Reactions, Volume 1, Number 396, 1992, pp. 8-8(1)


Other articles that you may want to be aware of:
Encephale. 1999 Nov-Dec;25(6):652-7.  
Courtet P, Pignay V, Castelnau D, Boulenger JP.
Service Universitaire de Psychiatrie Adultes, Hopital La Colombiere,
INSERM CJF 97-02, Montpellier.
[Abuse of and dependence on zolpidem: a report of seven cases]
[Article in French]
Scand J Public Health. 2003;31(3):224-8.
The role of benzodiazepines in elderly suicides.
Carlsten A, Waern M, Holmgren P, Allebeck P.
Department of Social Medicine, University of Goteborg, Sweden.

...In Sweden, suicides by drug poisoning have decreased in the
population at large during the past two decades. However, drug
poisoning suicides increased among the elderly during this period.

...The annual fatality ratios for the newer benzodiazepine-like
hypnotics zopiclone and zolpidem appear to be on the rise. CONCLUSION:
Benzodiazepines, especially the hypnotics flunitrazepam and
nitrazepam, are common in drug poisoning suicides in the elderly and
should be prescribed with caution for this age group.
Ann Clin Psychiatry. 1996 Jun;8(2):89-91.
Zolpidem-induced psychosis.
Markowitz JS, Brewerton TD.
Department of Psychiatry and Behavioral Sciences, Medical University
of South Carolina, Charleston 29425-0810,
J Am Geriatr Soc. 1997 Apr;45(4):533-4
Zolpidem-induced psychosis in an older woman.
Pitner JK, Gardner M, Neville M, Mintzer J.
Ugeskr Laeger. 1993 Dec 20;155(51):4196.
[Withdrawal psychosis and zolpidem]
[Article in Danish]
J Toxicol Clin Toxicol. 1998;36(3):195-203
Zolpidem-associated hallucinations and serotonin reuptake inhibition:
a possible interaction.
Elko CJ, Burgess JL, Robertson WO.
Washington Poison Center, Seattle 98125-8012, USA.
Lancet. 1992 Mar 28;339(8796):809.
Psychotic reactions to zolpidem.
Ansseau M, Pitchot W, Hansenne M, Gonzalez Moreno A.
Int J Clin Pharmacol Ther. 1996 Jul;34(7):318
Visual hallucinations and amnesia associated with the use of zolpidem.
van Puijenbroek EP, Egberts AC, Krom HJ.
Lancet. 1993 Dec 11;342(8885):1495-6
More on zolpidem side-effects.
Iruela LM, Ibanez-Rojo V, Baca E.
Ann Emerg Med. 1997 Feb;29(2):300-1
Zolpidem and hallucinations.
Markowitz JS, Rames LJ, Reeves N, Thomas SG
Gen Hosp Psychiatry. 1996 Nov;18(6):452-3
Zolpidem-induced agitation and disorganization.
Hoyler CL, Tekell JL, Silva JA.
Aust N Z J Psychiatry. 2002 Jun;36(3):425-6
Zolpidem, vascular headache, and hallucinations in an adolescent.


I hope these assist you in your efforts, and again, if there's
anything else I can help you with, just let me know.


search strategy -- Searched Google and several medical literature
sites for combinations of terms:

Subject: Re: increased suicidal ideation in ambien(zolpidem) users
From: fafad-ga on 20 Mar 2006 16:38 PST
Today, March 20, 2006, researched this question because after using
Ambien for three weeks am experiencing incredibly strong suicidal
ideation and hopelessness, no sense of a future, in crippling waves. 
Good thing I have lots of practice building fortitude dealing with
less severe, however still very severe suicidal tendencies in the
past.  This is the strongest i have ever dealt with in my 54 years of
depression and hopelessness, and I have even previously survived a
suicide attempt by massive overdose of an rx, which put me in
intensive care with seizures for five days.  My condolences and
prayers for peace to the families of those who were unable to cope and
succumbed; you must forgive them; it feels intolerable, it really
does.  I also have been forgetful without even realizing it; since
taking Ambien, family members have related conversations that I have
absolutely no recall of.  They repeatedly reminded me when this kept
happening and told me to stop takin Ambien, but I even forgot to not
take it and check it out on-line until this crisis situation today.  I
hope this gets out.
Subject: Re: increased suicidal ideation in ambien(zolpidem) users
From: umiat-ga on 20 Mar 2006 18:10 PST
My best to you, fafad! Take care of yourself, please, and thank you
for your input. umiat
Subject: Re: increased suicidal ideation in ambien(zolpidem) users
From: gunslinger92-ga on 21 Mar 2006 12:35 PST
This is a common question about many medications that affect mood,
whether directly or indirectly (as it is in this case, where the
medication aids with sleep).  The reason that you sometimes see an
increased tendency towards suicide after taking a new medication is
because it is *working*.  These types of medications, especially those
which alter mood, tend to restore energy to the person taking them
before it can stabilize the neurotransmitters in the brain, a process
which can take weeks.  As a result, the person now has increased
energy, but still has depression.

Unfortunately, this is the time when it seems to be most dangerous to
the patient.  While they were depressed and lacked energy, they may
very well have had suicidal thoughts, but simply didn't have the
energy to go through with them.  Now that the energy is restored, the
suicidal thoughts still exist and can be acted upon.

In this case, it makes sense that the medication was doing what it was
supposed to do, i.e., make the person sleep better.  As anyone can
attest, lack of sleep leads to an immense decrease in the amount of
energy available during the day.  It is entirely possible that after
regaining the energy he was then able to carry out the suicidal
impulses that he had all along.

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