Commentary Editor: Liam Clarke Submission address: School of Nursing and Midwifery, University of Brighton, Robert Dodd Building, 49 Darley Road, Eastbourne, BN20 7UR, UK Partial agonists and suicide: the role of the mental health nurse Key messages • Partial agonist is a novel treatment approach for people with schizophrenia. • Partial agonists may, theoretically, initially increase the risk of suicide for people with schizophrenia. • Mental health nurses need to combine a sophisticated pharmacological knowledge of the differential mechanisms of action of atypical antipsychotic medication, in particu- lar partial agonists. • Mental health nurses need to complete careful risk assessment of these potential risks, in combination with core mental health nurse interventions, to reduce the potential risk of suicide, in addition to guiding the clinical decision making of the multidisciplinary team in the safe use of partial agonists. Introduction Suicide is a devastating outcome for at least 10% of people with schizophrenia, which has been known for some time (Miles 1977, Fenton et al. 1997). It is a major contributor to excess mortality in people with schizophrenia, second only to cardio heart disease (Brown et al. 1999). Up to 40% of people with schizophrenia will attempt suicide at least once (Fenton et al. 1997). As a consequence, reduction in suicide remains a key public health priority. It is a core requirement of National Health Service pro- viders of mental health services to put in place mechanisms to reduce the risks of suicide for people for whom they provide a service (National Institute of Clinical Excellence 2006). The primary treatment for people with schizo- phrenia remains antipsychotic medication, whose efficacy in the treatment of positive symptoms and consequential reduction in suicide is beyond doubt (Taylor et al. 2005). The development of antipsy- chotic medication in the treatment of schizophrenia has made enormous advancements over the last 25 years (Gray et al. 2005). The older, typical antip- sychotics have been replaced by the use of atypical medications, a process that began in 1990 with clozapine, and then by the development of Resperi- done in 1993 (Gray et al. 2005). These antipsy- chotic medications, in comparison with typical antipsychotic medication such as haloperidol, appear to have a much lower propensity to Extra Pyramidal Side effects (Taylor et al. 2005), as a consequence of their targeted mechanism of action in the brain (Meltzer 1999). Atypical antipsychotic medication has a much-reduced affinity for inhibit- ing dopamine transmission in the basal ganglia (Stahl 2001). The most recent antipsychotic – arip- iprazole – is a partial agonist at dopamine D2 recep- tor and is believed to work as a dopamine system stabilizer (Burris et al. 2002), a pharmacological mechanism of action referred to as partial agonism. It is also a partial agonist at serotoin 5-HT1a recep- tors (Jordan et al. 2002). Although partial agonists have been used to treat other conditions, this is the first time that aripiprazole, as a partial agonist, has been used to treat schizophrenia. This paper explores the theoretical risks associ- ated with the increase of suicide in people with schizophrenia treated with partial agonists. The paper discusses what we think may be happening in the brains of people with schizophrenia which contributes to their difficulties, how antipsychotic medication can ease these difficulties, and the pharmacological theory as to why an increased risk of suicide may occur with the use of partial agonists. Finally, the core nursing interventions to minimize the potential risks of suicide when caring for people who are prescribed partial agonists are described. Journal of Psychiatric and Mental Health Nursing, 2008, 15, 253–259 © 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd 253