Do Antidepressants Increase Suicide Risk?

Abstract

Source: Simon G, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006;163:41–47.Researchers from the Group Health Cooperative Center for Health Studies in Seattle, Wash, and Harvard Medical School in Boston, Mass, sought to determine the relationship between antidepressant use and suicidal behaviors using data from a mixed-model prepaid health plan serving approximately 500,000 members in Washington and Idaho. An episode of antidepressant use was defined as an outpatient antidepressant prescription filled by a member with a diagnosis of unipolar major depressive disorder, dysthymia, or depressive disorder NOS who had not filled a prescription for antidepressant medication in the previous 180 days. Using computerized record systems, 82,285 episodes of antidepressant treatment were identified among 65,103 health plan members during 10.5 years (1992–2003): 9520 members had 2 episodes of antidepressant use, and 1916 contributed more than 2 episodes. A total of 5107 episodes, or 6.2%, occurred among children 17 years or younger.Serious suicide events included deaths (n=31) and attempts leading to hospitalization (n=76). The highest risk of serious attempt was in the month before starting treatment as compared with subsequent months. In the months following treatment, the risk of a serious attempt was higher in the month following treatment than in the subsequent 5 months (OR=2.4; 95% CI, 1.6–3.8). The total number of serious attempts in adolescents was much smaller (n=17), but the pattern of risk over time was similar to that of adults. The absolute rate of attempt was 314 attempts per 100,000 children and adolescents compared with 78 attempts per 100,000 adults (z=3.18, P <.001).The risk of suicide death in the first month of treatment was not higher than in subsequent months (OR=1.2; 95% CI, 0.5–2.9). The number of deaths in adolescents (n=3) was too small to support trend analysis. The risk of both attempt and death was not lower in patients treated with newer drugs. Among those treated with newer antidepressants (n=56,570 episodes of treatment), risk of suicide attempt was greatest in the month before starting treatment, and risk in the first month of treatment was not higher than in the subsequent months. On the other hand, those treated with older antidepressants (n=25,715 episodes) were at highest risk of attempt in the first month of treatment.Dr. Schonwald has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Adolescents are a particularly high-risk group, given their developmental tendency to engage in impulsive, high-risk behaviors without long-term planning. The higher rate of absolute suicide attempts in younger patients may reflect these developmental propensities, but also serves to highlight the need for close monitoring of children and adolescents treated for depression.The FDA issued a public health advisory in October 2004, directing manufacturers of 10 newer antidepressant drugs to revise product labeling to include a boxed warning and statements that alert health care providers to an increased risk of suicidality in children and adolescents being treated with these agents.1 Subsequently, 2 FDA committees re-analyzed 24 drug company studies and identified 109 events of suicidal ideation, a finding 2.19 times more likely in patients treated with a selective serotonin reuptake inhibitor (SSRI) than in patients assigned to control groups. There were no suicides, and no unique trends for specific agents.2 Providers are now left with the struggle to balance the risk of untreated depression with that of increasing suicidal ideation.While it is not surprising that suicide attempts occur before medication is started (since an attempt often triggers treatment), these data reinforce the high risk of untreated depression. While suicide attempts may be increased in the month after treatment is started, this risk is not nearly as great as the risk of untreated depression.