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Abstract
PurposeWe endeavored to investigate whether previous findings of an association between antemortem exposure to selective serotonin re-uptake inhibitors (SSRI) and method of suicide could be replicated.MethodsUsing the Swedish National Board of Forensic Medicine’s toxicology database and the Swedish National Board of Health and Welfare’s national registries of causes of death and prescriptions, 10,002 incidents of suicide were retrieved. Risks of violent suicide conferred by SSRIs, expressed as odds ratios (ORs) with 95% confidence intervals (CIs), were estimated using logistic regression. In accordance with previous work, suicide by violent means—cases—were defined as death attributable to causes designated by ICD-10 codes X70-X83 and Y20-Y33; and suicide by non-violent means—controls—by codes X60-X69 and Y10-Y19.ResultsOur results imply that SSRI exposure confers a risk of violent suicide for shorter treatment durations; and that antemortem exposure to other substances (including illegal drugs) confounds estimates of risk. After adjustment for age, sex, and other substances, SSRIs treatment not exceeding 28 days conferred an almost fourfold risk of violent suicide (OR 3.6 [95% CI 1.9–6.8]), a finding partly in line with a recent Swedish study that employed a case-crossover design.ConclusionsAlthough risks associated with shorter treatment duration may reflect latencies to onset of therapeutic effect, it is unclear how latencies would influence the choice of suicide method, unless conditions for which SSRIs are prescribed are themselves associated with violent suicide. Finally, in the total dataset, SSRIs were not associated with an increased risk of violent suicide; however, by adjusting for other substances, we avoided the spurious conclusion that the effect of medications in this regard is protective.
Highlights
The degree to which use of selective serotonin re-uptake inhibitors (SSRIs) may confer an elevated risk of suicidality and criminal violence has been a topic of recurrent discussion [1, 2]
Our work addresses a question previously addressed in an earlier Swedish dataset from 1992 to 2004; yet, it employs a novel design—entailing group-level matching for suicidal propensity, as well as individual-level adjustment for postmortem detection of other substances and duration of treatment—to investigate the potential association between violent methods of suicidal death and antemortem exposure to SSRIs
Our results indicate that SSRI exposure confers a risk of using a violent suicide method for shorter treatment durations, regardless of age-group; the association is prominent among subjects aged 70 years or older, which is in line with previous findings from Ontario, Canada, on SSRI use and suicide risk in the elderly [11]
Summary
The degree to which use of selective serotonin re-uptake inhibitors (SSRIs) may confer an elevated risk of suicidality and criminal violence has been a topic of recurrent discussion [1, 2]. Eur J Clin Pharmacol (2019) 75:393–400 serotonin’s role in depression, low serotonergic activity has been associated with risk-taking behavior and aggressiveness [4, 5]. The latter behaviors have been further conceptualized as part of an atypical depressive syndrome, in the male population [6, 7]. There is plausible support for the notion that the degree of aggression or violence in a suicidal act affects the likelihood of fatal outcome [8, 9]
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