Antidepressants and suicide risk

The relationship between antidepressant use and suicide risk is uncertain, complicated, and the target of medical research. Some studies have shown that the use of some antidepressants correlate with an increased risk of suicide in some patients, and this problem has been serious enough to warrant government interventions in some places to label greater likelihood of suicide as a risk of using antidepressants. The circumstances under which this can happen are not clear, and other studies show that antidepressants treat suicidal ideation.^[1]

Relationship between antidepressant use and suicide risk

A 2012 international review article states that the idea that antidepressants might contribute to suicide in depressed patients was first raised in 1958. For 30 years antidepressants were primarily used in severely depressed and often hospitalized patients. The issue of suicidality on selective serotonin reuptake inhibitors (SSRIs) became one of public concern with reports in 1990 that Prozac could lead to suicidality in patients.^[2] Fourteen years later, warning labels were put on antidepressants suggesting particular difficulties "during the early phase of treatment, during treatment discontinuation, and when the dose of treatment is being changed, and that treatment related risks may be present in patients being treated for syndromes other than depression, such as anxiety or smoking cessation".^[2]

Higher risk for youth

People under the age of 24 who suffer from depression are warned that the use of antidepressants could increase the risk of suicidal thoughts and behaviour.^[3] Federal health officials unveiled proposed changes to the labels on antidepressant drugs in December 2006 to warn people of this danger.^[4]

The FDA warns against the use of Paxil for children and teens depression in favor of Prozac.^[5]

SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents in both the United States with a 14% increase, and 50% increase in the Netherlands.^[6]

Warnings

The Food and Drug Administration (FDA) requires "Black box warnings" on all SSRIs, which state that they double suicidal rates (from 2 in 1,000 to 4 in 1,000) in children and adolescents.^[3][7] It remains controversial whether increased risk of suicide is due to the medication (a paradoxical effect) or part of the depression itself (i.e. the antidepressant enables those who are severely depressed - who ordinarily would be paralyzed by their depression - to become more alert and act out suicidal urges before being fully recovered from their depressive episode).^[3][8] The increased risk for suicidality and suicidal behaviour among adults under 25 approaches that seen in children and adolescents.^[9] Young patients should be closely monitored for signs of suicidal ideation or behaviors, especially in the first eight weeks of therapy.^[10]

Increased risk for quitting medication

A 2009 study showed increased risk of suicide after initiation, titration, and discontinuation of medication.^[11] A study of 159,810 users of either amitriptyline, fluoxetine, paroxetine or dothiepin found that the risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days.^[12]

Prevalence

On September 6, 2007, the Centers for Disease Control and Prevention reported that the suicide rate in American adolescents, (especially girls, 10 to 24 years old), increased 8% (2003 to 2004), the largest jump in 15 years,^[13] to 4,599 suicides in Americans ages 10 to 24 in 2004, from 4,232 in 2003, giving a suicide rate of 7.32 per 100,000 people that age. The rate previously dropped to 6.78 per 100,000 in 2003 from 9.48 per 100,000 in 1990. Jon Jureidini, a critic of this study, says that the US "2004 suicide figures were compared simplistically with the previous year, rather than examining the change in trends over several years".^[14] It has been noted that the pitfalls of such attempts to infer a trend using just two data points (years 2003 and 2004) are further demonstrated by the fact that, according to the new epidemiological data, the suicide rate in 2005 in children and adolescents actually declined despite the continuing decrease of SSRI prescriptions. "It is risky to draw conclusions from limited ecologic analyses of isolated year-to-year fluctuations in antidepressant prescriptions and suicides.^[15]

One promising epidemiological approach involves examining the associations between trends in psychotropic medication use and suicide over time across a large number of small geographic regions. Until the results of more detailed analyses are known, prudence dictates deferring judgment concerning the public health effects of the FDA warnings."^[16][17] Subsequest follow-up studies have supported the hypothesis that antidepressant drugs reduce suicide risk.^[18][19]

Another study was taken the overall rate of suicidal acts was 27 per 1000 person-years, and most events occurred within 6 months of medication initiation. According to this study, no commonly used antidepressant medication has an advantage in regard to suicide-related safety. It remains a question as to whether other therapeutic maneuvers, such as ongoing counseling, provide a protective counter-effect to children's and adolescents' antidepressant-associated risk of suicidal thoughts or behaviour.^[20]

Antidepressants decrease suicide risk

A study in 2012, involving the analysis of data from 41 clinical trials with more than 9,000 patients, concluded "Fluoxetine and venlafaxine decreased suicidal thoughts and behavior for adult and geriatric patients. This protective effect is mediated by decreases in depressive symptoms with treatment. For youths, no significant effects of treatment on suicidal thoughts and behavior were found, although depression responded to treatment. No evidence of increased suicide risk was observed in youths receiving active medication".^[21]

See also

• Paradoxical effect
• Black-box warning

References

Further reading

• Fergusson D, Doucette S, Cranley-Glass K (2005). "The association between suicide attempts and SSRIs: A systematic review of 677 randomised controlled trials representing 85,470 participants". British Medical Journal. 330: 396–399. 
• Healy D, Herxheimer A, Menkes D (2006). Antidepressants and violence: Problems at the interface of medicine and law. PLoS Medicine 3, September
• Healy D, Harris M, Tranter R, Gutting P, Austin R, Jones-Edwards G, Roberts AP (2006). Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts compared. British Journal of Psychiatry 188, 223–228. With Commentary by T Turner, 229–230.
• Reseland S, Le Noury J, Aldred G (2008). "National suicide rates 1961–2003: further analysis of Nordic data for suicide, autopsies and ill-defined death rates". Psychotherapy and Psychosomatics. 77: 78–82. doi:10.1159/000112884. 
• Healy D, Brent D (2009). "Are Selective Serotonin Reuptake Inhibitors a risk factor for adolescent suicides?". Canadian Journal of Psychiatry. 54: 69–71. 
• Healy D (2011). "Science, rhetoric and the causality of adverse events". International J Risk & Safety in Medicine. 23 (3): 149–162. 

External links

• message about antidepressants and suicide in youth from the National Institutes of Health

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