Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides

OBJECTIVE: To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents. METHOD: Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000. RESULTS: There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs. CONCLUSION: The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.     

Association between the accessibility to lethal methods and method-specific suicide rates: An ecological study in Taiwan

OBJECTIVE: To examine the association between availability of lethal methods of suicide and method-specific suicide rates at the city/ county level in Taiwan. METHOD: Age-adjusted and age-specific suicide rates of 23 cities/counties in Taiwan for the years 1999 to 2003 were calculated. Partial correlation coefficients were used to examine cross-sectional associations between independent variables, i.e., proportion of agricultural population and proportion of households living on the sixth floor or above, and suicide rates by different methods (poisoning by solids/liquids, jumping, and hanging) after adjusting for unemployment rates and prevalence of depression. RESULTS: The partial correlation coefficient was 0.77 (p < .001) for proportion of agricultural population with solids/liquids poisoning suicide rates. It was 0.73 (p < .001) for the proportion of households living on the sixth floor or above with suicide rates by jumping. Correlations between hanging suicide rates and proportion of agricultural population or between hanging suicide rates and proportion of households living on the sixth floor or above were not significant. CONCLUSION: The results showed strong positive associations between access to lethal methods and method-specific suicide rates. Controlling the availability of pesticides and fencing high buildings or installing window guards may be effective measures for suicide prevention.     

Are suicide rates in Sweden associated with changes in the prescribing of medicines?

A key issue in the debate on suicide prevention is the extent to which suicide rates are affected by the availability of means of committing suicide. The aim of this study was to analyse the changes in rates of suicides committed by poisoning in Sweden between 1969 and 1992, and to determine to what extent these were associated with changes in the prescribing of medicines. We compared suicide rates from 1969 to 1992 with trends in the sales of antidepressants, barbiturates, neuroleptics and analgesics during the same period. The incidence of suicide by poisoning decreased during the 1970s, especially in younger and middle-aged men. This was mainly due to a decrease in suicides by barbiturate poisoning, which closely followed a decrease in sales of barbiturates. Sales of analgesics and antidepressants increased during the study period, and so did the rates of suicide using these drugs. We conclude that the availability of medicines is an important factor influencing suicide rates, and that changes in the prescribing of medicines may influence suicide rates.     

Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets

OBJECTIVE: In late 2006, a U.S. Food and Drug Administration advisory committee recommended that the 2004 black box warning regarding suicidality in pediatric patients receiving antidepressants be extended to include young adults. This study examined the relationship between antidepressant treatment and suicide attempts in adult patients in the Veterans Administration health care system. METHOD: The authors analyzed data on 226,866 veterans who received a diagnosis of depression in 2003 or 2004, had at least 6 months of follow-up, and had no history of depression from 2000 to 2002. Suicide attempt rates overall as well as before and after initiation of antidepressant therapy were compared for patients who received selective serotonin reuptake inhibitors (SSRIs), new-generation non-serotonergic-specific (non-SSRI) antidepressants (bupropion, mirtazapine, nefazodone, and venlafaxine), tricyclic antidepressants, or no antidepressant. Age group analyses were also performed. RESULTS: Suicide attempt rates were lower among patients who were treated with antidepressants than among those who were not, with a statistically significant odds ratio for SSRIs and tricyclics. For SSRIs versus no antidepressant, this effect was significant in all adult age groups. Suicide attempt rates were also higher prior to treatment than after the start of treatment, with a significant relative risk for SSRIs and for non-SSRIs. For SSRIs, this effect was seen in all adult age groups and was significant in all but the 18-25 group. CONCLUSIONS: These findings suggest that SSRI treatment has a protective effect in all adult age groups. They do not support the hypothesis that SSRI treatment places patients at greater risk of suicide.     

Trends in suicide case fatality in Italy, 1983-2007

The proportion of suicide attempts ending up in the death of the attempter was used in past studies as an index of suicide lethality, or case fatality. This study aimed at investigating whether case fatality of suicide has decreased in Italy over the latest 25 ears using available data, as an alternative hypothesis to the proposed general decrease in suicidal behavior resulting from better identification and treatment of people with mental disorders. The official data on completed and attempted suicides by males and females in Italy, from 1983 to 2007, were analyzed with joinpoint regression analysis, to identify the points (i.e., "joinpoints") where linear trends changed significantly in direction or magnitude. It should be noted that only the most severe suicide attempts are recorded in Italian official statistics. Suicide rates decreased in both sexes, particularly from 1990 onward. Attempted suicide rates increased progressively in males, while in females they reached their peak in 1996-1998 and then decreased. In both sexes suicide case fatalities significantly decreased from 1990 onward. Improved survival after a suicide act is probably the main reason behind this favorable trend. The spreading of emergency services may prevent suicide.     

Mortality in severe depression

ABSTRACT: Twelve hundred and six psychiatric in-patients, 506 men and 700 women, with severe depression/melancholia were rated at discharge with a multidimensional diagnostic schedule during 1956–1969. The sample was followed up until December 31, 1983. A total of 476 deaths were recorded including 103 suicides. Suicides and to a small proportion diseases of the nervous system constituted the total excess mortality in unipolar disorders. In bipolar disorders there was also an increased mortality from physical disorders, while the suicide frequency was lower (9% versus 4%). Male suicides had higher initial ratings for the items brittle, sensitive, maritial problems, acute onset and lower ratings for psychomotor retardation than other men. Female suicides had a higher frequency of attempted suicides than other women. Acute onset and attempted suicide were associated with suicides early in the course contrary to the other differentiating items. The suicide frequency was similar in admissions during 1956–1962 compared with those during 1963–1969.     

Trends in self-poisoning in the elderly 1974–1983

Although the total suicide rate in England and Wales has risen between 1974 and 1983, the proportion due to self - poisoning has fallen, particularly in the younger age groups. While analgesics are now the commonest means of suicidal self - poisoning in both sexes and at all ages, barbiturates still account for a significant proportion of elderly suicides. Tricyclics and benzodiazepines are implicated in a relatively small proportion of suicides in old age. If removal of the means of suicide is an effective preventive strategy in the elderly, then more careful prescribing practices could lead to a lower suicide rate in this age group.     

Suicide seasonality and antidepressants: a register‐based study in Sweden

Objective: Seasonality of completed suicides with a peak in spring and early summer is a well‐documented finding. The circannual serotonergic functioning is hypothesized to be central in this phenomenon. Antidepressant medications exert their pharmacological action mainly by regulating serotonin. Our aim is to study the amplitude of the seasonal effect among suicide victims positive for different classes of antidepressants or without any antidepressants at the time of death. Method: By using Swedish Registers, 12 448 suicides with forensic data for antidepressive medication and information on in‐patient‐treated mental disorder were identified during 1992–2003. Seasonality was estimated with a Poisson regression variant of the circular normal distribution of completed suicides. Results: Higher suicide seasonality was found for individuals treated with selective serotonin reuptake inhibitor (SSRIs) compared to those with other antidepressant treatment or without any antidepressant treatment. The finding is more evident for men and violent suicide methods and those without history of in‐patient treatment. Conclusion: Our results provide preliminary support for the serotonergic hypothesis of suicide seasonality and raise the question of a possible accentuation of the natural suicide seasonality in patients treated with SSRIs, a hypothesis that warrants further investigation.     

Age, period of death and birth cohort effects on suicide mortality in Italy, 1955-1979

Trends in death rates from all suicides and specific methods of suicide in Italy over the period 1955-79 were analysed on the basis of age-specific and age-standardised rates, and through a log-linear Poisson model to isolate the effects of age, birth cohort and calendar period. In both sexes, a large decrease in mortality from suicide was evident in the late 1950's and early 1960's. Thereafter, death certification rates showed fluctuating trends up to the mid 1970's, when steady increases became evident for both sexes. Nevertheless, overall age-standardized mortality rates from suicide in the late 1970's were still considerably lower than in the two previous decades (15% in males, 7% in females). The observed variations in suicide mortality, mostly in males, can be explained in terms of period of death effect and be related to changes in the Italian economic situation. This view finds further support from analysis of age-specific trends (e.g. mortality rates in the younger age groups started rising in the early 1970's, together with a rise in unemployment rates among the young). Cohort curves for males born in the current century were U-shaped as well, with marked declines for generations born between 1905 and 1930, and moderate increases for more recent cohorts. For females, the cohort curve was remarkably flat. Some of the changes in the various methods of suicide can be explained in terms of well-defined exogenous factors (e.g., the large fall in poisoning by domestic gas is obviously attributable to domestic gas detoxification).     

Suicide rates in clinical trials of SSRIs,other antidepressants,and placebo: analysis of FDA reports

OBJECTIVE: Previous reports suggesting that selective serotonin reuptake inhibitor (SSRI) use is associated with increased suicidal risk have not assessed completed suicides. The authors analyzed reports from randomized controlled trials to compare suicide rates among depressed patients assigned to an SSRI, other antidepressants, or placebo. METHOD: Food and Drug Administration (FDA) summary reports of the controlled clinical trials for nine modern FDA-approved antidepressants provided data for comparing rates of suicide. RESULTS: Of 48,277 depressed patients participating in the trials, 77 committed suicide. Based on patient exposure years, similar suicide rates were seen among those randomly assigned to an SSRI (0.59%, 95% confidence interval [CI]=0.31%-0.87%), a standard comparison antidepressant (0.76%, 95% CI=0.49%-1.03%), or placebo (0.45%, 95% CI=0.01%-0.89%). CONCLUSIONS: These findings fail to support either an overall difference in suicide risk between antidepressant- and placebo-treated depressed subjects in controlled trials or a difference between SSRIs and either other types of antidepressants or placebo.     

How have the selective serotonin reuptake inhibitor antidepressants affected suicide mortality?

OBJECTIVE: We review evidence on two claims that have been made about the effects of selective serotonin reuptake inhibitor (SSRI) antidepressants; that they have: (i) decreased suicide rates in the population; and (ii) increased suicide rates in some individuals early in treatment. METHOD: We critically review evidence in the English-speaking peer-reviewed medical literature on: (i) meta-analyses of randomized controlled trials (RCTs) of SSRIs; (ii) observational studies of suicide risk in patients prescribed SSRIs and other antidepressants; and (iii) ecological studies of correlations between population use of SSRI use and population suicide rates. RESULTS: The largest and most recent meta-analyses of RCTs of SSRIs have found suggestive evidence that SSRIs increase suicidal ideation early in treatment compared with placebo. Observational studies have found an increased risk of self-harm within 9 days of an antidepressant drug being prescribed but the risk has been similar for the older tricyclic antidepressants and the SSRIs. Ecological studies in developed countries have found either that suicide rates have declined as SSRI use has increased, or have found no relationship between suicide rates and increased SSRI use. CONCLUSIONS: Meta-analyses of RCTs suggest that SSRIs increase suicide ideation compared with placebo but the observational studies suggest that SSRIs do not increase suicide risk more than older antidepressants. If SSRIs increase suicide risk in some patients, the number of additional deaths is very small because ecological studies have generally found that suicide mortality has declined (or at least not increased) as SSRI use has increased.     

Antidepressant medication prevents suicide in depression

Isacsson G, Reutfors J, Papadopoulos FC, Ösby U, Ahlner J. Antidepressant medication prevents suicide in depression. Objective: Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increasing use of antidepressants. To investigate on the individual level the hypothesis that antidepressant medication was a causal factor. Method: Data on the toxicological detection of antidepressants in 18 922 suicides in Sweden 1992–2003 were linked to registers of psychiatric hospitalization as well as registers with sociodemographic data. Results: The probability for the toxicological detection of an antidepressant was lowest in the non‐suicide controls, higher in suicides, and even higher in suicides that had been psychiatric in‐patients but excluding those who had been in‐patients for the treatment of depression. Conclusion: The finding that in‐patient care for depression did not increase the probability of the detection of antidepressants in suicides is difficult to explain other than by the assumption that a substantial number of depressed individuals were saved from suicide by postdischarge treatment with antidepressant medication.     

Psychotropic medication utilization in a child and adolescent mental health service

OBJECTIVES: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. METHODS: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. RESULTS: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (>1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. CONCLUSIONS: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.