David Baxter PhD
Late Founder
SSRI and suicide risk - the evidence is contradictory and confusing
June 17, 2006
An article in the June 17 Lancet asks whether SSRI antidepressants have affected suicide risk. The author notes that there are two potentially conflicting claims: that SSRI use reduce suicide rates, and the SSRI increase suicide risk in some patients. The evidence available is imperfect and involves a range of studies, and he attempts to summarize the overall picture from these.
Randomised trials have shown no evidence of increased risk, however these have been too small and too short to detect such a change reliably. Meta-analyses of randomized trials have found an effect on suicidal ideation; while these improve the numbers available for study, they cannot get round the short treatment periods of the trials analyzed. There is also uncertainty over how valid suicidal ideation is as a surrogate for suicide risk.
Observational studies have been larger, but are subject to confounding. These seem to show an increased risk of suicide associated with use of any antidepressant, but show only limited evidence for an increased risk with SSRI: a significant confounding factor is that patients at higher risk of suicide were more likely to be prescribed SSRI. Ecological studies, covering whole populations, have found either no change or reduced suicide rates associated with SSRI.
Overall, the author concludes that the evidence supports clinical wisdom that in patients with depression, suicide risk increases in the first few weeks of treatment as psychomotor retardation decreases before mood lifts. It also suggests that any increase in suicide risk from SSRI is probably not specific to these drugs, and is very small and in adults is outweighed by the clinical benefit. The risk to benefit ratio is less clear for children and adolescents because of the limited clinical data available. On the available evidence, he suggests that prescribers would be prudent to monitor depressed patients in the first few weeks after initiation of antidepressants, especially children and adolescents.
How have the SSRI antidepressants affected suicide risk?
The Lancet 2006; 367:1959-1962
June 17, 2006
An article in the June 17 Lancet asks whether SSRI antidepressants have affected suicide risk. The author notes that there are two potentially conflicting claims: that SSRI use reduce suicide rates, and the SSRI increase suicide risk in some patients. The evidence available is imperfect and involves a range of studies, and he attempts to summarize the overall picture from these.
Randomised trials have shown no evidence of increased risk, however these have been too small and too short to detect such a change reliably. Meta-analyses of randomized trials have found an effect on suicidal ideation; while these improve the numbers available for study, they cannot get round the short treatment periods of the trials analyzed. There is also uncertainty over how valid suicidal ideation is as a surrogate for suicide risk.
Observational studies have been larger, but are subject to confounding. These seem to show an increased risk of suicide associated with use of any antidepressant, but show only limited evidence for an increased risk with SSRI: a significant confounding factor is that patients at higher risk of suicide were more likely to be prescribed SSRI. Ecological studies, covering whole populations, have found either no change or reduced suicide rates associated with SSRI.
Overall, the author concludes that the evidence supports clinical wisdom that in patients with depression, suicide risk increases in the first few weeks of treatment as psychomotor retardation decreases before mood lifts. It also suggests that any increase in suicide risk from SSRI is probably not specific to these drugs, and is very small and in adults is outweighed by the clinical benefit. The risk to benefit ratio is less clear for children and adolescents because of the limited clinical data available. On the available evidence, he suggests that prescribers would be prudent to monitor depressed patients in the first few weeks after initiation of antidepressants, especially children and adolescents.
How have the SSRI antidepressants affected suicide risk?
The Lancet 2006; 367:1959-1962
