Lines of Evidence on the Risks of Suicide with Selective Serotonin Reuptake Inhibitors

Abstract

Background: There has been a long-standing controversy about the possibility that selective serotonin reuptake inhibitor (SSRI) antidepressants might induce suicidality in some patients. Methods: Starting from the clinical studies that gave rise to this issue, this paper reviews an unselected cohort of randomized clinical trials (RCTs), a series of meta-analyses undertaken to investigate aspects of the problem, studies in recurrent brief depressive disorders, epidemiological studies and healthy volunteer studies using SSRIs to shed light on this issue. Results: The original clinical studies produced evidence of a dose-dependent link, present on a challenge, dechallenge and rechallenge basis, between SSRIs and both agitation and suicidality. Meta-analyses of RCTs conducted around this time indicate that SSRIs may reduce suicidal ideation in some patients. These same RCTs, however, yield an excess of suicides and suicide attempts on active treatments compared with placebos. This excess also appears in the best-controlled epidemiological studies. Finally, healthy volunteer studies give indications that SSRIs may induce agitation and suicidality in some individuals. Conclusions: The data reviewed here, which indicate a possible doubling of the relative risk of both suicides and suicide attempts on SSRIs compared with older antidepressants or non-treatment, make it difficult to sustain a null hypothesis, i.e. that SSRIs do not cause problems in some individuals to whom they are given. Further studies or further access to data are indicated to establish the magnitude of any risk and the characteristics of patients who may be most at risk.

Screening, Diagnosis, and Treatment of Depression in Patients with End-Stage Renal Disease

“…One potential beneficial effect of SSRI in patients with ESRD is that they can decrease orthostatic hypotension, a common problem especially in HD patients (10,68); however, if the diagnosis of an MDD is uncertain, then caution is advised when prescribing SSRI, because they may enhance the risk for mania in patients who have bipolar disorder (69 -72). There is also controversy regarding the use of SSRI and possible increased suicide risk (73)(74)(75). (76 -79).…”

Antidepressants Reduce the Risk of Suicide among Elderly Depressed Patients

“…Despite the enthusiasm shown by several research groups for the use of SSRIs as potently decreasing the risk of suicide, others have reported increased impulsivity and increased rates of suicide associated with exposure to SSRIs (Teicher et al, 1993;Donovan et al, 1999;Healy, 2003). In a recent review of several meta-analyses, Healy and Whitaker (2003) emphasized the need to identify the characteristics of patients who may be most at risk.…”

Suicide in Europe: an on-going public health concern

“…This is somewhat supported by the fact that in individuals with depression (by psychological autopsy) who took their own life, fewer of them were on anti-depressants than the depressed population norm (10). The concern, however, about anti-depressants inducing new onset suicidal thinking is at odds with this position (11,12) and has led to various regulatory standards (13,14 …”