Suicidal antidepressant overdoses: A comparative analysis by antidepressant type

Abstract

Introduction: The safety of antidepressants following overdose is critical because of the high risk of suicide attempts in depressed patients. This study was conducted to decrease the fatality rate of antidepressant overdoses by providing data to shift prescribing toward safer antidepressants.Methods: US poison control data for 2000-2004 were analyzed by 25 antidepressant types. Medical outcome differences were quantified using a hazard index (number of major or fatal outcomes per 1000 reported antidepressant ingestions).Results: Of 82,802 suicidal single-agent ingestions of identifiable antidepressants approved for use in the US, cases occurred predominantly in females and peaked in teens. Fatal cases peaked at 40 to 49 years of age. Suicidal ingestions of the SSRIs, SNRIs, and other antidepressants peaked in teens, lithium in the twenties, tricyclics and tetracyclics in the thirties, and MAO inhibitors in the forties. There were 40 major or fatal outcomes per 1000 cases. Weighted by antidepressant type, the mean hazard index for the 25 antidepressants was 79 (range: 0 to 292). Amoxapine (292), maprotiline (211), and desipramine (187) had the highest hazard indices. The tricyclic antidepressants, MAO inhibitors, maprotiline, and bupropion were in the more severe half of antidepressants, ranked by hazard index. All SSRIs had low hazard indices. Hazard index and exposure frequency were inversely correlated (R ϭ Ϫ0.423, p ϭ 0.035), while hazard index and use of critical care were positively correlated for the 25 antidepressant types (R ϭ 0.797, p Ͻ 0.001). Clinical effect profiles for each antidepressant type are presented.Conclusion: Suicidal overdose severity varied considerably by antidepressant type. Prescribing decisions should be informed by regularly updated comparative overdose severity data.

Morbidity and Mortality Associated With Medications Used in the Treatment of Depression: An Analysis of Cases Reported to U.S. Poison Control Centers, 2000–2014

“…Our results regarding second-generation antidepressants replicate the findings of White et al (20). Bupropion has the highest morbidity of this group of agents.…”

“…Finally, morbidity indices for three agents identified by White et al (20) as more dangerous (bupropion, citalopram, and venlafaxine) during the period 2000-2004 were compared with similar indices in the present data set during the period 2005-2014. For this comparison, we used the "hazard index" (defined as the number of fatal and major outcomes per 1,000 exposures) employed by White et al (20). We also included sertraline, the SSRI with the greatest number of exposures, as a comparator.…”

“…The mortality indices for bupropion, quetiapine, venlafaxine, and valproic acid are significantly higher than that for diphenhydramine. We compared our morbidity data with those reported by White et al (20) for the three second-generation antidepressants that those authors found most hazardous (bupropion, citalopram, and venlafaxine) (Figure 4). We used the same hazard index as White et al but included all exposures in cases 12 years and older, while White limited exposures to suspected suicides.…”

“…In 2008, White et al (20) used a 5-year sample (2000)(2001)(2002)(2003)(2004)) from the National Poison Data System (NPDS) to examine serious overdose outcomes with antidepressants. Their data suggested that citalopram, venlafaxine, and bupropion were more hazardous than other second-generation antidepressants; however, the small number of exposures for some agents limited comparisons.…”

“…The objectives of this study are to examine the relative morbidity and mortality of the broad range of medications used to treat depression during the period 2000-2014 (these medications include antidepressant drugs and other agents often used to treat unipolar or bipolar depression, including atypical antipsychotics, lithium, and anticonvulsant agents); to examine specific clinical effects associated with serious outcomes for individual medications; and to compare our findings with those of White et al (20), who found that citalopram, venlafaxine, and bupropion have greater morbidity than other second-generation antidepressants.…”