Antidepressant medication and suicide in Sweden

[Changes in the perception of benefits and risks of antidepressive pharmacotherapy]

Antidepressive pharmacotherapy has undergone various phases in its history. The euphoria of the early years on the relief of depressive symptoms was followed by a long period of clinical experience and intensive scientific work resulting in a more balanced perspective. Current debates circle around the actual effectiveness, especially with respect to long-term treatment, the prevention of suicide and the sequelae of discontinuation of an antidepressant. The evaluation of antidepressants as a group and often also the risk-benefit ratio of an individual treatment change over time. Antidepressants are typical for many forms of psychiatric treatment which, in a term from Hanfried Helmchen, are just as Janus-faced as psychiatry in a general sense is as a science and as a clinical discipline.

Population heterogeneity in associations between hormonal contraception and antidepressant use in Sweden: a prospective cohort study applying intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

OBJECTIVES

From a reproductive justice framework, we aimed to investigate how a possible association between hormonal contraceptive (HC) and antidepressants use (as a proxy for depression) is distributed across intersectional strata in the population. We aimed to visualise how intersecting power dynamics may operate in combination with HC use to increase or decrease subsequent use of antidepressants. Our main hypothesis was that the previously observed association between HC and antidepressants use would vary between strata, being more pronounced in more oppressed intersectional contexts. For this purpose, we applied an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy approach.

DESIGN

Observational prospective cohort study using record linkage of national Swedish registers.

SETTING

The population of Sweden.

PARTICIPANTS

All 915 954 women aged 12-30 residing in Sweden 2010, without a recent pregnancy and alive during the individual 1-year follow-up.

PRIMARY OUTCOME MEASURE

Use of any antidepressant, meaning being dispensed at least one antidepressant (ATC: N06A) during follow-up.

RESULTS

Previously mentally healthy HC users had an OR of 1.79 for use of antidepressants compared with non-users, whereas this number was 1.28 for women with previous mental health issues. The highest antidepressant use were uniformly found in strata with previous mental health issues, with highest usage in women aged 24-30 with no immigrant background, low income and HC use (51.4%). The largest difference in antidepressant use between HC users and non-users was found in teenagers, and in adult women of immigrant background with low income. Of the total individual variance in the latent propensity of using antidepressant 9.01% (healthy) and 8.16% (with previous mental health issues) was found at the intersectional stratum level.

CONCLUSIONS

Our study suggests teenagers and women with immigrant background and low income could be more sensitive to mood effects of HC, a heterogeneity important to consider moving forward.

Passive and active suicidal ideation in Swedish 85-year-olds: Time trends 1986-2015

BACKGROUND

Older adults have high suicide rates. We investigated potential time trends in the prevalence of passive and active suicidal ideation in 85-year-olds. Further, we examined factors associated with such ideation in this age group.

METHODS

Population-based samples of 85-year-olds were interviewed in 1986 (N = 347), 2008 (N = 426) and 2015 (N = 320). Past-month passive/active suicidal ideation was evaluated with the Paykel questions.

RESULTS

Reporting any type of passive or active suicidal ideation was less common in 2008 (7.3%, p < 0.001) and 2015 (7.2%, p < 0.001) compared to 1986 (16.4%). The change was driven by decreases in passive ideation. Passive/active suicidal ideation was associated with higher MADRS score (OR: 1.2, 95% CI: 1.1-1.2, p < 0.001), institution residence (OR: 3.9, 95% CI: 1.7-8.9, p = 0.001) and feelings of loneliness (OR: 2.7, 95% CI: 1.4-5.2, p = 0.003). When stratified by sex, it was associated with institution residence (OR: 3.7, 95% CI: 1.4-9.9, p = 0.008) and feelings of loneliness (OR: 3.0, 95% CI: 1.4-6.3, p = 0.005) in women. In men, we observed a tenfold higher risk in those without partners (OR: 9.8, 95% CI: 2.9-33.5, p < 0.001).

LIMITATIONS

While differential three-year mortality was not observed in 1986, mortality was higher among non-participants in 2008 and 2015. This might have inflated cohort differences in passive/active suicidal ideation.

CONCLUSION

An initial decrease in the prevalence of passive/active suicidal ideation in 85-year-olds was observed but this positive trend did not persist. Results underline that preventive strategies targeting loneliness and focusing on institutional settings are needed, as are interventions for men without partners.

Antidepressant use in Australia and Sweden-A cross-country comparison

PURPOSE

To compare the dispensed use of antidepressants in Australia and Sweden.

METHODS

We analysed publicly available data from Australia and Sweden on dispensed use of antidepressants from 2006 to 2018.

RESULTS

The dispensed use of antidepressants has increased in both Australia and Sweden. Australia had a more rapid increase resulting in a higher total use. The utilisation profile was similar in both countries; SSRIs were the most commonly used group, "other antidepressants" were the group that increased the most, and seven of the eight most used substances were the same. There were differences in which antidepressants were most used, with the three most prescribed antidepressants being escitalopram, sertraline, and venlafaxine in Australia; and mirtazapine, sertraline, and citalopram in Sweden.

CONCLUSION

Dispensed use of antidepressants has increased remarkably in both Australia and Sweden between 2006 and 2018. Although similar with regard to economic status and health care system, use of antidepressants differs between both countries. This may be a result of a combination of factors related to medical, contextual and policy evidence. The differences displayed in this study may reflect varying accessibility of treatments, national programmes enhancing mental health literacy in the population, clinical prescribing guidelines and timing of approval of new antidepressants.

Psychotropic medication use before and after suicidal presentations to the emergency department: A longitudinal analysis

OBJECTIVE

The rates of annual emergency department (ED) visits in the United States for suicidal behaviour has nearly doubled over the last 10-15 years, with a decreased rate of hospitalizations, indicating the importance of intervention in the ED presentation. This paper describes the patterns of psychotropic use immediately before and after emergency department presentation to enhance understanding of interventions for increasing safety in these individuals.

METHODS

5070 adults seen in psychiatric consultation in two tertiary EDs with linkage to population-based administrative data to describe psychotropic prescriptions immediately before and after ED presentation.

RESULTS

55.9% of suicide attempts were by overdose, with 13.4% of suicide attempts occurring in the 18-21 age group. While no causal relationship can be inferred, half of those who presented to the ED with suicidal ideation or behaviour or non-suicidal self-injury were prescribed an antidepressant prior to ED presentation, with a spike in new prescriptions in the month immediately prior. 20% of those who presented to the ED with thoughts or behaviour received a new or different prescription for an antidepressant in the 1-month post-presentation. Prescribing of tricyclic antidepressants and opioids were decreased following ED presentation, however 21% of people still received opioids after a suicide attempt. Rates of antipsychotic prescriptions were increased.

CONCLUSION

Patients are seeking help in the one-month prior to emergency presentation. Clinicians must consider the risk in this period of heightened clinical distress, especially among those under age 21. It is important to consider the changes that can be made in the ED to impact safety.

Just what the nurse practitioner ordered: Independent prescriptive authority and population mental health

We examine whether relaxing occupational licensing to allow nurse practitioners (NPs)-registered nurses with advanced degrees-to prescribe medication without physician oversight improves population mental health. Exploiting time-series variation in independent prescriptive authority for NPs from 1990 to 2014, we find that broadening prescriptive authority leads to improvements in self-reported mental health and decreases in mental health-related mortality. These improvements are concentrated in areas that are underserved by physicians and among populations that have difficulty accessing physician-provided care. Our results demonstrate that extending independent prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations.

Availability and use of mental health services in European countries: Influence on national suicide rates

BACKGROUND

Previous research suggests significant increases in suicide mortality rates in European countries following the economic crisis of 2008. However, the relationship between national differences in availability and use of mental health services and suicide rates has not been extensively examined yet.

MATERIALS AND METHODS

Data on mental health services and socioeconomic variables were derived from Eurostat for the years 2000-2013 for ten European countries. The national health care variables consisted of suicide mortality rate (SMR), average length of hospital stay and number of hospitalizations due to affective disorder or any psychiatric disorder, number of psychiatric beds and number of prescribed antidepressants. Economic variables included the gross domestic product (GDP), the gross domestic product per 1000 inhabitants (Real GDP), the rate of unemployment and the GINI-coefficient as a measurement for the equality of wealth distribution. Mixed models were used to investigate the potential influence of the onset of the economic crisis in 2008 on each of the psychiatric variables. Multivariable regression analyses were used to assess the influence on suicide mortality rates.

RESULTS

In this study, a significant change in slope starting from 2008 was revealed for the number of psychiatric beds, hospitalizations due to affective disorder or any psychiatric disorder and for prescribed antidepressants. Furthermore, a significant step change for hospitalizations due to affective disorder was observed in 2008. SMR exhibited a significant step change in 2008 for males and females as well as a significant change in slope from 2008 onwards for males only. Contrary to our hypothesis, most variables showed no statistically significant influence on SMR. Only a higher number of available psychiatric beds was significantly associated with higher suicide mortality rates. This effect, however, was only significant for females and did not remain significant after correcting for economic variables. Less than 10% of suicide mortality rate variability could be explained by a model including all variables, further corroborating the multifactorial etiology of suicide.

LIMITATIONS

Since administrative registry data was used, the results should be interpreted with caution. Results might not be applicable to countries not included.

CONCLUSION

While significant changes in the psychiatric variables, as well as SMR, were observed, no statistically significant influence on SMR remained after correcting for country, time and economic variables. Our study suggests the necessity of a more comprehensive international data gathering effort. Further research is needed to identify populations at risk of suicide.

The relationship between the prescription of pyschotropic drugs and suicide rates in adults in England and Wales

BACKGROUND

A few studies have demonstrated an inverse relationship between the general population and suicide rates and antidepressant prescribing rates. Correlations between general population suicide rates and prescribing rates of other psychotropic drugs have also been observed. There have not been any studies during the last decade.

METHODS

The relationship between adult suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. selective serotonin reuptake inhibitors) and for individual psychotropic drugs was examined over a 12-year period (1995-2006) was examined using Spearman's rank correlation. All data were ascertained from the archives of the Office for National Statistics.

RESULTS

There was an absence of significant correlations between adult suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological errors. Should the findings be accurate, then the following approaches require consideration to reduce suicide rates further: (i) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (ii) development of strategies to improve non-pharmacological measures, including improved mental health services provision for adults, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (iii) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

The relationship between bupropion and suicide in post-mortem investigations

We reviewed the 33727 postmortem toxicology investigations performed in Finland over a period of 5years (2009-2013) and identified those in which the antidepressant bupropion was detected. Cases positive for other antidepressant drugs were reviewed for comparison. The postmortem toxicological examination included, in all cases, the routine screening and quantification of hundreds of drugs and poisons using quality-controlled methods. Bupropion was detected in 65 cases. A large proportion of the bupropion-positive deaths resulted from suicide (55%). In fatal poisoning cases found positive for bupropion, the proportion of suicide was even higher (77%). The measured median bupropion postmortem blood concentration (0.69mg/L) was markedly higher than the normal therapeutic range in plasma in the treatment of depression (up to 0.1mg/L) and even higher in fatal bupropion poisonings (13mg/L). Only 14% of the deceased positive for bupropion were estimated to be drug abusers. However, nearly all of the drug abuse cases were from the last year of the study (2013), indicating a recent increase of the use of bupropion among drug abusers and possibly even abuse of bupropion itself. Suicide victims positive for bupropion were younger than those who died with other antidepressant drugs in their blood. In addition, the percentage of fatal poisonings among bupropion-positive postmortem cases was higher than among the users of other antidepressant drugs. Suicide was significantly more common among the deceased positive for bupropion than among users of other antidepressant drugs. An unknown degree of bupropion degradation before the assay and post-mortem redistribution of bupropion may have impacted the measured levels. Nonetheless, all post-mortem concentrations of bupropion were elevated and especially high concentrations were detected in suicides.

Disparities in suicide mortality trends between United States of America and 25 European countries: retrospective analysis of WHO mortality database

The objective was to examine changes in temporal trends in suicide mortality in 26 Western countries by retrospective trend analysis of the WHO mortality database on causes of deaths. From 1990 to 2010, there was a median reduction in suicide mortality of 22.7%, ranging from a 46% reduction in Estonia to a 26.2% increase in Romania. Suicide mortality decreased by ≥ 20% in 15 countries, and the reduction tended to be greater in countries with higher mortality in 1990. In most of the central European countries mortality strongly declined. The median changes in the age groups were -25.3% (range -62.9% to 72.6%) in people aged 15-24 years, -36.9% (-60.5% to 32.4%) in 25-34 years, -3.6% (-57.1% to 92%) in 35-54 years, -12.2% (-37% to 65,7%) in 55-74 years and -16.1% (-54.5% to 166.7%) in ≥ 75 years. Suicide prevention programs in youths and in the elderly seem to be effective (at least in females for the elderly) and efforts should be pursued in this way. However, suicide mortality of the people aged 35-54 years has increased in half of the studied countries between 1990 and 2010. Public policies should further orientate their efforts toward this population.

Patterns of presentation for attempted suicide: analysis of a cohort of individuals who subsequently died by suicide

All suicides and related prior attempts occurring in Northern Ireland over two years were analyzed, focusing on number and timing of attempts, method, and mental health diagnoses. Cases were derived from coroner's records, with 90% subsequently linked to associated general practice records. Of those included, 45% recorded at least one prior attempt (with 59% switching from less to more lethal methods between attempt and suicide). Compared with those recording one attempt, those with 2+ attempts were more likely to have used less lethal methods at the suicide (OR = 2.77: 95% CI = 1.06, 7.23); and those using less lethal methods at the attempts were more likely to persist with these into the suicide (OR = 3.21: 0.79, 13.07). Finally, those with preexisting mental problems were more likely to use less lethal methods in the suicide: severe mental illness (OR = 7.88: 1.58, 39.43); common mental problems (OR = 3.68: 0.83, 16.30); and alcohol/drugs related (OR = 2.02: 0.41, 9.95). This analysis uses readily available data to highlight the persisting use of less lethal methods by visible and vulnerable attempters who eventually complete their suicide. Further analysis of such conditions could allow more effective prevention strategies to be developed.

[Antidepressive agents and suicidal tendencies]

In the last 2 years the discussions on the question whether antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) can lead to suicidality, aggression and violence, flared up again. The available data on the problem, which has been discussed since the introduction of this substance group in the late 1980s, is presented in this article. A systematic literature search showed that a scientific consensus exists that the benefits of antidepressant pharmacotherapy in general, and of treatment with SSRIs and selective serotonin/norepinephrine reuptake inhibitors (SSNRIs) in particular, outweigh the risks of their use. This also applies to the treatment of children, adolescents and young adults. The agitation occasionally occurring at the beginning of treatment, which can be experienced as aversive in susceptible patients, can intensify or even trigger suicidal thoughts or impulses. This has to be paid particular attention to especially at the beginning of treatment. It is recommended that the indications for antidepressant pharmacotherapy of children, adolescents and young adults are assessed by a specialist.

The public health approach to reducing suicide: opportunities for curriculum development in psychiatry residency training programs

The authors review the current status of suicide prevention curricula in psychiatry training programs, describe the public health approach to suicide prevention, discuss public health strategies for reducing suicides and the unique role played by psychiatrists with respect to suicide prevention, and offer public health-oriented suicide prevention curriculum guidelines for psychiatry residents.

The relationship between the prescription of psychotropic drugs and suicide rates in older people in England and Wales

BACKGROUND

Several studies have reported an inverse correlation between general population and elderly suicide rates and antidepressant prescribing rates. Correlations between general population and elderly suicide rates and prescribing rates of other psychotropic drugs have also been reported. All studies of elderly suicide rates have used data over a decade old.

METHODS

The relationship between elderly suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. SSRIs), and for individual psychotropic drugs was examined over a 12-year period (1995-2006) using Spearman's rank correlation. All data were ascertained from the archives of the National Statistics Office.

RESULTS

There was an absence of significant correlations between elderly suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological flaws. However, if they are genuine, then the following approaches require consideration to further reduce suicide rates: (1) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (2) development of strategies to improve non-pharmacological measures, including improved mental health services provision for older people, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (3) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Chances and limits of method restriction: a detailed analysis of suicide methods in Switzerland

The objective of this study was to estimate the potential of method restriction as a public health strategy in suicide prevention. Data from the Swiss Federal Statistical Office and the Swiss Institutes of Forensic Medicine from 2004 were gathered and categorized into suicide submethods according to accessibility to restriction of means. Of suicides in Switzerland, 39.2% are accessible to method restriction. The highest proportions were found in private weapons (13.2%), army weapons (10.4%), and jumps from hot-spots (4.6%). The presented method permits the estimation of the suicide prevention potential of a country by method restriction and the comparison of restriction potentials between suicide methods. In Switzerland, reduction of firearm suicides has the highest potential to reduce the total number of suicides.

Efficacy and safety of antidepressant drug treatment in children and adolescents

Depression and anxiety are common disorders in youth that can have profound influences on functioning and even mortality. In the late 1990s, large controlled trials began demonstrating the efficacy of selective serotonin reuptake inhibitors for these conditions in the pediatric population. By 2003, regulatory agencies began warning the public of unrecognized risk and misrepresented benefit. The current review article summarizes a series of published and unpublished efficacy and safety data regarding antidepressant use in children and adolescents. The resulting complex synthesis suggests that these medications may offer mild-to-moderate benefit, with notable exceptions depending on medication and indication, but they may also heighten the risk for suicidal ideation and parasuicidal behavior. However, reviewed epidemiological data does not demonstrate a relationship between newer antidepressant prescription and completed suicide in large populations of youth. In conclusion, this breadth of mixed research data is applied to clinical decision making.

Suicide in young men

Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider mortality measures indicate that rates remain high in specific regions, ethnic groups, and socioeconomic groups within those nations where rates have fallen, and that young men account for a substantial proportion of the economic cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few interventions to reduce suicides in young men have been assessed. Efforts to change help-seeking behaviour and to restrict access to frequently used methods hold the most promise.

[Recommendations for the prevention and management of suicidal behaviour]

INTRODUCTION

Suicidal behaviour is a major public health issue. Suicidal behaviour is one of the main causes of years of life lost and it is the third leading cause of death among young adults. This project was initiated by the Spanish Society of Psychiatry and the Spanish Society of Biological Psychiatry with the aim of providing a document containing the main recommendations on the prevention and management of suicidal behaviour; these recommendations should be based on the best available evidence and the experts' opinion.

MATERIAL AND METHODS

In this article we summarize the review of the available evidence on the epidemiology and impact of suicidal behaviour, risk and protective factors, evaluation tools for the assessment of suicide risk, international and local preventive protocols, educational interventions for health professionals, and potential interventions for at risk populations.

RESULTS

Based on this review, a panel of psychiatrists summarized and agreed a set of recommendations about the impact, prevention and management of suicidal behaviour.

CONCLUSION

The recommendations on the prevention and management of suicidal behaviour were summarized in the ten conclusions reported in this article.

Psychotropic drug use in relation to mental disorders and institutionalization among 95-year-olds: a population-based study

BACKGROUND

The prevalence of psychotropic drug use is high among the elderly, but research on how psychotropic drugs are used among individuals aged 90 years and older is limited. An increased knowledge on this topic may contribute to improved prescribing patterns in this vulnerable population. The aim of this study was to assess the use of psychotropic drugs in relation to mental disorders and institutionalization among 95-year-olds and to identify use of potentially inappropriate psychotropic drugs.

METHODS

All 95-year-olds born in 1901-1903 living in nursing homes or community settings in Gothenburg, Sweden were invited to participate. The response rate was 65% and 338 95-year-olds were examined (263 women, 75 men). Psychotropic drug use in relation to mental disorders and institutionalization was assessed. Information on drug use was collected primarily from multi-dose drug dispensing lists. Participants were examined by trained psychiatrists using the Comprehensive Psychopathological Rating Scale and a battery of cognitive tests. Dementia, depression, anxiety and psychotic disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R).

RESULTS

Sixty percent of the 95-year-old participants used psychotropic drugs; hypnotics were most common (44%). Potentially inappropriate psychotropics were observed in one third (33%). Antidepressants were used by 7% of the participants without dementia who fulfilled criteria for a depressive disorder, while 56% used hypnotics and 30% used anxiolytics.

CONCLUSIONS

The high prevalence of psychotropic drug use and the nonspecific nature of these treatments among 95-year-olds indicate a need for improvement in prescribing patterns.

Antidepressants and Suicide Risk: A Comprehensive Overview

The annual worldwide suicide rate currently averages approximately 13 per 100,000 individuals per year (0.013% per year), with higher average rates for men than for women in all but a few countries, very low rates in children, and relatively high rates in elderly men. Suicide rates vary markedly between countries, reflecting in part differences in case-identification and reporting procedures. Rates of attempted suicide in the general population average 20-30 times higher than rates of completed suicide, but are probably under-reported. Research on the relationship between pharmacotherapy and suicidal behavior was rare until a decade ago. Most ecological studies and large clinical studies have found that a general reduction in suicide rates is significantly correlated with higher rates of prescribing modern antidepressants. However, ecological, cohort and case-control studies and data from brief, randomized, controlled trials in patients with acute affective disorders have found increases, particularly in young patients and particularly for the risk of suicide attempts, as well as increases in suicidal ideation in young patients. whether antidepressants are associated with specific aspects of suicidality (e.g., higher rates of completed suicide, attempted suicide and suicidal ideation) in younger patients with major affective disorders remains a highly controversial question. In light of this gap this paper analyzes research on the relationship between suicidality and antidepressant treatment.

Suicidal ideation during treatment of depression with escitalopram and nortriptyline in genome-based therapeutic drugs for depression (GENDEP): a clinical trial

BACKGROUND

Suicidal thoughts and behaviours during antidepressant treatment, especially during the first weeks of treatment, have prompted warnings by regulatory bodies. The aim of the present study is to investigate the course and predictors of emergence and worsening of suicidal ideation during tricyclic antidepressant and serotonin reuptake inhibitor treatment.

METHODS

In a multicentre part-randomised open-label study, 811 adult patients with moderate to severe unipolar depression were allocated to flexible dosage of escitalopram or nortriptyline for 12 weeks. The suicidality items of three standard measures were integrated in a suicidal ideation score. Increases in this score were classified as treatment emergent suicidal ideation (TESI) or treatment worsening suicidal ideation (TWOSI) according to the absence or presence of suicidal ideation at baseline.

RESULTS

Suicidal ideation decreased during antidepressant treatment. Rates of TESI and TWOSI peaked in the fifth week. Severity of depression predicted TESI and TWOSI. In men, nortriptyline was associated with a 9.8-fold and 2.4-fold increase in TESI and TWOSI compared to escitalopram, respectively. Retirement and history of suicide attempts predicted TWOSI.

CONCLUSION

Increases in suicidal ideation were associated with depression severity and decreased during antidepressant treatment. In men, treatment with escitalopram is associated with lower risk of suicidal ideation compared to nortriptyline. Clinicians should remain alert to suicidal ideation beyond the initial weeks of antidepressant treatment.

TRIAL REGISTRATION

EudraCT (No.2004-001723-38) and ISRCTN (No. 03693000).

Suicide trends diverge by method: Swiss suicide rates 1969-2005

We examined the change in Swiss suicide rates since 1969, breaking down the rates according to the method used. The descriptive analyses of the main suicide methods are presented. The suicide rates reached a peak in the late 1970s/early 1980s and declined in more recent years. Firearm suicides and suicides by falls were the exception and sustained their upwards trend until the 1990s. Suicide by vehicle exhaust asphyxiation showed a rapid decline following the introduction of catalytic converters in motor vehicles. No substantial method substitution was observed. Suicide by poisoning declined in the 1990s but rose again following an increase in assisted suicide in somatically incurable patients. Suicide is too often regarded as a homogeneous phenomenon. With regard to the method they choose, suicide victims are a heterogeneous population and it is evident that different suicide methods are chosen by different people. A better understanding of the varying patterns of change over time in the different suicide methods used may lead to differentiated preventive strategies.

Number of addictive substances used related to increased risk of unnatural death: a combined medico-legal and case-record study

BACKGROUND

Substance use disorders have repeatedly been found to lead to premature death, i.e. drug-related death by disease, fatal intoxications, or trauma (accidents, suicide, undetermined suicide, and homicide). The present study examined the relationship between multi-drug substance use and natural and unnatural death.

METHODS

All consecutive, autopsied patients who had been in contact with the Addiction Centre in Malmö University Hospital from 1993 to 1997 inclusive were investigated. Drug abuse was investigated blindly in the case records and related to the cause of death in 387 subjects.

RESULTS

Every substance apart from alcohol used previously in life added to the risk of unnatural death in a linear way. There were independent increased risks of fatal heroin overdoses or undetermined suicide. Death by suicide and violent death were unrelated to additional abuse.

CONCLUSION

The number of drugs used was related to an increased risk of unnatural death by undetermined suicide (mainly fatal intoxications) and heroin overdose.

Detecting suicidality among adolescent outpatients: evaluation of trained clinicians' suicidality assessment against a structured diagnostic assessment made by trained raters

BACKGROUND

Accurate assessment of suicidality is of major importance. We aimed to evaluate trained clinicians' ability to assess suicidality against a structured assessment made by trained raters.

METHOD

Treating clinicians classified 218 adolescent psychiatric outpatients suffering from a depressive mood disorder into three classes: 1-no suicidal ideation, 2-suicidal ideation, no suicidal acts, 3-suicidal or self-harming acts. This classification was compared with a classification with identical content derived from the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) made by trained raters. The convergence was assessed by kappa- and weighted kappa tests.

RESULTS

The clinicians' classification to class 1 (no suicidal ideation) was 85%, class 2 (suicidal ideation) 50%, and class 3 (suicidal acts) 10% concurrent with the K-SADS evaluation (gamma2 = 37.1, df 4, p = 0.000). Weighted kappa for the agreement of the measures was 0.335 (CI = 0.198-0.471, p < 0.0001). The clinicians under-detected suicidal and self-harm acts, but over-detected suicidal ideation.

CONCLUSION

There was only a modest agreement between the trained clinicians' suicidality evaluation and the K-SADS evaluation, especially concerning suicidal or self-harming acts. We suggest a wider use of structured scales in clinical and research settings to improve reliable detection of adolescents with suicidality.

Do SSRIs or antidepressants in general increase suicidality? WPA Section on Pharmacopsychiatry: consensus statement

In the past few years several papers have reported critically on the risk of suicidal thoughts and behaviour associated with antidepressants, primarily SSRIs. The risk-benefit ratio of antidepressant (AD) treatment has been questioned especially in children and adolescents. The critical publications led to warnings being issued by regulatory authorities such as the FDA, MHRA and EMEA and stimulated new research activity in this field. However, potential harmful effects of antidepressants on suicidality are difficult to investigate in empirical studies because these have several methodological limitations. Randomised controlled trials (RCTs) are the most reliable way to test the hypothesis that AD have such side effects. In addition to meta-analyses of RCTs, complementary research methods should be applied to obtain the most comprehensive information. We undertook a comprehensive review of publications related to the topics ADs, suicide, suicidality, suicidal behaviour and aggression. Based on this comprehensive review we conclude that ADs, including SSRIs, carry a small risk of inducing suicidal thoughts and suicide attempts, in age groups below 25 years, the risk reducing further at the age of about 30-40 years. This risk has to be balanced against the well-known beneficial effects of ADs on depressive and other symptoms (anxiety, panic, obsessive-compulsive symptoms), including suicidality and suicidal behaviour. According to the principles of good clinical practice, decision making should consider carefully the beneficial effects of AD treatment as well as potentially harmful effects and attempt to keep the potential risks of AD treatment to a minimum. It is the major problem facing efforts to identify the possible 'suicidal effects' of antidepressants.

Antidepressant prescription and suicide rates: effect of age and gender

To determine whether the effect of antidepressant exposure on suicide rate is modified by age and gender in Hungary, annual antidepressant prescription rates and suicide rates of about 10 million inhabitants between 1999-2005 were analyzed by age and gender groups. The suicide rate was inversely related to the increased use of antidepressants in both genders. The strongest association was found in the oldest age groups, where the increase in antidepressant use was highest, while there was no association in the under 20 or 50-69 age groups in either gender. Antidepressant prescription rate was related to suicide rate after controlling for divorce rate or unemployment rate, but not after controlling for alcohol consumption rate.

National suicide rates 1961-2003: further analysis of nordic data for suicide, autopsies and ill-defined death rates

BACKGROUND

Concerns about the risk-benefit ratio of treatment with antidepressants in the light of recent evidence pointing to a risk of suicide induction during the course of treatment with antidepressants. These concerns have led to a series of recent studies exploring national rates of suicide and correlating these with data on antidepressant consumption.

METHODS

We have compared suicide rates in the Nordic countries with autopsy and ill-defined death rates, and antidepressant sales, during the period 1961 through to 2003.

RESULTS

There is a close correlation between suicide rates and both autopsy and ill-defined death rates.

CONCLUSIONS

The role of autopsies and other factors in the registration of a death as a suicide appear to need further clarification.

The sales of antidepressants and suicide rates in Norway and its counties 1980-2004

BACKGROUND

Suicide is a major public health problem and depression is among the most important risk factors for suicide. Treatment of depression might prevent suicide. To study this hypothesis further we conducted an ecological study.

METHODS

An ecological study using sales data for antidepressants and numbers of suicides in Norway and Norwegian counties 1980-2004 was performed. Data on alcohol consumption and unemployment rates were registered and taken into account. Data were analyzed using Cochrane-Orcutt time series for the country as a whole. The county specific data were analyzed with a random coefficient model with county as subject and intercept and time (slope) as random variables using an unstructured covariance matrix.

RESULTS

Sales of non-tricyclic antidepressants (non-TCAs) and suicide were clearly negatively related, even when controlling for alcohol and unemployment (adjusted r(2): 0.57). There was an effect modification between time and level of sales of non-TCAs. Studying the relationship between the sales of non-TCAs and the suicide rate, we found that it was significant and stronger for the low sales figures, but non-existent for the high sales figures.

LIMITATIONS

Ecological studies cannot infer causality.

CONCLUSIONS

The fall in suicide rates in Norway and its counties was related to the increased sales of non-TCAs. The effect was mostly a result of a sales increase in the lower sales segment, indicating that a change from the more toxic TCAs, or heightened awareness of depression and its treatment, could explain the relationship found between sales of newer antidepressants and a decrease in suicide rate.

Ecological studies of antidepressant treatment and suicidal risks

Ongoing discussion of potential benefits and risks of antidepressant treatment with respect to suicidal behaviors includes many ecological, or population-based, correlational studies of temporal or regional trends in suicide rates and rates of usage of modern antidepressants including serotonin-reuptake inhibitors (SRIs). Since this body of research has not been compiled and evaluated, we used computerized literature searching to identify 19 relevant published studies. They yielded heterogeneous findings: only 8/19 found significant inverse correlations between rising sales of modern antidepressants in the 1990 s and falling suicide rates not anticipated in the 1980s. Average reductions in suicide rates in the 1990 s (10.7%) and 1980s (10.0%) differed little in 11 studies with data from both eras. Reduction of suicide rates in the 1990 s was unrelated to geographic region, population size, units of analysis, publication year, or growth in antidepressant usage, but was greater with higher initial suicide rates, in men, and in older persons. In the same decade, suicides rates decreased in only half of 79 large countries. Overall, these findings yield limited and inconsistent support for the hypothesis that increased use of modern antidepressants might limit suicide risk, and no evidence that the risk increased. Suicidal risk is determined by complex factors, including access to clinical services, in general, and more comprehensive treatment of depression, in particular. Overall, as with findings from randomized trials and cohort or case-control studies, evidence of specific antisuicidal effects of antidepressant treatment from ecological analyses remains elusive.

Association of suicide and antidepressant prescription rates in Japan, 1999-2003

OBJECTIVE

We examined the relationship of increasing prescription volume of newer antidepressants, introduced in Japan in 1999, to national rates of suicide.

METHOD

The relationship between annual changes in rates of suicide (obtained from the Japanese Ministry of Health, Labor, and Welfare Vital Statistics Database) and prescription volume of the newer antidepressants paroxetine, fluvoxamine, and milnacipran (obtained from the database of IMS Japan K.K.), stratified by gender and age groups, was modeled statistically for the years 1999 through 2003. Effects of unemployment and alcohol consumption and the interaction of gender and age with antidepressant prescribing were assessed.

RESULTS

From 1999 through 2003 in Japan, total antidepressant prescriptions increased 57% among males and 50% among females. Approximately 80% of this increase involved the selective serotonin reuptake inhibitors (SSRIs). To reduce a limitation of ecological analysis, we compared annual change in prescription and suicide rates, which eliminates the effect of long-term (secular) linear trends. We found an inverse association between year-to-year changes in the suicide rate and prescription volume of newer antidepressants (fluvoxamine, paroxetine, and milnacipran) (beta = -1.34, p = .008) and SSRIs specifically (fluvoxamine, paroxetine) (beta = -1.41, p = .019). An increase of 1 defined daily dose of SSRI use/1000 population/day was associated with a 6% decrease in suicide rate. Exploratory analysis suggested a stronger association in males, who experienced a greater increase in antidepressant use. Changes in unemployment and alcohol consumption rates did not explain the association.

CONCLUSION

In Japan during 1999 through 2003, absent long-term linear trend effects, annual increases in prescribing of newer antidepressant medications, mainly SSRIs, were associated with annual decreases in suicide rates, particularly among males.

Antidepressants and youth: healing or harmful?

A series of drug innovations that began in 1987, including the introduction of several selective serotonin reuptake inhibitors (SSRIs), has led to a tremendous growth in the use of antidepressants in the United States. This growth, however, has been accompanied by a growing concern about the risks of prescribing antidepressants, particularly to children. Indeed, research linking the use of antidepressant drugs to an increased risk of suicidal behaviors in youth motivated the US Food and Drug Administration to direct antidepressant drug manufacturers to include warning labels about the potential dangers. This paper examines the relationship between antidepressants and suicide among youth in the USA. Using state-level data on youth suicides and age-specific prescriptions for antidepressants, we find no relationships between suicides for adolescents aged 15-19 and prescriptions for SSRIs/serotonin-norepinephrine reuptake inhibitors or tricyclic and tetracyclic antidepressants. In contrast, we find that newer generation antidepressants are associated with lower numbers of suicides for this age group. For younger children aged 10-14, we find no relationship with suicides for any type of antidepressant.

Assessing the impact of media guidelines for reporting on suicides in Austria: interrupted time series analysis

OBJECTIVE

Media guidelines for reporting on suicides are a widely used means of preventing imitative suicides, but scientific accounts of their impact on suicide numbers are sparse. This report provides an evaluation of the Austrian guidelines that were introduced in 1987 as a natural experiment.

METHODS

The impact of the guidelines was tested by applying an autoregressive integrated moving average (ARIMA) model and a linear regression model. In addition to a nationwide evaluation, Austria was divided into three areas according to regional differences in coverage rates of the collaborating newspapers and the impact of the intervention was tested for each area separately. Main outcome measures were the overall annual suicide numbers, and the numbers of Viennese subway suicides that were exceptionally newsworthy for the mass media. In order to test intermediate impacts, also quantitative and qualitative changes in media reporting after the introduction of the guidelines were analysed.

RESULTS

There was some evidence of a nationwide impact of the guidelines, calculated as a significant reduction of 81 suicides (95% confidence interval: -149 to -13; t = -2.32, df = 54, p <0.024) annually. This effect was particularly due to a significant reduction in the area with the highest coverage rates of the collaborating newspapers. Viennese subway suicides showed a highly significant level shift (t = -4.44, df = 19, p <0.001) and a highly significant trend change (t = -4.20, df = 19, p <0.001) after the introduction of the guidelines. These effects corresponded to significant changes in the quality and quantity of media reporting.

CONCLUSIONS

The present results clearly support the hypothesis that the media guidelines have had an impact on the quality of reporting as well as on suicidal behaviour in Austria, and stress the importance of collaborating with nationwide, but also with regional media to achieve efficacy. Further research is needed to provide an international insight into this public health issue.

Is there evidence for negative effects of antidepressants on suicidality in depressive patients? A systematic review

The role of antidepressants in suicide prevention is a major public health question given the high prevalence of both depression and depression-related suicidality. Therefore all available means should be utilised to clarify the influence of antidepressants on suicidality, especially in view of the ongoing intensive debate about possible suicidality-inducing effects of antidepressants that may outweigh their traditionally hypothesised beneficial effects. This paper gives a systematic and comprehensive review of the empirical data which might indicate that antidepressants have negative effects on suicidality. First, principal methodological issues related to this research question are discussed. Thereafter, the results of controlled trials and epidemiological and cohort studies are presented. Altogether, there seems to be only a small amount of evidence from different research approaches that antidepressants, not only serotonin reuptake inhibitors (SSRIs), might induce, aggravate or increase the risk of suicidal ideation and suicide attempts. As to suicide, there are no hints in this direction. TCAs have a higher risk of fatal outcome in overdose compared to SSRIs, which, in case of mono-intoxication, carry almost no risk of lethal consequences. The ongoing discussion about suicidality-inducing effects should not prevent physicians from prescribing SSRIs and other antidepressants to their patients if they are clinically indicated. However, they should take into account potential risks and manage them by good clinical practice.

[Safety of selective serotonin reuptake inhibitor antidepressants in children and adolescents]

Some behavioral side effects of selective serotonin reuptake inhibitor (SSRI) antidepressants have been known for a long time. Since the introduction of these drugs in the 1990s, publications have regularly reported behavioral side effects in children and adolescents, including excitation, motor restlessness, social disinhibition, and above all self-injurious ideation and behavior. Clinical trials provide only limited data. Although these data suggest that some self-injurious and suicidal behavior may indeed occur in children and adolescents receiving SSRIs, they are too disparate to specify the frequency of these acts. Clinical trials provide useful data about drug efficacy, but their methodology is inappropriate for determining the frequency of such side effects. SSRI and suicidality: the data are difficult to read. Although some epidemiologic data suggest that SSRIs may increase the risk of occurrence of self-injurious and suicidal behavior in children and adolescents, other epidemiologic data show that the rate of suicide mortality in children and adolescents has decreased since the introduction of SSRIs. No known mechanism explains how SSRIs might increase the risk of these behavioral side effects. It is clear, however, that these effects are not particular to children and adolescents but may also be observed among adults. SSRIs must be used rationally and carefully in children and adolescents. They should not be administered routinely in youth with obsessive-compulsive or depressive disorders. Their use should be reserved for severe disorders or when psychotherapy alone has been shown to be inadequate, and when they are used, efficacy and side effects must be monitored carefully and frequently.

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.

Antidepressants and suicidal behavior in bipolar disorder

Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167-181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.

Antidepressants and youth suicide in New York City, 1999-2002

OBJECTIVE

To determine the proportion of youth suicides in New York City from 1999 to 2002 in which antidepressants were detected at autopsy.

METHOD

This is a medical examiner surveillance study of suicides in New York City among those younger than 18 years of age. The outcome measure is serum toxicology for antidepressants.

RESULTS

From 1999 through 2002, there were 41 individuals younger than 18 years of age among residents of New York City who committed suicide. Thirty-six (87.8%) had a serum toxicological analysis and an injury death interval of 3 days or less. There was one (2.8%) suicide in which both bupropion and sertraline were detected at the time of autopsy. Antidepressants were not detected in any of the other youth suicides.

CONCLUSIONS

The detection of antidepressants at autopsy was quite rare in youth suicides in New York City from 1999 to 2002.

Association between antidepressant prescribing and suicide in Israel

The effects of antidepressants on suicide are controversial; on the one hand they decrease the incidence of death by suicide, as reflected in epidemiological studies, and on the other hand, there are claims that they increase the risk of impulsivity and suicide. In 1998, primary care physicians in Israel were not allowed to prescribe selective serotonin reuptake inhibitors and in 1999 this prohibition was lifted. We thus evaluated the association between patterns of antidepressant prescribing and the rate of death by suicide in Israel in 1998 compared with that in 2002. Data regarding deaths by suicide were obtained from the Central Bureau of Statistics. Annual rates of antidepressant prescribing were computed from the Intercontinental Marketing Services database. The Intercontinental Marketing Services data covers three out of the four Health Maintenance Organizations in Israel, encompassing 46% of all citizens. Prescribing of all antidepressants increased 2.6-fold between 1998 and 2002. This increase was significantly more pronounced for the selective serotonin reuptake inhibitors. A shift in prescription practices was noted, with a 1.37-fold increase in prescribing by primary care physicians. While the concomitant decrease in overall national rates of completed suicide did not reach significance (17-14 per 100,000), the incidence decreased significantly in men aged 55-74 years (33-22 per 100,000; P=0.029). An overall reduction in suicides, which was significant only in elderly men, was noted in association with increased rates of antidepressant prescription. This study is limited in scope but adds a unique viewpoint related to the possible positive effect of increased antidepressant prescribing in primary care on suicide.

Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a systematic review

The role of antidepressants in suicide prevention is a major public health question, given the high prevalence of both depression and depression-related suicidality. Therefore all means available should be utilised to clarify the influence of antidepressants on suicidality. This paper gives a comprehensive overview of the positive effects of antidepressants on suicidality. In the first section, principal methodological issues related to suicidology in general as well as to clinical and epidemiological studies that investigate the influence of antidepressants on suicidality are discussed. In the second section, the results of controlled clinical studies on the efficacy of antidepressants in suicidality are presented. The third section reports on the results of other types of studies, especially epidemiological studies. Altogether, there seems to be reasonable evidence from different research approaches that antidepressants are able to reduce suicidal ideation and also suicidal behaviour in depressive patients. While the evidence for the beneficial effect on suicidal ideation comes from randomised control group studies, some of which used a placebo arm, the evidence for the prophylactic effect on suicidal behaviour, especially suicide, was primarily obtained from well-designed epidemiological studies.

Modeling of the temporal patterns of fluoxetine prescriptions and suicide rates in the United States

BACKGROUND

To study the potential association of antidepressant use and suicide at a population level, we analyzed the associations between suicide rates and dispensing of the prototypic SSRI antidepressant fluoxetine in the United States during the period 1960-2002.

METHODS AND FINDINGS

Sources of data included Centers of Disease Control and US Census Bureau age-adjusted suicide rates since 1960 and numbers of fluoxetine sales in the US, since its introduction in 1988. We conducted statistical analysis of age-adjusted population data and prescription numbers. Suicide rates fluctuated between 12.2 and 13.7 per 100,000 for the entire population from the early 1960s until 1988. Since then, suicide rates have gradually declined, with the lowest value of 10.4 per 100,000 in 2000. This steady decline is significantly associated with increased numbers of fluoxetine prescriptions dispensed from 2,469,000 in 1988 to 33,320,000 in 2002 (r(s) = -0.92; p < 0.001). Mathematical modeling of what suicide rates would have been during the 1988-2002 period based on pre-1988 data indicates that since the introduction of fluoxetine in 1988 through 2002 there has been a cumulative decrease in expected suicide mortality of 33,600 individuals (posterior median, 95% Bayesian credible interval 22,400-45,000).

CONCLUSIONS

The introduction of SSRIs in 1988 has been temporally associated with a substantial reduction in the number of suicides. This effect may have been more apparent in the female population, whom we postulate might have particularly benefited from SSRI treatment. While these types of data cannot lead to conclusions on causality, we suggest here that in the context of untreated depression being the major cause of suicide, antidepressant treatment could have had a contributory role in the reduction of suicide rates in the period 1988-2002.

Relationship between antidepressant sales and secular trends in suicide rates in the Nordic countries

BACKGROUND

The effect of recent increases in antidepressant prescribing on population suicide rates is uncertain.

AIMS

To investigate the relationship between antidepressant sales and trends in suicide rates.

METHOD

Graphical and quantitative assessment of trends in suicide and antidepressant sales in Norway, Sweden, Denmark and Finland.

RESULTS

Suicide rates declined in all four countries during the 1990 s, whereas antidepressant sales increased by 3- to 4-fold. Decreasing suicide rates in Sweden and Denmark preceded the rise in antidepressant sales by over 10 years, although the reductions accelerated between 1988 and 1990. In Norway, a modest but short-lived decline in suicide rates began around the time of the increase in antidepressant sales. In Finland, decreases in male suicide rates and to a lesser extent in female suicide rates began around the time of increased antidepressant sales. In all four countries decreases in suicide rates appeared to precede the widespread use of SSRIs.

CONCLUSIONS

We found mixed evidence that increases in antidepressant sales have coincided with a reduction in the number of suicides in Nordic countries.

Suicide trends in discharged patients with mood disorders: associations with selective serotonin uptake inhibitors and comorbid substance misuse

We determined the rates of suicide in two consecutive time intervals of low and high selective serotonin reuptake inhibitor (SSRI) prescribing for men and women with mood disorders, who were at relatively high risk of suicide, in a discharged hospitalized sample. High quality Swedish national registers were cross-linked to estimate rates of suicide. The results were stratified by three age-bands, and rates of comorbid substance misuse were explored. These were compared with general population suicide rates. There were 1606 suicides in discharged patients with mood disorders. Suicide rates decreased for all women during 1989-94 and 1995-2000 [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.64-0.85] and a trend was found towards lower rates in men (OR = 0.89, 95% CI = 0.78-1.02). Approximately 90% of suicides occurred in those aged over 40 years; thus, the inpatient sample lacked the power to discriminate clear effects in the younger age groups. There was no increase or decrease in the rates of substance use disorders in patients who committed suicide. There were 20 851 suicides in the general population during 1989-2000. Suicide rates were lower at all ages for men and women in the general population in the interval of high SSRI prescribing. We conclude that there is no evidence from this study of an increase in suicide rates following the introduction of SSRIs in the general population or in a high-risk inpatient sample.

ACNP Task Force report on SSRIs and suicidal behavior in youth

This Task Force report by the American College of Neuropsychopharmacology evaluates the safety and efficacy of selective serotonin reuptake inhibitor (SSRIs) antidepressants for depressed youth under 18 years. The report was undertaken after regulatory agencies in the United States and United Kingdom raised concerns in 2003 about the possibility that treatment of depression in children and adolescents with SSRIs may increase the risk of suicidal thinking or suicide attempts.