Decrease in suicide among the individuals treated with antidepressants: a controlled study of antidepressants in suicide, Sweden 1995-2005

Existing and Novel Biological Therapeutics in Suicide Prevention

We summarize outcomes for several pharmacologic and neurostimulatory approaches that have been considered potential treatments to reduce suicide risk, namely, by reducing suicide deaths, attempts, and ideation in various clinical populations. Available treatments include clozapine, lithium, antidepressants, antipsychotics, electroconvulsive therapy, and transcranial magnetic stimulation. The novel repurposing of ketamine as a potential suicide risk-mitigating agent in the acute setting is also discussed. Research pathways to better understand and treat suicidal ideation and behavior from a neurobiological perspective are proposed in light of this foundation of information and the limitations and challenges inherent in suicide research. Such pathways include trials of fast-acting medications, registry approaches to identify appropriate patients for trials, identification of biomarkers, neuropsychological vulnerabilities, and endophenotypes through the study of known suicide risk-mitigating agents in hope of determining mechanisms of pathophysiology and the action of protective biological interventions. Reprinted from Am J Prev Med 2014; 47:S195-S203, with permission from Elsevier. Copyright © 2014.

Spatio-Temporal Distribution of Suicide Risk in Iran: A Bayesian Hierarchical analysis of repeated cross-sectional data

Objectives

We aimed to estimate the space-time distribution of the risk of suicide mortality in Iran from 2006 to 2016.

Methods

In this repeated cross-sectional study, the age-standardized risk of suicide mortality from 2006 to 2016 was determined. To estimate the cumulative and temporal risk, the Besag, York, and Mollié and Bernardinelli models were used.

Results

The relative risk of suicide mortality was greater than 1 in 43.0% of Iran’s provinces (posterior probability >0.8; range, 0.46 to 3.93). The spatio-temporal model indicated a high risk of suicide in 36.7% of Iran’s provinces. In addition, significant upward temporal trends in suicide risk were observed in the provinces of Tehran, Fars, Kermanshah, and Gilan. A significantly decreasing pattern of risk was observed for men (β, −0.013; 95% credible interval [CrI], −0.010 to −0.007), and a stable pattern of risk was observed for women (β, −0.001; 95% CrI, −0.010 to 0.007). A decreasing pattern of suicide risk was observed for those aged 15–29 years (β, −0.006; 95% CrI, −0.010 to −0.0001) and 30–49 years (β, −0.001; 95% CrI, −0.018 to −0.002). The risk was stable for those aged >50 years.

Conclusions

The highest risk of suicide mortality was observed in Iran’s northwestern provinces and among Kurdish women. Although a low risk of suicide mortality was observed in the provinces of Tehran, Fars, and Gilan, the risk in these provinces is increasing rapidly compared to other regions.

Risk of Suicidal Behaviors and Antidepressant Exposure Among Children and Adolescents: A Meta-Analysis of Observational Studies

OBJECTIVES

Although several studies have reviewed the suicidal risk of antidepressants, the conclusions remain inconsistent. We, therefore, performed a meta-analysis of observational studies to address the association between exposure to antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and the risk of suicide and suicide attempt in children and adolescents.

METHODS

MEDLINE and Embase were searched from January 1990 to April 2021. Seventeen cohort and case-control studies were identified that reported suicide or suicide attempt in children and young adults (aged 5-25 years) who were exposed to any antidepressants. We extracted the estimates and corresponding 95% confidence intervals (CIs) from each publication.

RESULTS

The results showed that antidepressant exposure significantly increased the risk of suicide and suicide attempt when compared with no antidepressant usage among children and adolescents. The pooled relative risk (RR) was 1.38 (95% CI: 1.16-1.64; I ² = 83.1%). Among the antidepressants, SSRI use was associated with an increased risk of suicide and suicide attempt, and the pooled RR was 1.28 (95% CI: 1.09-1.51; I ² = 68.8%). In subgroup analysis, the attempted suicidal risk of antidepressant and SSRI was significantly increased (RR = 1.35, 95% CI: 1.13-1.61; I ² = 86.2% for all antidepressants; and RR = 1.26, 95% CI: 1.06-1.48; I ² = 73.8% for SSRIs), while the completed suicidal risk of antidepressant and SSRI was not statistically significant (RR = 2.32, 95% CI: 0.82-6.53; I ² = 6.28% for all antidepressants; and RR = 1.88, 95% CI: 0.74-4.79; I ² = 52.0% for SSRIs). In addition, the risk of suicide and suicide attempt between SSRIs and other antidepressants was similar (RR 1.13, 95% CI: 0.87-1.46, I ² = 32.4%).

CONCLUSION

The main findings of this meta-analysis provide some evidence that antidepressant exposure seems to have an increased suicidal risk among children and young adults. Since untreated depression remains one of the largest risk factors for suicide and the efficacy of antidepressants is proven, clinicians should evaluate carefully their patients and be cautious with patients at risk to have treatment emergence or worsening of suicidal ideation (TESI/TWOSI) when prescribing antidepressants to children and young patients.

Effects of somatic treatments on suicidal ideation and completed suicides

OBJECTIVE

This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide.

METHODS

Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides.

RESULTS

Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term.

CONCLUSIONS

Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.

Evaluating the Role of Ketamine/Esketamine in the Management of Major Depressive Disorder with Suicide Risk

Nearly 5% of individuals in the USA had serious thoughts of suicide in 2019 and over 30% of individuals suffering with major depressive disorder reported suicidal ideation with 2 million of those reporting suicidal ideation with some level of intent. However, options to treat depressed individuals considered at imminent risk of suicide remain limited. Until the recent approval of esketamine in the treatment of patients with major depressive disorder with serious suicidal thoughts or actions, no medications had been specifically evaluated for use in this population in the acute setting. This review discusses the history and the current understanding of the role of ketamine and esketamine in depression and suicidal ideation and behavior. It covers some of the pivotal studies in this field and provides a summary of their major findings. The trials of esketamine in patients with major depressive disorder with active suicidal ideation or behavior are the first large-scale trials in patients considered at imminent risk of suicide. As such, the design of these studies is by definition novel, a fact that complicates the interpretation of the data and assessment of the true clinical meaningfulness of the findings. Despite this, the findings in toto draw a consistent picture of benefits that appears to outweigh the potential risks of the treatment. The studies also serve to highlight the complexities and limitations associated with clinical trials aiming to test the ability of novel therapeutics to reduce the burden and risks in patients with suicide ideation and behavior.

Electroconvulsive Therapy and the Risk of Suicide in Hospitalized Patients With Major Depressive Disorder

IMPORTANCE

Electroconvulsive therapy (ECT) is indicated for severe depression, including depression with psychosis, catatonia, and/or an elevated suicide risk. However, the association of ECT with suicide risk is uncertain.

OBJECTIVE

To determine the association between ECT and the risk of suicide in patients with unipolar major depressive disorder.

DESIGN, SETTING, AND PARTICIPANTS

This registry-based cohort study used patient data from Swedish national registers. Patients with a record of inpatient care between January 1, 2012, and October 31, 2018, for moderate depression, severe depression, or severe depression with psychosis were included in the study. Propensity score matching (1:1) was used to balance risk factors for suicide at baseline between patients treated with and without ECT during the inpatient episode.

EXPOSURES

Data from the Swedish National Quality Register for ECT and the Swedish National Inpatient Register were combined to identify patients who had received ECT during the inpatient episode. National registers were used to identify risk factors for suicide.

MAIN OUTCOMES AND MEASURES

Suicide within 3 and 12 months of admission to inpatient care was analyzed. Cox regression analyses were used to adjust for confounders.

RESULTS

The study included 28 557 patients (mean [SD] age, ECT group, 55.9 [18.4] years; non-ECT group, 45.2 [19.2] years; 15 856 women [55.5%]). In the matched sample of 5525 patients in each group, 62 patients (1.1%) in the ECT group and 90 patients (1.6%) in the non-ECT group died of suicide within 12 months (hazard ratio [HR], 0.72; 95% CI, 0.52-0.99). Electroconvulsive therapy was significantly associated with a decreased risk of suicide in patients with psychotic features (HR, 0.20; 95% CI, 0.08-0.54) and those aged 45 to 64 years (HR, 0.54; 95% CI, 0.30-0.99) or 65 years or older (HR, 0.30; 95% CI, 0.15-0.59), but not in patients aged 44 years or younger (HR, 1.22; 95% CI, 0.68-2.16).

CONCLUSIONS AND RELEVANCE

The results of this cohort study support the continued use of ECT to reduce suicide risk in hospitalized patients who are severely depressed, especially those who are older than 45 years and those with a psychotic subtype.

Suicides in Greece before and during the period of austerity by sex and age group: Relationship to unemployment and economic variables

BACKGROUND

There is disagreement on the specific mechanism through which the economic recession increased suicides in Greece. Unemployment is considered by many authors to be the determining factor but the data are inconclusive and often negative, especially concerning the temporal relationship between onset of increase in unemployment and increase in suicides AIMS: The aim of this paper was to clarify the specific role of unemployment as well as of other socioeconomic variables on specific age-by-gender groups concerning the increase in suicides.

METHODS

Data of the Hellenic Statistical Authority ELSTAT (www.

STATISTICS

gr) were analyzed with Linear Regression Analysis and Bonferroni correction for multiple testing RESULTS: Unemployment correlates with suicide rates only in males aged 20-24, 50-54 and 60-64 years (p < 0.001). Unemployment could held responsible for an additional 148 male deaths during the period 2009-2015, which accounts for 5.3% of the total (29 additional deaths per year). The changes in all the socioeconomic conditions could held responsible for 317 cases of suicide or 9.4% of total CONCLUSIONS: The results of the current study suggest that there was a 33% increase in deaths by suicide in Greece during the early years of recession (2009-2015); one third could be directly attributed to unemployment, one third to other consequences of recession while another third is of unknown origin. The effect of unemployment is specifically restricted to males at the beginning of their working career (20-24 years old) and to middle aged (45-49 and 55-59 years old).

Comparisons of the risk of medication noncompliance and suicidal behavior among patients with depressive disorders using different monotherapy antidepressants in Taiwan: A nationwide population-based retrospective cohort study

BACKGROUND

The aim of this study was to assess the association between various classes of antidepressants and the risk of medication noncompliance as well as suicidal behavior among depressed patients.

METHODS

A retrospective cohort study was conducted utilizing two nationwide population-based datasets in Taiwan from 2010 to 2016. The outcome measures included the risk of medication noncompliance, attempted suicide, and completed suicide. Cox proportional hazards models with stratification of the propensity score deciles were performed.

RESULTS

A total of 447,411 new antidepressant users were identified. Compared to SSRIs, patients who received SARIs [adjusted hazard ratio (aHR) = 1.124, 95% confidence interval (CI) = 1.108-1.142], SNRIs (aHR = 1.049, 95% CI = 1.033-1.065), and other classes of antidepressants (aHR = 1.037, 95% CI = 1.024-1.051) were more likely to exhibit poor medication noncompliance. Patients who received SNRIs had a higher risk of attempted suicide (aHR = 1.294, 95% CI = 1.114-1.513), compared to SSRIs. However, patents in the TCAs group revealed the opposite result (aHR = 0.543, 95% CI = 0.387-0.762). Concerning the risk of completed suicide, this analysis detected no statistical significance across different types of antidepressants.

LIMITATIONS

Although the universal coverage of Taiwan's national health insurance program tends to minimize the risk of selection and recall bias, it is difficult to rule out medical surveillance bias by using claim data.

CONCLUSIONS

This study demonstrated that classes of antidepressants exert different degrees of impact on the risk of medication noncompliance and attempted suicide, but not completed suicide, among depressed patients.

Antidepressant sales and regional variations of suicide mortality in Germany

Suicides account for over one million deaths per year worldwide with depression among the most important risk factors. Epidemiological research into the relationship between antidepressant utilization and suicide mortality has shown heterogeneous and contradictory results. Different methodological approaches and limitations could at least partially explain varying results. This is the first study assessing the association of suicide mortality and antidepressant sales across Germany using complex statistical approaches in order to control for possible confounding factors including spatial dependency of data. German suicide counts were analyzed on a district level (n = 402) utilizing ecological Poisson regressions within a hierarchical Bayesian framework. Due to significant spatial effects between adjacent districts spatial models were calculated in addition to a baseline non-spatial model. Models were adjusted for several confounders including socioeconomic variables, quality of psychosocial care, and depression prevalence. Separate analyses were performed for Eastern and Western Germany and for different classes of antidepressants (SSRIs and TCAs). Overall antidepressant sales were significantly negatively associated with suicide mortality in the non-spatial baseline model, while after adjusting for spatially structured and unstructured effects the association turned out to be insignificant. In sub-analyses, analogue results were found for SSRIs and TCAs separately. Suicide risk shows a distinct heterogeneous pattern with a pronounced relative risk in Southeast Germany. In conclusion, the results reflect the heterogeneous findings of previous studies on the association between suicide mortality and antidepressant sales and point to the complexity of this hypothesized link. Furthermore, the findings support tailored suicide preventive efforts within high risk areas.

Antidepressant use in suicides: a case-control study from the Friuli Venezia Giulia Region, Italy, 2005-2014

PURPOSE

To compare the use of antidepressant (AD) classes and compounds in individuals who committed suicide and in controls from the general population and to assess to what extent adherence and current use of different AD classes can affect the risk of committing suicide.

METHODS

Individual data on suicide, diagnoses and AD use in Friuli Venezia Giulia from 2005 to 2014 were obtained from the Regional Social and Health Information System. All suicides that had at least one prescription of AD in the 730 days before death (N = 876) were included as cases. Each case was matched with regard to age and sex with five controls from the general population. The association between suicide and AD use was assessed using conditional logistic regression analysis.

RESULTS

Almost 70% of all suicides occurring in the10-year period had been prescribed AD. Selective serotonin reuptake inhibitors (SSRIs) accounted for more than the 90% of the prescriptions, with paroxetine the most prescribed AD. All AD compounds and classes were not associated with a higher suicide risk, with the exception of SSRI (OR = 1.6). A decreasing trend in suicide risk was observed when adherent subjects or current AD users were compared to the others.

CONCLUSIONS

AD treatment is an important factor for preventing suicide, since the use of AD at adequate dosage and for a proper duration was associated with a lower suicide risk. The proper use of AD should be ascertained by physicians, particularly in a primary care context.

Suicide prevention strategies revisited: 10-year systematic review

BACKGROUND

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

METHODS

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

FINDINGS

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

INTERPRETATION

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

FUNDING

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

SUICIDAL DEPRESSED PATIENTS RESPOND LESS WELL TO ANTIDEPRESSANTS IN THE SHORT TERM

BACKGROUND

Suicidal thoughts and behaviors could be associated to a poor response to antidepressant treatment, but the exclusion of suicidal patients from randomized clinical trials restricts the available knowledge. In this study, we aimed at defining more precisely the response to antidepressants among suicidal patients and the threshold of suicidality that best predicts a poor response.

METHOD

We investigated the short-term response to a new antidepressant treatment of 4,041 depressed outpatients depending on their suicidal status (passive or active suicidal ideation (SI), history of suicide attempts [SAs]), either self-rated or clinician-rated. Depression outcomes, measured with the Hospital Anxiety and Depression Scale, and remission rates were compared depending on suicidal status at baseline using logistic regression models.

RESULTS

Using either a qualitative or a quantitative approach to measure SI, we found that suicidal patients were less likely to improve or attain remission, but not more likely to worsen, than nonsuicidal patients. In the multivariate analyses, SI (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.18-1.65) and a history of SA (OR = 1.39; 95% CI: 1.16-1.66) were the best predictors of nonremission, independently of the class of antidepressant treatment.

CONCLUSION

Antidepressant treatment seems to be less effective among those patients that need it most. Clinical trials including suicidal patients are needed to investigate specific treatment options.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008

OBJECTIVE

To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals.

METHODS

Case-control study based on a health register.

RESULTS

Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide.

CONCLUSIONS

Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

Serotonergic medication enhances the association between suicide and sunshine

BACKGROUND

An association between suicide and sunshine has been reported. The effect of sunshine on hormones and neurotransmitters such as serotonin has been hypothesized to exert a possible triggering effect on susceptible individuals. The aim of this study is to examine if there is an association between sunshine and suicide, adjusting for season, and if such an association differs between individuals on different antidepressants.

METHODS

By using Swedish Registers and the Swedish Meteorological and Hydrological Institute we obtained information, including forensic data on antidepressive medication for 12,448 suicides and data on monthly sunshine duration. The association between monthly suicide and sunshine hours was examined with Poisson regression analyses while stratifying for sex and age and controlling for time trend and season. These analyses were repeated in different groups of antidepressant treatment.

RESULTS

We found a significantly increased suicide risk with increasing sunshine in both men and women. This finding disappeared when we adjusted for season. Among both men and women treated with selective serotonin reuptake inhibitors (SSRIs) there was a positive association between sunshine and suicide even after adjustment for season and time trend for suicide. Pair comparisons showed that the sunshine-suicide association was stronger among men treated with SSRIs compared to other antidepressant medications or no medication at all.

LIMITATIONS

Other meteorological factors were not controlled (i.e. temperature) for in the analyses.

CONCLUSIONS

There is an enhanced association between sunshine and suicide among those with SSRI medication, even after adjusting for season. This may have interesting theoretical and clinical implications.

Antidepressant use and the risk of suicide: a population-based cohort study

BACKGROUND

The existing literature provides contradictory evidence on antidepressant use and risk of suicide. Some studies have shown that the use of Selective Serotonin Reuptake Inhibitors (SSRIs) is associated with an increased risk of suicide, especially during the first months of treatment, whereas other studies did not confirm this association. For this reason, our objective was to investigate the association between antidepressant use and risk of suicide in incident antidepressant users in relation to time since starting therapy.

METHODS

We conducted a population-based cohort study within the Dutch Integrated Primary Care Information (IPCI) database, in incident users of antidepressant therapy between 1994 and 2012 (n=27,712). Cox proportional hazard models were used to study the association between current use of SSRIs, tricyclic antidepressants (TCA) and other antidepressants and risk of suicide or attempted suicide.

RESULTS

During follow-up, a total of 280 incident antidepressant users attempted or committed suicide. Current use of SSRIs (hazard ratio (HR): 0.78, 95% CI: 0.57-1.07), TCAs (HR: 0.82, 95% CI: 0.48-1.42) or other antidepressants (HR: 0.75, 95% CI: 0.47-1.18) was not statistically significantly associated with suicide compared to past use of any of the antidepressants.

LIMITATIONS

Although a large healthcare database was used, the number of reported cases of suicide (attempt) was low.

CONCLUSIONS

This study did not indicate an increase in risk of suicide after starting treatment with SSRIs, TCAs or other antidepressants compared with past antidepressant use.

Relationship of suicide rates to economic variables in Europe: 2000-2011

BACKGROUND

It is unclear whether there is a direct link between economic crises and changes in suicide rates.

AIMS

The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates.

METHOD

Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation.

RESULTS

There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged.

CONCLUSIONS

Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Poor response to antidepressants predicts new suicidal ideas and behavior in depressed outpatients

BACKGROUND

Only a few studies have investigated the factors associated with suicidal behavior after antidepressant treatment onset in adults. We examined the specific predictors of de novo suicidal ideas or attempts among depressed patients in the community, including subjects potentially at risk of suicidal behaviors, who initiated a new antidepressant treatment.

METHODS

A large set of GPs and psychiatrists throughout France followed-up, for 6 weeks, 4357 outpatients for whom an antidepressant drug was prescribed. Dimensions related with antidepressant-induced suicidal events, such as depression, anxiety or hopelessness, were assessed longitudinally using univariate and multivariate approaches among subjects with treatment-emergent suicide ideation or attempts.

RESULTS

New suicidal ideas were observed in 9% of patients with no suicidal ideation at baseline (n=81), while suicidal attempts were reported for 1.7% of the sample during the 6-week observation period (n=75). The onset of suicidal ideas and attempts was associated with the initial features of the patients (baseline level of anxiety, past history of suicide attempts and alcohol misuse) and the non-improvement of depression. Worsening of depressive symptoms during the follow-up increased the onset of new suicidal ideas (OR=5.67, p<0.001) and attempts (OR=2.60, p=0.002), corresponding to 67.5% and 56.5% of attributable risk respectively.

CONCLUSIONS

When the analyses are restricted to the occurrence of suicidal ideas or attempts, the link between antidepressants and suicide risk might be more adequately explained by a poor response to antidepressant treatment rather than by a direct trigger-effect. This naturalistic study is limited by the use of non-structured diagnoses and self-report outcomes.

Social inequalities in suicide: the role of selective serotonin reuptake inhibitors

We aimed to examine the relationship between socioeconomic status (SES) and suicide associated with the introduction and diffusion of selective serotonin reuptake inhibitors (SSRIs). Negative binomial regression was used to estimate county-level suicide rates among persons aged 25 years or older using death certificate data collated by the National Center for Health Statistics from 1968 to 2009; SES was measured using the decennial US Census. The National Health and Nutrition Examination Survey and the Medical Expenditure Panel Survey were used to measure SSRI use. Once SSRIs became available in 1988, a 1% increase in SSRI usage was associated with a 0.5% lower suicide rate. Prior to the introduction of SSRIs, SES was not related to suicide. However, with each 1% increase in SSRI use, a 1-standard deviation (SD) higher SES was associated with a 0.6% lower suicide rate. In 2009, persons living in counties with SES 1 SD above the national average were 13.6% less likely to commit suicide than those living in counties with SES 1 SD below the national average--a difference of 1.9/100,000 adults aged ≥25 years. Higher SSRI use was associated with lower suicide rates among US residents aged ≥25 years; however, SES inequalities modified the association between SSRI use and suicide.

Existing and novel biological therapeutics in suicide prevention

We summarize outcomes for several pharmacologic and neurostimulatory approaches that have been considered potential treatments to reduce suicide risk, namely, by reducing suicide deaths, attempts, and ideation in various clinical populations. Available treatments include clozapine, lithium, antidepressants, antipsychotics, electroconvulsive therapy, and transcranial magnetic stimulation. The novel repurposing of ketamine as a potential suicide risk-mitigating agent in the acute setting is also discussed. Research pathways to better understand and treat suicidal ideation and behavior from a neurobiological perspective are proposed in light of this foundation of information and the limitations and challenges inherent in suicide research. Such pathways include trials of fast-acting medications, registry approaches to identify appropriate patients for trials, identification of biomarkers, neuropsychological vulnerabilities, and endophenotypes through the study of known suicide risk-mitigating agents in hope of determining mechanisms of pathophysiology and the action of protective biological interventions.

Antidepressant drugs and the risk of suicide in children and adolescents

Government agencies have issued warnings about the use of antidepressant medications in children, adolescents, and young adults since 2003. The statements warn that such medications may cause de novo 'suicidality' in some people. This review explores the data on the treatment of depression that led to these warnings and subsequent data that are relevant to the warnings. It also addresses the effectiveness of antidepressant treatment in general and the relationship of suicide rates to antidepressant treatment. It concludes that the decisions for the 'black box' warnings were based on biased data and invalid assumptions. Furthermore, the decisions were unsupported by the observational data regarding suicide in young people that existed in 2003. The following recommendations would seem to follow from these observations. First, drug authorities should re-evaluate the basis for their imposed warnings on antidepressant medicines, and analyze the actual public health consequences the warnings have had. In the absence of substantial evidence supporting the warnings, they should be removed. Second, physicians and other providers with prescription privileges should continue to be educated regarding the importance of aggressively treating depression in young people, using antidepressants when indicated. Third, physicians and other professionals who treat depressed young people must always be aware of the risk of suicide (albeit quite low) and observe them closely for any signs of increased risk of suicide. This is necessary regardless of the type of treatment being provided.

Antidepressants and the risk of suicide in young persons--prescription trends and toxicological analyses

OBJECTIVE

To assess trends in the use of antidepressants among young suicides after the warning that these drugs might increase the risk of suicide.

METHOD

Individual data of all 845 suicides in the 10- to 19-year age group in Sweden in the time period 1992-2003 (baseline), and in 2004-2010 (after the warning). Outcome data are prescriptions of antidepressants prior to death and detections of antidepressants in post-mortem toxicology.

RESULTS

After the warning, suicide in this age group increased for five consecutive years (60.5%). The increase occurred among individuals not treated with antidepressants.

CONCLUSION

This study provides further support for the hypothesis that the warning, contrary to its intention, may have increased young suicides by leaving a number of suicidal young persons without treatment with antidepressants.

Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study

BACKGROUND

More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population.

METHOD

We used data from a national cohort study of 7,140,589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide.

RESULTS

There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men.

CONCLUSIONS

All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.

Toxicology findings in suicides: concentrations of ethanol and other drugs in femoral blood in victims of hanging and poisoning in relation to age and gender of the deceased

Over-consumption of alcohol and/or abuse of other drugs are closely linked to attempted or completed suicides. In this retrospective 10-year study (2001-2010), we compared the toxicology findings in hanging suicides (n = 4551) with drug poisoning (intoxication) suicides (n = 2468). The mean age of hanging deaths was 49 ± 19 y (±SD) and 80% were male, compared with a mean age of 52 ± 17 y and 47% males for the intoxication deaths. Poly-drug use was more common in poisoning suicides with an average of 3.6 drugs/case compared with 1.8 drugs/case in hangings. Moreover, 31% of hangings were negative for alcohol and/or drugs. Alcohol was detected (>0.20 g/L) in femoral blood in 30% of hanging suicides (mean 1.39 g/L) and 36% of drug poisonings (mean 1.39 g/L). The median BACs did not depend on the person's age or gender (p > 0.05). Ethanol, paracetamol, citalopram, diazepam, propiomazine, alimemazine and zopiclone were amongst the top-ten drugs detected in both methods of suicide. With the exception of ethanol, the concentrations of drugs in blood were considerably higher in the poisoning deaths, as might be expected. Regardless of the method of suicide, antidepressants and/or antipsychotics were common findings, which could implicate mental health as a significant suicide risk factor.

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.

A longitudinal population-based study exploring treatment utilization and suicidal ideation and behavior in major depressive disorder

BACKGROUND

This study aimed to longitudinally examine the relationship between treatment utilization and suicidal behavior among people with major depressive disorder in a nationally representative sample.

METHODS

Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Wave 1: N=43,093; Wave 2: N=34,653). Suicidal and non-suicidal individuals at Wave 1 were compared based on subsequent treatment utilization. Suicidal behavior at Wave 2 was compared between people with major depressive disorder who had sought treatment at Wave 1 versus those that had not.

RESULTS

Individuals with past year major depressive disorder at Wave 1 who attempted suicide were more likely to be hospitalized at follow up compared to non-suicidal people with major depressive disorder [adjusted odds ratio (AOR)=4.46; 95% confidence interval [95% CI]: 2.54-7.85]; however, they were not more likely to seek other forms of treatment. Among those with past year major depressive disorder who sought treatment at baseline, visiting an emergency room (AOR=3.08; 95% CI: 1.61-5.89) and being hospitalized (AOR=2.41; 95% CI: 1.13-5.14), was associated with an increased likelihood of attempting suicide within 3 years even after adjusting for mental disorder comorbidity, depression severity, and previous suicidal behavior.

LIMITATIONS

Unable to draw conclusions about completed suicide or adequacy of treatment.

CONCLUSIONS

Suicidal behavior does not lead individuals with major depressive disorder to seek treatment with professionals or use antidepressant medications; instead, they are more likely to use emergency services. These findings suggest that treatment efforts for people with major depressive disorder who are suicidal need improvement.

Exposure to prescription drugs labeled for risk of adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide, 2006-2009

Prescription drugs for many indications are labeled with warnings for potential risk of suicidal ideation or behavior. Exposures to prescription drugs labeled for adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide between 2006 and 2009 are described. Air Force registry data were linked to administrative prescription data. Descriptive statistics illustrate utilization: 89 personnel had a prescription history, 35 filled at least one prescription labeled with a warning, 26 had antidepressants on hand at death, and 2 died by drug overdose. Most airmen were not exposed to any prescriptions labeled for risk of suicidal ideation or behavior prior to death by suicide.

A 10-year analysis of the effects of media coverage of regulatory warnings on antidepressant use in The Netherlands and UK

Background

In 2003–2004 and 2007–2008, the regulatory banning of SSRI use in pediatrics and young adults due to concerns regarding suicidality risk coincided with negative media coverage. SSRI use trends were analyzed from 2000–2010 in the Netherlands (NL) and the UK, and whether trend changes might be associated with media coverage of regulatory warnings.

Methods

Monthly SSRIs sales were presented as DDDs/1000 inhabitants/day. SSRI-use trends were studied using time-series segmented regression analyses. Timing of trend changes was compared with two periods of media coverage of warnings. Annual Dutch SSRI prescription data were analyzed by age group.

Results

Trend changes in SSRI use largely corroborated with the periods of media coverage of warnings. British SSRI use declined from 3.9 to 0.7 DDDs/month (95%CI 3.3;4.5 & 0.5;0.9, respectively) before the first warning period (2003–2004). A small decrease of −0.6 DDDs/month (−1.2; −0.05) was observed in Dutch SSRI use shortly after 2003–2004. From 2007–2008, British SSRI use stabilized, whilst Dutch SSRI use diminished to −0.04 DDDs/month (−0.4;0.3). Stratified analyses showed a rapid decrease of −1.2 DDDs/month (−2.1; −1.7) in UK paroxetine use before 2003–2004, but only a minimal change in Dutch paroxetine use (−0.3 DDDs/month −0.8;0.2). Other SSRI use, especially (es)citalopram, increased during 2003–2004 in both countries. Significant reductions in Dutch paroxetine use were observed in pediatrics, adolescents, and young adults after 2003–2004.

Conclusion

Changes in SSRI use (NL & UK) were associated with the timing of the combined effect of media coverage and regulatory warnings. Our long-term assessment illustrates that changes in SSRI use were temporal, drug-specific and more pronounced in pediatrics and young adults. The twofold increase in SSRI use over one decade indicates that regulatory warnings and media coverage may come and go, but they do not have a significant impact on the overall upward trend of SSRI use as a class in both countries.

Should we treat depression with drugs or psychological interventions? A reply to Ioannidis

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy. Our most important criticism is Ioannidis' basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found. We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary.

Brain functional changes (QEEG cordance) and worsening suicidal ideation and mood symptoms during antidepressant treatment

OBJECTIVE

Antidepressant medications are efficacious overall; however, some individuals experience worsening mood symptoms and increased suicidal ideation (SI) during treatment. We examined the quantitative electroencephalographic (QEEG) cordance biomarker of brain function biomarker in relation to treatment-emergent symptom worsening.

METHOD

Seventy-two major depressive disorder (MDD) subjects were treated with fluoxetine 20 mg (n = 13), venlafaxine 150 mg (n = 24), or placebo (n = 35) under double-blind conditions. Behavioral ratings determined whether each subject demonstrated worsening of depressed mood, anxiety, or SI during treatment. QEEG cordance data were analyzed to determine whether symptom worsening was associated with neurophysiological changes.

RESULTS

Antidepressant treatment-emergent SI (13.5%) was associated with a large transient decrease in midline-and-right-frontal (MRF) cordance 48 h after start of medication.

CONCLUSION

Hypothesis-generating results suggest a pattern of functional changes in midline and right frontal brain regions associated with antidepressant treatment-emergent SI in MDD.

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.

The evolution of depression and suicidality in first episode psychosis

OBJECTIVE

To have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms.

METHOD

Ninety-two patients with first episode psychosis (FEP) completed measures of depression, including prodromal depression, self-harm and duration of untreated psychosis. Follow-up took place over 12 months.

RESULTS

Depression occurred in 80% of patients at one or more phases of FEP; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm.

CONCLUSION

Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking. Efforts to predict and reduce depression and deliberate self-harm in psychosis may need to target this early phase to reduce later risk.

The increased use of antidepressants has contributed to the worldwide reduction in suicide rates

Numerous ecological studies have shown an inverse association between antidepressant use and suicide rates and a smaller number of individual-based studies have shown an association between current antidepressant use and reduced suicide risk. Such evidence is often cited in support of the notion that antidepressants prevent suicide. However, more recently, the premises underlying this proposition, namely that suicide is caused by depression and that antidepressants relieve depression, have been challenged and the potential harm caused by antidepressants has been highlighted. In this article, Goran Isacsson and Charles Rich debate with Jon Jureidini and Melissa Raven the motion that the increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

Indicators of pretreatment suicidal ideation in adults with major depressive disorder

OBJECTIVE

In order to evaluate the presence of treatment emergent suicidal ideation (SI), it becomes necessary to identify those patients with SI at the onset of treatment. The purpose of this report is to identify sociodemographic and clinical features that are associated with SI in major depressive disorder (MDD) patients prior to treatment with a selective serotonin reuptake inhibitor.

METHOD

This multisite study enrolled 265 out-patients with non-psychotic MDD. Sociodemographic and clinical features of participants with and without SI were compared post hoc.

RESULTS

Social phobia, bulimia nervosa, number of past depressive episodes, and race were independently associated with SI by one or more SI measure.

CONCLUSION

Concurrent social phobia and bulimia nervosa may be potential risk factors for SI in patients with non-psychotic MDD. Additionally, patients with more than one past depressive episode may also be at increased risk of SI.

Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years' data

CONTEXT

A US Food and Drug Administration advisory has warned that antidepressants may be associated with an increased risk of suicidal thoughts and behaviors in adolescents. This prompted a meta-analysis of trials in adults that found no overall increase in risk, but individual agents could not be studied.

OBJECTIVE

To assess the risk of suicide and suicide attempts associated with individual antidepressant agents.

DESIGN

Cohort study of incident users of antidepressant agents.

SETTING

Population-based health care utilization data of all residents of British Columbia, Canada, aged 18 years and older between January 1, 1997, and December 31, 2005.

PATIENTS

British Columbia residents who had antidepressant therapy initiated and had a recorded diagnosis of depression.

INTERVENTION

Initiation of various antidepressant medications.

MAIN OUTCOME MEASURES

Combined suicide death or hospitalization due to self-harm.

RESULTS

In a population of 287,543 adults aged 18 years and older with antidepressant therapy initiated, we observed outcome rates ranging from 4.41/1000 person-years to 9.09/1000 person-years. Most events occurred in the first 6 months after treatment initiation. After extensive propensity score adjustment, we found no clinically meaningful variation in the risk of suicide and suicide attempt between antidepressant agents compared with fluoxetine hydrochloride initiation: citalopram hydrobromide, hazard ratio = 1.00 (95% confidence interval, 0.63-1.57); fluvoxamine maleate, hazard ratio = 0.98 (95% confidence interval, 0.63-1.51); paroxetine hydrochloride, hazard ratio = 1.02 (95% confidence interval, 0.77-1.35); and sertraline hydrochloride, hazard ratio = 0.75 (95% confidence interval, 0.53-1.05). Compared with selective serotonin reuptake inhibitors as a drug class, other classes including serotonin-norepinephrine reuptake inhibitors, tricyclic agents, and other newer and atypical agents had a similar risk. Restriction to patients with no antidepressant use in the past 3 years further reduced apparent differences between groups.

CONCLUSIONS

Our finding of equal event rates across antidepressant agents supports the US Food and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent.

Gender differences in antidepressant use-related seasonality change in suicide mortality in Hungary, 1998-2006

OBJECTIVES

Studies show that the seasonality of suicide (spring/early summer peak, winter low) is mainly the consequence of the seasonal incidence of depression-related suicides. The aim of the present study was to analyse the relationship between increasing antidepressant utilization and national suicide rate of Hungary between 1998 and 2006, with particular regard to seasonal patterns and gender differences.

METHODS

Time trend analysis (ARIMA) had been applied to investigate the correlation between the trend of antidepressant prescription and both of suicide rates and seasonality index.

RESULTS

During the 9 years of the study period there was a significant (P<0.001) correlation between the steadily increasing antidepressant prescription (113%) and continuous decline in total national suicide rate (23%) as well as both in females and males (21 and 23%, respectively), but this relationship was 8-fold stronger in males. Increasing antidepressant utilization was associated with significantly decreased seasonality of suicides only among males.

CONCLUSIONS

The results suggest that decreasing seasonality of suicides could be a good marker of lowering rate of depression-related suicides in the population particularly among males.

Youth suicide prevention: does access to care matter?

PURPOSE OF REVIEW

Recent increases in adolescent suicide rates after a decade of decline highlight the relevance of pediatric suicide prevention. Existing strategies to intervene with youth at risk for suicide are largely based on the premise that access to effective services is of critical importance. This review aims to examine the relationship between youth suicide and access to care.

RECENT FINDINGS

Promising reductions in suicidal thinking and behavior have been associated with the application of manualized psychotherapies, collaborative interventions in primary care, lithium for mood-disordered adults, and clozapine in schizophrenia. Suicide rates correlate inversely with indices of care access across the lifespan, including antidepressant prescription rates.

SUMMARY

Suicide is a preventable cause of death, and any public health relevant effort to prevent youth suicide must include improving access to effective care for at-risk youth as a strategy. Education and training of professionals and consumers, the integration of mental health services in primary care, and the use of novel technologies to track and maintain contact with at-risk youth are worthy of study. Additional research on the relationship between specific treatments, especially antidepressants, and youth suicide risk reduction is desperately needed.