selective serotonine reuptake inibitors and suicidal behavior

In the last years a variety of anecdotal studies suggested that treatment with selective sertraline inibitors (SSRIs) (paroxetine, sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine) may induce suicidal behaviours.
Taking into account all methodological difficulties in studying suicidal behaviour in a population of depressed patients (by definition with higher suicide risk than general population), a revision of the literature on this topic ha recently been published. This study finally allows to establish some firm points on the matter:

– Available scientific studies have not shown any increase of suicide risk during the treatment with SSRIs both if compared to placebo, both if compared to other medicines of reference

– Non conclusive data exist about the SSRI paroxetine

– Higher suicide risk does exist in children or teen-agers with depression in comparison with adults, but such risk is not specifically increased by SSRIs

– The rating scales used to assess suicidal ideation show a reduction of scores during SSRIs treatment in all the analyzed samples   

– A data analysis of all the studies completed by the international authorities of study and vigilance about drug treament and suicide risk haven’t demonstrated any statistical difference among the patients treated with SSRIs, with placebo or with other antidepressants

– In the data analyses performed after all literature reviews none of the authors could find any evidence that SSRIs treatment can increase suicide risk

An analysis has recently been effected on this matter by a special task force of Food and Drug Administration (FDA) of the United States to study the relationship among suicidality in the adults and antidepressant treatment.
The numbers drawn from this job are impressive. Vast databases of studies on the use of drugs active on central nervous system with various indications have been checked. The result has been the inclusion of over 372 studies with a total sample of 15,505 subjects per year.
The results clearly pointed out that the risk of suicide did not increase with antidepressant treatment and could not assess any statistically significant difference or meaningful data among treatments.
These conclusions allow some considerations:

In extreme synthesis the more refined epidemiological studies haven’t shown an increase of suicide risk during treatment with antidepressants and particularly with SSRIs , but rather the contrary evidencing a risk reduction with the use of SSRIs and other antidepressants.

The considerations on “..medicines for depression that led patients to commit suicide have to be considered deprived of scientific base.
The proposals to limit the marketing of SSRIs in the youngest patients without any demonstration of the risk (when medicines with as dangerous as documented side effects are commercialized without any limitation) seem to be based on economic (the SSRIs are expensive) and political (to limit psychoactive drugs always make good impression).
These considerations do not mean to somehow lower our vigilance when we have to treat a depressed patient with SSRIs or with any other medicine.
Depression introduces a meaningful risk for suicidal behaviour. physicians and relatives have to keep in mind the necessity of a close follow up of the patient.
The medicine doesn’t replace in any way the good sense and the careful observation that should be the pillars of the good clinical practice in a depressed patient who begins a pharmacologic treatment.

Essential bibliography:

Moller et al “Do antidepressants in general increase suicidality?” Eur Arch Cli Neurosi (2008) 258 (suppl 3) : 3-23

Stone & Jones “Relationship between antidepressant drug and suicide in adults (2006) www.fda.gov/OHRMS/DOCKETS/AC/06/briefing/2006-4272b1-01-FDA.pdf

Hammad et al “Suicidality in pediatric patients treated with antidepressant drugs” Arch Gen Psychiatry 63:332-339

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