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Suicide, Self-Harm Rates, and Antidepressants
Which medications carry the highest risk?
In patients with clinical depression, rates of suicide and self-harm are similar among those treated with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, but higher among those treated with other antidepressants, according to a review of 238,963 patients who were diagnosed with depression.
During an average 5 years follow-up, researchers noted 198 cases of suicide and 5,243 cases of attempted suicide or self-harm. The following hazard ratios (HR) were associated with antidepressant use:
Suicide
• tricyclic antidepressants compared to SSRIs: HR, 0.84
• other antidepressants compared to SSRIs: HR, 2.64
• mirtazpine compared with citalopram: HR, 3.70
Suicide or self-harm
• venlafaxine compared to SSRIs: HR, 1.85
• trazadone compared to SSRIs: HR, 1.73
• mirtazapine compared to SSRIs: HR, 1.70
• amitriptyline compared to SSRIs: HR, 0.71
The absolute risk of suicide ranged from 0.02% for amitriptyline to 0.19% for mirtaxapine.
Citation: Coupland C, Hill T, Morriss R, Arthur A, Moore M, Hippisley-Cox J. Antidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: cohort study using a primary care database. BMJ. 2015;350:h517. doi: 10.1136/bmj.h517.
Commentary: This large study suggests suicide rate may be greater with non-SSRI antidepressant compared to SSRIs. This data is far from solid though, because there are a small number of events and there might be systematic differences in how SSRI and non-SSRI antidepressants are prescribed. For instance, if dual norepinephrine and serotonin agents are prescribed more often to individuals with more severe depression, then the increased suicide risk with use of combined NE/Seretonin angents such as venlafaxine would relate to the severity of the depression treated, not to an effect of the medication. Of importance is that the rate of suicide was increased in the first 28 days after starting an antidepressant and in the 28 days after stopping the antidepressant, times where we should have increased vigilance for suicidal ideations. —Neil Skolnik, M.D.