Antidepressants and Suicide Reexamined

Nassir Ghaemi, MD, Psychiatry/Mental Health, 12:39PM Jun 27, 2010

In the recent NCDEU meeting, Thomas Laughren, the head of the FDA neuropsychopharmacology branch, once again reviewed the question of antidepressants and suicide. In reviewing the published FDA meta-analysis of the randomized clinical trials (RCTs) of antidepressants, he summarized the rather clear finding that antidepressants seemed to have an age-dependent effect on suicide risk: In children and young adults below age 25, they increased the risk (relative risk 2.22 in children and adolescents, 1,55 age 18-24), in later adult years they were neutral (risk 1.00 for age 25-30), and in middle age and in the elderly they were protective (risk 0.77 age 31-64, risk 0.39 above age 65). When all these age groups are summarized, antidepressants have a small protective benefit for suicide (relative risk 0.84, confidence intervals 0.69 to 1.02). In all these analyses, suicidality (defined as actual suicide, suicide attempts, or notable increase in suicidal ideation) is being assessed, one should say, rather than completed suicide. There were only 8 suicides in 77382 subjects, though 2 were on placebo and 6 on antidepressant. Predictors of antidepressant-related suicidality with antidepressants were interesting: Suicide attempts (i.e., actual behavior) were more associated with antidepressants rather than increase in suicidal ideation (thoughts without behavior). Also, non-depressed persons (e.g., studies of antidepressants in other conditions such as anxiety disorders or PTSD) were more likely to be suicidal with antidepressants than those diagnosed with clinical depression (major depressive disorder).

Dr. Laughren also addressed the common critique that adolescent suicides increased after the FDA warning, which led to a decrease in antidepressant prescriptions in children. He reviewed data showing that suicides per 100,000 population for adolescents occurred at rate of 7.3 in 2003, 8.2 in 2004, 7.6 in 2005, and 7.2 in 2006. The FDA warning came out in 2004, but that increase in suicide rates occurred before the decline in antidepressant prescription rates for adolescents, which happened more in 2005 and 2006, corresponding to a decrease in adolescent suicide rates.

It is a not entirely appealing aspect of our profession that we wish to criticize, but not be criticized: Many of us are critical of the pharmaceutical industry, or of diagnosing mental illnesses like bipolar disorder in children, and yet we react angrily when asked to restrain our use of drugs. Instead, we should think seriously about the clear question arising from these data: Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?

# posted by roodbont @ 11:35 PM