Updates on Antidepressant Use

SUICIDE, SELF-HARM RATES, AND ANTIDEPRESSANTS
Coupland C, Hill T, Morriss R, et al. 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.

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 significantly higher among those treated with other antidepressants, according to a review of 238,963 patients who were diagnosed with depression.

During an average five 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:

Absolute risk for suicide over one year ranged from 0.02% for amitriptyline to 0.19% for mirtazapine.

COMMENTARY
This large study suggests suicide rates may be greater with non-SSRI antidepressants than with SSRIs. The data are far from solid, though, because of the small number of events and the potential for systematic differences in how these 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 norepinephrine/serotonin agents (eg, venlafaxine) could 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 when we should have increased vigilance for suicidal ideation.