Use of antidepressants among people committing suicide in Sweden

Antidepressants and suicide mortality

BACKGROUND

This paper presents a nationwide analysis of suicide mortality in Finland from 1990 to 1995, when the total use of antidepressants, especially that by selective serotonin reuptake inhibitors (SSRIs) expanded in the country.

METHODS

Suicide rate was analysed by various methods including that by intake of antidepressants. Various antidepressants were compared by calculating fatal toxicity indices (FTI) by relating number of fatal poisonings by a drug to its consumption.

RESULTS

The expanded use of antidepressants coincided with an increased number of deaths caused by these drugs. The proportion of suicides committed by use of antidepressants among all suicides increased from 5.6% to 8.4%. The total suicide rate, however, declined significantly. This was mainly accounted for by the reduced suicide rates by hanging and carbomonoxide poisoning, which outnumbered the increased figures of suicides by poisoning. On the whole, 82% of suicides by antidepressants were committed by use of tricyclics. Use of doxepin and amitriptyline remained steady, and their FTIs were constantly high. The lowest FTIs were associated with fluoxetine, citalopram, mianserin and moclobemide.

LIMITATIONS

The method ignores causality between the increased use of SSRIs and suicide mortality. Various factors affecting risk of suicide or choice of a method remain outside the scope of the data.

CONCLUSION

The increased use of SSRIs coincided with a significant decline in suicide mortality. However, suicides by use of antidepressants showed an upward trend. Therefore, in suicide prevention, risks and benefits of antidepressants should be considered in choosing treatment for depressive patients.

Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification

A comparative study of 174 homicidal and 105 suicidal sharp force deaths in the Stockholm area is presented in order to identify variables of importance in the differentiation between homicides and suicides. In homicides, a significantly (p < 0.05) higher number of cut and stab wounds were seen in the head, upper and lower extremities and a significantly higher number of vertical stab wounds were found in the chest. Lower numbers were seen in the wrist and the crook of the arm. When counting the injured areas, irrespective of the number of injuries, abdominal wounds and horizontal chest stab wounds were also significantly more often found in victims of homicide. Injuries to the back and to the genitals were not seen in suicides. The suicide victims were significantly older and had significantly lower blood alcohol levels. A new variable pointing at a statistically significant difference between homicides and suicides was found: In homicides, stab wounds with a horizontal axis of entrance wound in the chest was found to be less common than those with a vertical axis. Other variables studied were prevalence of defence and tentative wounds, farewell notes and suicidal ideation, earlier parasuicides, venue, gender of the victims and the types of sharp objects used.

Risk of suicide attempts after benzodiazepine and/or antidepressant use

PURPOSE

Recent publications imply the existence of associations between psychotropic drugs use and risk of suicide. Some studies have measured the tissue level of these drugs in suicide deaths, while others compared toxicity indices, defined as number of suicide deaths per million prescriptions for individual antidepressants. Few of these studies used unexposed controls. The objective of this cohort study was to evaluate suicide attempts in subjects recently exposed to benzodiazepines and/or antidepressants, as compared to unexposed controls.

METHODS

A population of 225,796 persons with prescriptions for benzodiazepines were selected from the Saskatchewan Health Data Bases. Controls consisted of 97,862 individuals who did not receive benzodiazepines.

RESULTS

Stratifying the populations into antidepressant users and non-antidepressant users indicated that nonantidepressant users had statistically significant associations between suicide attempts and benzodiazepine use (odds ratio (OR) = 6.2), antipsychotic use, (OR = 2.6), and a history of past treatment for drug/alcohol abuse (OR = 13.4). Antidepressant users showed a statistically significant relation only with past treatment for drug/alcohol use (OR = 5.8). It is argued that the large OR for antidepressant use is due to confounding by indication. If so, the concept of toxicity index is misleading and should not be used.

CONCLUSIONS

The association between benzodiazepine use and attempted suicide is especially high for nonantidepressant users, for the young, and for males. Whether this relationship is causal or not, physicians should be aware of the high potential for suicide attempts when prescribing benzodiazepines for patients in these high risk groups.

Advantages and limitations of the concept of antidepressant therapy

The current availability of a range of effective treatments make it more than ever necessary for depression to be recognised. The emphasis of treatment has moved from acute episodes to the longitudinal course of affective disorders. In addition to Major Depressive Disorder, the need for treatment is now established in less severe variants, particularly Dysthymia; the same drugs are applicable, but should be part of a global strategy. In general, antidepressants have to be considered in relation to non-pharmacological treatment methods, of which the most important is ECT. A great variety of new drugs have been found to have antidepressant efficacy, but pharmacologically this action is not a specific or exclusive one. Side-effects have on the whole not been studied for long enough, or in depressed patients rather than healthy volunteers; there are marked variations between individuals in their reactions to different drugs. Co-morbidity is a frequent issue in the treatment of depression, particularly for the elderly. Since overall suicide rates have not fallen in many countries, the treatment particularly of Major Depressive Disorder and Bipolar Disorder needs to be strengthened.

Suicide and antidepressants in south Alabama: evidence for improved treatment of depression

The purpose of this study was to investigate the occurrence of antidepressants among suicides in the era since the introduction of newer less toxic antidepressants. Comprehensive post mortem toxicological examinations were performed on 94% of certain and uncertain suicides in Mobile County, Alabama, between October 1, 1990 and September 30, 1995. Comparisons were made between current data from Mobile and data from the San Diego study in 1981-83. About twice as many suicides in Mobile were positive for antidepressants than in San Diego (15% vs. 8%). The proportions of antidepressant overdose deaths were the same (5%), however. Antidepressants were found in significantly fewer males than females and blacks than whites in Mobile. Although antidepressants were found in a greater proportion of people who committed suicide in Mobile, they were not used more frequently as a means of suicide. The authors conclude that this may represent improvement in care received by people with depression. It remains to be determined what suicide preventive effects individual antidepressants or groups of antidepressants may have.

The utilization of antidepressants--a key issue in the prevention of suicide: an analysis of 5281 suicides in Sweden during the period 1992-1994

Antidepressants detected by the National Department of Forensic Chemistry in 5281 suicides in Sweden during the period 1992-1994 were related to data on usage expressed in person-years of exposure. Antidepressants were detected in 874 subjects (16.5%). In relation to their use, fluvoxamine, citalopram, moclobemide, mianserin and trimipramine were found more often than the reference drug, amitriptyline (i.e. over-risks). Toxic concentrations of antidepressants were detected in 232 subjects (4.4%). Most people committing suicide were not taking antidepressants immediately before their death, even though 40-85% may have been depressed. Undertreatment and therapeutic failure are the main problems with antidepressants, not the risk of using antidepressants in overdose. Comparisons of new antidepressants should focus on efficacy in relation to reference tricyclics. The huge increase in the use of antidepressants in Sweden since 1990-1991 has been paralleled by a significant decrease in suicide rates.

Drugs taken in fatal and non-fatal self-poisoning: a study in south London

This study compared the number and type of substances taken in deliberate self-poisoning with fatal (n = 127) and non-fatal (n = 521) outcome. The aims were (i) to describe substances typically involved in self-poisoning in England and Wales, (ii) to examine the role of drug "cocktails' and (iii) to examine whether toxic substances are over-represented in cases with fatal outcome. Over-the-counter (OTC) analgesics, minor tranquillizers and antidepressants accounted for about 70% of substances taken, irrespective of outcome. Compared with survivors, cases who died had taken a higher mean number of substances. Among self-poisonings with a single substance, antidepressants and paracetamol-opiate combinations were over-represented in fatal-outcome cases. This report emphasizes the role of OTC analgesics and antidepressants in overdose-related mortality in England and Wales.

Which antidepressant? A commentary from general practice on evidence-based medicine and health economics

BACKGROUND

With increasing demand for health care, evidence-based medicine combined with health economics offers a method of optimizing allocation of limited resources. Depression is an illness that has a high prevalence with important medical, social and economic implications. More than 90% of depression is diagnosed and treated in general practice.

AIM

To review the effectiveness of an evidence-based approach combined with health economics in deciding whether a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) should be used in the treatment of depression in general practice.

METHOD

An evidence-based strategy tested the two treatments against the criteria of appropriateness, efficacy, effectiveness and value for money.

RESULTS

Although both drugs were equally efficacious, their relative effectiveness and value for money could not be accurately defined.

CONCLUSION

An evidence-based approach does not make clear whether SSRIs or TCAs should be used for the treatment of depression in general practice. Research questions arising from general practice should be addressed in a relevant setting and should yield answers that will complement and support a more pragmatic system of medicine rather than seek to direct it.

Acute medical costs of fluoxetine versus tricyclic antidepressants. A prospective multicentre study of antidepressant drug overdoses

Despite demonstrated differences in toxicity profiles between tricyclic antidepressants (TCAs) and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), no studies have examined hospital costs associated with acute antidepressant overdoses. Given the high incidence of such overdoses, it is important to examine treatment patterns and associated costs. This prospective, multicentre cohort study compared the hospital and physician costs associated with TCA and fluoxetine drug overdoses. Over a 30-month period, 622 consecutive patients with a fluoxetine or TCA overdose presented to the emergency departments, or were admitted to intensive care or medical units, of 9 participating medical centres across the US. Inclusion criteria were: ingestion of a single antidepressant (fluoxetine or a TCA), without clinically significant co-ingestants; laboratory confirmation of the overdose; and retrievable hospital bills. Patients were followed until discharge from the emergency department or hospital. Hospital and physician charges were collected from billing data. Hospital charges were adjusted using Health Care Financing Administration cost: charge ratios to estimate costs; physician charges were adjusted to estimate costs. Patient demographic and clinical data were prospectively gathered during the course of medical treatment. Clinical data recorded included level of consciousness, cardiopulmonary complications, vital sign or ECG abnormalities, agitation, seizures, CNS depression and death. 136 patients (121 with TCA overdose and 15 with fluoxetine overdose), representing 21.8% of the 622 patients entered, met the inclusion criteria. Mean length of stay varied from 0.73 [+/-standard error of the mean (SEM) 0.33] days for fluoxetine overdose patients to 3.59 (+/-SEM 0.48) days for TCA overdose patients (p = 0.038). Mean hospital costs were $US668 for patients with a fluoxetine overdose compared with $US4691 for those with a TCA overdose (p < 0.0001). No significant differences were observed between the TCA and fluoxetine overdose groups with regard to physician costs. Median hospital and physician costs increased from $US3029 to $US4396 from the first 15-month period of the study to the second 15-month period of the study for the TCA overdose group, but decreased from $US881 to $US396 for the fluoxetine overdose group. Patients with fluoxetine overdoses had lower hospital and total medical costs compared with patients with TCA overdoses. There was some evidence supporting a reduction in the medical costs of treating fluoxetine overdoses over the 30-month study period.

Prevention of depression and suicide by education and medication: impact on male suicidality. An update from the Gotland study

Depression is an endemic disease with high morbidity, and a high mortality in depression-related suicide. Suicidal tendencies, especially among males, are increasing today in East European countries. General practitioners are considered to have a very important role in the prevention and treatment of depression. Matters of depression are more openly discussed in society. Patients showing up in primary care are nowadays less reluctant to see depression as a causative factor behind their symptoms. Taboos concerning the stigma of depression and suicidality are weaker. In spite of this, important problems still exist regarding poor diagnostic and treatment routines in primary care and the inability of depressive and suicidal men to seek for help or to be recognized. In the years 1983-1984, the Swedish Committee for Prevention and Treatment of Depression (PTD) offered an educational programme to all general practitioners (GPs) on the Swedish island of Gotland. During the 1980s this education was shown to lead to a significant decrease in inpatient care, morbidity, suicide, mortality and costs of depressive illness on the island. The use of anxiolytic and sedative medication decreased and that of antidepressant medication increased. This all showed that an educational programme in primary care on depression and suicide was effective. However, the effects faded and, unexpectedly, the number of male suicides was almost unaffected by the educational programme and by the GPs' ability to diagnose and treat depression. Repeated educational activities during the 1990s again led to a decrease in suicides, mainly in females. Also, the increase in antidepressant prescriptions following GP education in the 1990s was mostly in the treatment of female patients. One of the reasons was that few suicidal males are known to the medical services although many of these people are known to the police and social welfare services. The reasons why depressed and suicidal men do not show up in the medical services are discussed, and found to lie in the differences between the male and the female depressive syndrome, leading to difficulties in reaching, diagnosing and treating these patients. Strategies for finding and treating suicidal depressives are discussed. One conclusion is that males are as often depressed as females, but in different ways, and that one of the reasons behind the dramatic over-representation of males amongst suicide victims may be found in the low rate of diagnosis and treatment of the male depressive syndrome, (hit J Psych Clin Pract 1997; 1: 39-46).

Epidemiological data suggest antidepressants reduce suicide risk among depressives

In spite of the availability of antidepressant medication for several decades, it has not been shown that such medication lowers the risk for suicide in depressed patients. This report explores this apparent paradox by means of pharmacoepidemiological methods. Data on the prevalence of depression in the population and among suicides as well as data on the prevalence of antidepressant medication in depressed suicides were obtained from a review of the literature. Data on the prevalence of antidepressant medication in the population in 1990-1991 were obtained from the statistics of the Swedish National Corporation of Pharmacies. It was found that only one in five depressed individuals with major depression were treated with antidepressants in Sweden. The calculated risk for suicide among depressed patients who were treated with antidepressants was 141 per 100,000 person years and, among the untreated, 259 per 100,000 person years (i.e., 1.8 times higher among the untreated). This supports the hypothesis that antidepressant medication decreases the risk for suicide in depressed patients. The reason this has not been obvious in the general suicide statistics seems to be that so few depressed people are treated with antidepressants. Effective suicide prevention strategies should include intensive efforts to recognize and treat more depressed people.

Are suicide rates in Sweden associated with changes in the prescribing of medicines?

A key issue in the debate on suicide prevention is the extent to which suicide rates are affected by the availability of means of committing suicide. The aim of this study was to analyse the changes in rates of suicides committed by poisoning in Sweden between 1969 and 1992, and to determine to what extent these were associated with changes in the prescribing of medicines. We compared suicide rates from 1969 to 1992 with trends in the sales of antidepressants, barbiturates, neuroleptics and analgesics during the same period. The incidence of suicide by poisoning decreased during the 1970s, especially in younger and middle-aged men. This was mainly due to a decrease in suicides by barbiturate poisoning, which closely followed a decrease in sales of barbiturates. Sales of analgesics and antidepressants increased during the study period, and so did the rates of suicide using these drugs. We conclude that the availability of medicines is an important factor influencing suicide rates, and that changes in the prescribing of medicines may influence suicide rates.

Alcohol and drugs in suicides

BACKGROUND

Alcohol and drugs use were assessed in a nationwide one year suicide study in Finland.

METHOD

Alcohol and drugs use were analysed in 1348 suicides, 96.5% of all suicides in the study year. Relative suicide risks for drugs were defined by relating the number of suicides committed by use of various drugs to drug availability.

RESULTS

Alcohol was detected twice as often in men as in women; the opposite was the case with drugs. The drugs most commonly used for suicide were neuroleptics and antidepressants, which were, in 74.3% and 77.4% of the cases, respectively, the victims own prescribed drugs. Antidepressants were found in 19.0% of women and only 4.8% of men. Relative suicide risk for antidepressants varied substantially between different compounds.

CONCLUSIONS

Undertreatment of depression is a challenge for suicide prevention. Those who commit suicide by antidepressants use their own drugs. Relative suicide risk for a drug should be considered when choosing treatment for depressive patients.

Increased risk of suicide with exposure to pesticides in an intensive agricultural area. A 12-year retrospective study

Several reports have suggested that exposure to agricultural pesticides (mainly chronic exposure to organophosphates) produces depression, and depression is a major risk factor for suicide. A retrospective epidemiological study of 251 suicide cases was undertaken to explore the possible relationship between the high suicide rates in an intensive agricultural area, and a specific group of population at risk, namely farmers with chronic exposure to pesticides, who are at risk to develop mood disorders (mainly depression). Our data show that the suicide rate in that area is significantly higher than the suicide rates from other geographic areas with very similar socioeconomic and demographic features. In addition, the mortality from suicide in this population (farmers) does differ significantly from that of the rest of the population.

The treatment of depression: prescribing patterns of antidepressants in primary care in the UK

BACKGROUND

Consensus has been achieved about how depression should be treated in primary care, and guidelines have been issued by the Royal Colleges of General Practitioners and Psychiatrists, and by the British Association for Psychopharmacology. One of the principal recommendations is to prescribe antidepressant medicine at effective doses. This study was established to investigate how current prescribing practices in primary care compared with these guidelines.

METHOD

Information on prescribing of antidepressant medicines was obtained using three independent data sources: Prescribing Analysis and Cost (PACT) data; medical notes; and a large, computerised patient record database.

RESULTS

Data were obtained on populations in excess of 1.5 million people, and over 80,000 prescriptions were reviewed. All three data sources showed very similar patterns of prescribing, in particular that as many as 88% of prescriptions for older tricyclic antidepressants are prescribed by GPs at doses below those recommended by the consensus guidelines. Newer antidepressants-lofepramine and the SSRIs-are prescribed comparatively well.

CONCLUSIONS

Prescribing of antidepressants by GPs is not in line with the consensus recommendations on dosage. This may have major educational implications for GPs. A pragmatic approach to improve prescribing in the short term may be to advocate the use of lofepramine or the SSRIs as first line treatment for depression. This study validates the use of PACT data as a useful audit tool in this area of clinical practice.

Prevention of suicide in old age

The prevention of suicide in old age has received little attention, despite suicide rates being highest in older men. About 90% of older people who attempt or complete suicide have a mental disorder, usually depression, which often has been inadequately treated. Other treatable contributing factors include pain, grief, loneliness, alcoholism and carer stress. Few suicides in older people occur in the context of terminal illness or can be regarded as "rational". Educational programs are required to improve the recognition and treatment of depression in primary care.

One hundred cases of suicide in elderly people

BACKGROUND

The White Paper The Health of the Nation targets a reduction in suicide rates. Preventive strategies must be guided by an understanding of the demography and antecedents of suicide. These issues are examined in relation to suicide by old people in Manchester.

METHOD

One hundred consecutive coroners' inquisitions on people aged over 65 occurring between 1980 and 1991 in which the verdict was suicide were scrutinised and related to Health Service notes.

RESULTS

Suicides were rare, numbers ranging from 0 to seven per annum per Health District. Rates did not vary between district but did within smaller sub-populations. Most individuals died at home; 65% were physically ill, of whom 23% had been hospitalised within the previous year. At least 60% were clinically depressed, with 25% being prescribed antidepressants. A total of 43% had seen their general practitioner in the previous month but only 14% were in contact with psychiatric services.

CONCLUSIONS

Many elderly people who commit suicide are not in close contact with primary care services; those who are may not be prescribed appropriate treatment, and few are referred for specialist care. Specialist services will fail to reduce suicide rates unless they embark upon programmes to increase public awareness of therapeutic possibilities and work more closely with primary care agencies to realise these possibilities.

Antidepressants and suicide

OBJECTIVE

To estimate the rate and means of suicide among people taking 10 commonly prescribed antidepressant drugs: dothiepin, amitriptyline, clomipramine, imipramine, flupenthixol, lofepramine, mianserin, fluoxetine, doxepin, and trazodone.

DESIGN

Open cohort study with a nested case-control analysis.

SETTING

General practices in the United Kingdom that used VAMP computers to maintain their patient records from January 1988 to February 1993.

SUBJECTS

172,598 people who had at least one prescription for one of the 10 antidepressants during the study period.

MAIN OUTCOME MEASURE

Suicide confirmed by general practitioner or on death certificate, or both.

RESULTS

143 people committed suicide. The overall rate of suicide was estimated to be 8.5 per 10,000 person years (95% confidence interval 7.2 to 10.0). Rates of suicide were higher in men than women (relative risk 2.8 (95% confidence interval 1.9 to 4.0)), people with a history of feeling suicidal (19.2 (9.5 to 38.7)), and people who had taken several different antidepressants (2.8 (1.8 to 4.3)). People who received high doses of antidepressants and those who had had a prescription in the 30 days before they committed suicide were also at higher risk than those who had received low doses and had had their prescriptions 30 or more days previously (2.3 (1.4 to 3.7) and 2.3 (1.6 to 3.4)) respectively. Rates of suicide were higher in patients who received fluoxetine, but this may be explained by selection biases which were present for those drug users.

CONCLUSION

Several factors correlate with the risk of suicide in people taking antidepressants. After controlling for these factors, the risk of suicide was similar among the 10 study antidepressants. Overdose with antidepressants accounted for only 14% of the suicides.

Relative mortality from overdose of antidepressants

OBJECTIVE

To compare the fatal toxicities of antidepressant drugs in 1987-92.

DESIGN

Retrospective epidemiological review of prescription data of the Department of Health, Scottish Office Home and Health Department, and Welsh Health Common Services Authority (excluding data from most private general practices and most hospitals), and mortality data from the Office of Population Censuses and Surveys and General Register Office in Scotland.

SETTING

General practice, England, Scotland, and Wales.

MAIN OUTCOME MEASURES

Deaths per million prescriptions and deaths per defined daily dose.

RESULTS

81.6% (1310/1606) of deaths from antidepressant overdose were due to two drugs, amitriptyline and dothiepin. The overall average of deaths per million prescriptions was 30.1. The overall rate for tricyclic drugs was 34.14 (95% confidence interval 32.47 to 38.86; P < 0.001), monoamine oxidase inhibitors 13.48 (6.93 to 22.19; P < 0.001), atypical drugs 6.19 (4.04 to 8.80; P < 0.001), and selective serotonin reuptake inhibitors 2.02 (0.64 to 4.17; P < 0.001). The numbers of deaths per million prescriptions of amoxapine, dothiepin, and amitriptyline were significantly higher than expected, while nine drugs had a significantly lower number of deaths per million prescriptions than expected. Analysis of deaths per defined daily dose showed a similar pattern.

CONCLUSIONS

Safety in overdose should be considered in risk-benefit and cost-benefit considerations of antidepressants. A switch in prescribing, from drugs with a high number of deaths per million prescriptions to drugs with a low number, could reduce the numbers of deaths from overdose. Although this form of suicide prevention can be implemented easily and immediately, its introduction needs to be considered against the higher costs of some of the newer drugs.

Choice of antidepressants: questionnaire survey of psychiatrists and general practitioners in two areas of Sweden

OBJECTIVE

To identify factors that affect physicians' choice of specific antidepressant drugs in order to evaluate the validity of epidemiological studies of the risks (particularly suicide) and benefits of different compounds.

DESIGN

Questionnaire survey of 264 psychiatrists and general practitioners in an urban area and a rural area of Sweden with validation of data by independent prescription surveys.

SETTING

Urban area of greater Stockholm and rural county of Jämtland, Sweden.

SUBJECTS

228 physicians (86%) who answered the questionnaire.

MAIN OUTCOME MEASURES

The drugs used as first line drugs of choice, as drugs of choice in particularly severe depression, and as drugs of choice for disorders other than depression.

RESULTS

Amitriptyline was the most common first line drug of choice among both psychiatrists and general practitioners. The patterns of choice of antidepressants in the two areas accorded with prescribing patterns in two independent prescription surveys. Amitriptyline was chosen even more frequently for severe depression and depression with severe insomnia. Clomipramine was chosen comparatively more often for depression with severe anxiety. Low toxicity compounds (mainly lofepramine, mianserin, and moclobemide) were more often the drug of choice in depression associated with overt risk of suicide. Amitriptyline and clomipramine were used extensively for disorders other than depression (40% and 54% of prescriptions, compared with 13-19% for some other major antidepressants).

CONCLUSION

Patient groups treated with different antidepressant compounds may not be comparable with respect to diagnoses and severity of disease. In particular, lofepramine, mianserin, and moclobemide, and possibly amitriptyline, seem to be chosen more often for patients prone to suicide.

Antidepressants, depression and suicide: an analysis of the San Diego study

Depression has been consistently reported in 40-50% of suicides. Previous toxicologic studies of suicides have not included diagnostic information, however. This report includes 247 (87%) of 283 suicides in whom it was possible to perform toxicological analyses for tricyclic antidepressants. We wanted to see if any relationships existed among the presence of antidepressants at autopsy, diagnosis of Depression, recent contact with physicians and prescription of antidepressant medication. Toxicology was positive in 19 (8%) subjects. Only 12% of the subjects with a DSM-III diagnosis of Major or Atypical Depression were positive. Lethal blood levels of antidepressants were found in only 4% of all subjects and most of those involved multiple drugs. Also, most of those subjects had co-morbid Depression and Substance Abuse. More than half of the Depressed subjects had seen a physician within 90 days from suicide but less than half of these were prescribed antidepressants and only one-third of the latter were positive for antidepressants in toxicology. These data suggest that more suicides might be averted by decisively treating Depressed patients with ADs, including strict monitoring of dosage and compliance, than by not treating them to avoid AD overdoses. Diagnostic caution should be observed to identify co-morbid Substance Abuse when treating patients with Depression and suicidal ideation.

Fluoxetine

Fluoxetine was developed as an antidepressant drug. It is more effective than placebo, but a dose-effect relation has not been established. Fluoxetine is almost as effective as tricyclic antidepressant drugs, but the available studies do not allow accurate comparisons. Fluoxetine may be less effective than tricyclic antidepressant drugs for the treatment of inpatients with severe melancholic depression, and it should not be the first choice of a drug for them. Fluoxetine may be most appropriate for patients with moderate depression who can be treated as outpatients. If there is little improvement after treatment for four to six weeks, an alternative treatment should be offered. Fluoxetine does not have the anticholinergic, hypotensive, and sedative effects of tricyclic antidepressant drugs and has no particular cardiovascular effects; overdoses do not cause serious toxic effects. Nausea, anorexia, insomnia, and nervousness--the most common side effects--may be controlled with a careful adjustment to the dose. Clinically important drug interactions may occur with monoamine oxidase inhibitors, tricyclic antidepressant drugs, and other drugs. The published data on the antidepressant effect of fluoxetine do not fully explain its popularity. One may speculate that fluoxetine has psychobiologic effects not strictly related to the biology of depression and that it acts primarily as a mood- or affect-modulating agent.