Reduction of suicidal thoughts with paroxetine in comparison with reference antidepressants and placebo

Effects of selective serotonin reuptake inhibitors (SSRIs) on suicide: A network meta-analysis of double-blind randomized trials

The relationship between the use of selective serotonin reuptake inhibitors (SSRIs) and suicide risk in patients with mental disorders remains controversial. We conducted a network meta-analysis to examine the effects of SSRIs on suicide risk in patients with mental disorders. A comprehensive search was conducted across PubMed, Web of Science, PsycINFO, CENTRAL, Wanfang Database, and China National Knowledge Infrastructure for articles published until December 19, 2023. The main outcomes were suicidal ideation and instances of suicidal behavior. We included 29 double-blind randomized trials in our analysis. The findings suggest that SSRIs primarily offer short-term protection against suicidal ideation. By week 2, paroxetine, fluoxetine, escitalopram, and non-SSRI treatments were linked to a decreased suicide risk compared with a placebo, with the exception of sertraline. This protective effect was diminished by week 8. In contrast, studies on instances of suicidal behavior from weeks 1 to 10 found no significant difference in efficacy between SSRIs, non-SSRIs, and placebo. These results indicate that SSRIs may offer short-term protection against suicidal ideation. However, their long-term effectiveness in mitigating suicidal ideation and preventing suicidal behaviors is limited.

Evaluating the Role of Ketamine/Esketamine in the Management of Major Depressive Disorder with Suicide Risk

Nearly 5% of individuals in the USA had serious thoughts of suicide in 2019 and over 30% of individuals suffering with major depressive disorder reported suicidal ideation with 2 million of those reporting suicidal ideation with some level of intent. However, options to treat depressed individuals considered at imminent risk of suicide remain limited. Until the recent approval of esketamine in the treatment of patients with major depressive disorder with serious suicidal thoughts or actions, no medications had been specifically evaluated for use in this population in the acute setting. This review discusses the history and the current understanding of the role of ketamine and esketamine in depression and suicidal ideation and behavior. It covers some of the pivotal studies in this field and provides a summary of their major findings. The trials of esketamine in patients with major depressive disorder with active suicidal ideation or behavior are the first large-scale trials in patients considered at imminent risk of suicide. As such, the design of these studies is by definition novel, a fact that complicates the interpretation of the data and assessment of the true clinical meaningfulness of the findings. Despite this, the findings in toto draw a consistent picture of benefits that appears to outweigh the potential risks of the treatment. The studies also serve to highlight the complexities and limitations associated with clinical trials aiming to test the ability of novel therapeutics to reduce the burden and risks in patients with suicide ideation and behavior.

The acute antisuicidal effects of single-dose intravenous ketamine and intranasal esketamine in individuals with major depression and bipolar disorders: A systematic review and meta-analysis

The efficacy of ketamine in reducing suicidal ideation (SI) has been previously reported. We aimed to evaluate acute anti-SI effects of single-dose ketamine in different formulations/routes of administration by pooling results from randomized controlled trials (RCTs). A systematic search was conducted on Cochrane, Embase, Medline, and PubMed from inception to July 1st, 2020. Studies were selected based on pre-determined eligibility criteria. Effect sizes of different formulations/routes at various time points were computed using random-effects models. With data from nine eligible RCTs (n = 197), the pooled effect size for anti-SI effects at the 24-h time point was 1.035 (N = 6, CI: 0.793 to 1.277, p < 0.001) for intravenous (IV) racemic ketamine and 1.309 (N = 1, CI: 0.857 to 1.761, p < 0.001) for intranasal (IN) esketamine. An additional five RCTs were available for qualitative analysis. RCTs were identified for oral/sublingual ketamine for depression, however, none of these trials reported anti-SI effects preventing quantitative analysis for these routes of delivery. No RCTs for intramuscular (IM) ketamine were identified. The findings suggest that single-dose IV ketamine/IN esketamine is associated with robust reductions in suicidal thoughts at 2-h, 4-h, and 24-h post-intervention. In addition, future studies on IM/oral/sublingual ketamine and comparative studies are warranted to evaluate the anti-SI efficacy of distinct formulations and routes of administration.

Major Depression and the Degree of Suicidality: Results of the European Group for the Study of Resistant Depression (GSRD)

BACKGROUND

This European multicenter study aimed to elucidate suicidality in major depressive disorder. Previous surveys suggest a prevalence of suicidality in major depressive disorder of ≥50%, but little is known about the association of different degrees of suicidality with socio-demographic, psychosocial, and clinical characteristics.

METHODS

We stratified 1410 major depressive disorder patients into 3 categories of suicidality based on the Hamilton Rating Scale for Depression item 3 (suicidality) ratings (0=no suicidality; 1-2=mild/moderate suicidality; 3-4=severe suicidality). Chi-squared tests, analyses of covariance, and Spearman correlation analyses were applied for the data analyses.

RESULTS

The prevalence rate of suicidality in major depressive disorder amounted to 46.67% (Hamilton Rating Scale for Depression item 3 score ≥1). 53.33% were allocated into the no, 38.44% into the mild/moderate, and 8.23% into the severe suicidality patient group. Due to the stratification of our major depressive disorder patient sample according to different levels of suicidality, we identified some socio-demographic, psychosocial, and clinical variables differentiating from the patient group without suicidality already in presence of mild/moderate suicidality (depressive symptom severity, treatment resistance, psychotic features, add-on medications in general), whereas others separated only when severe suicidality was manifest (inpatient treatment, augmentation with antipsychotics and benzodiazepines, melancholic features, somatic comorbidities).

CONCLUSIONS

As even mild/moderate suicidality is associated with a failure of achieving treatment response, adequate recognition of this condition should be ensured in the clinical practice.

Use of Prescription Medication by Individuals Who Died by Suicide in Northern Ireland

To understand medication use prior to suicide in relation to patterns, polypharmacy, and adherence. A total of 1,371 suicide cases were coded and latent class analysis used to identify combinations of medications prescribed prior to death. Two thirds had been prescribed medication with 30.7% prescribed 3 or more. Latent class analysis revealed three classes: Mixed medication use, primarily mental medication use, and baseline/low medication use. There are potentially high rates of medication non-adherence. Not only medication use but also non-adherence rates were high in this sample of individuals who died by suicide. Potential implications and areas for future research are discussed.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Pharmacological interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm.

OBJECTIVES

To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.

SELECTION CRITERIA

We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

Suicidal behaviour and cognitive problem solving therapy: theory, application and review

Suicidal behaviour is a major public health problem worldwide, both with regard to mortality and treatment of clients who have deliberately harmed themselves. It is a multifaceted problem resulting from complex interactions between social, biological and psychological factors. There is insufficient evidence on which to make firm recommendations about the most effective forms of treatment This is remarkable considering the extent of the problem worldwide, and the importance of dealing with it appropriately in order to prevent further suicides.

Antidepressant therapy in severe depression may have different effects on ego-dystonic and ego-syntonic suicidal ideation

The objective of the present study was to investigate whether ego-dystonic and ego-syntonic suicidal ideation occurred at different frequencies during antidepressant therapy. A blind evaluation has been performed on records of 100 suicides with a primary severe depression and 100 matched controls, admitted to the Department of Psychiatry, Lund, Sweden. Ego-dystonic suicidal ideation was more commonly reported during adequate treatment as compared to ego-syntonic ideation (P = .004). Men who committed suicide during adequate antidepressant therapy more often reported ego-dystonic suicidal ideation earlier in their lives compared with those who were not treated (P = .0377). This may indicate that treatment failure for ego-dystonic ideation was a precursor of their suicides. Consequently, ego-dystonic ideation seems to show a poorer response to antidepressant therapy as compared to ego-syntonic ideation, which may be more directly related to depression. Ego-dystonic ideation is proposed to be related to depressive psychosis.

Clinical correlates of the worsening or emergence of suicidal ideation during SSRI treatment of depression: an examination of citalopram in the STAR*D study

BACKGROUND

Untreated major depressive disorder (MDD) is a major risk factor for suicide, but some data suggest antidepressants may be associated with increased suicidal ideation (SI) in some depressed patients. The purpose of this study was to determine whether, and in whom, treatment of MDD is associated with increased or emergent SI.

METHODS

Patients were treated with Citalopram, 10-60 mg/day for 12-14 weeks. A score >0 on Item 12 of the Quick Inventory of Depressive Symptomatology - Self-Report indicated the presence of SI. Worsening was defined by a >or=1 point increase. Emergent SI was defined by an increase from 0 at baseline to >or=1 during treatment.

RESULTS

Of the 1909 participants with baseline SI, 57% experienced improvement in SI by their first post-baseline visit and 5% worsened. By the final visit, 74% experienced improvement and 4% worsened. Of 1721 participants without baseline SI, 7% experienced emergence by the first postbaseline visit. Of these, 63% had no SI at their final visit. Major risk factors for treatment-emergent SI at the first treatment visit were drug abuse, severe depression and melancholic features.

LIMITATIONS

Main limitations are lack of a comparison group to help pinpoint whether citalopram treatment added risk or protection, a placebo group to determine whether changes in SI were related to illness factors, medication effects or other factors, and more detailed and validated measures of SI.

CONCLUSIONS

SI and behaviors, core features of MDD, wax and wane in intensity before, during, and perhaps after treatment. It is clinically important to understand risk factors, maintain careful surveillance and treat as vigorously as necessary to attain remission.

A stubborn behaviour: The failure of antidepressants to reduce suicide rates

Over the past decades the rate of completed suicide has remained quite stable, that of suicide attempts even seems to have increased (to the extent it has been studied in defined regions). These are puzzling observations, since depression is the major suicide precursor and since antidepressants over the years have been increasingly used in the treatment of depression. These observations have not attracted sufficient attention, possibly because they do not accord with consensus opinions about depression treatment in psychiatry today. In this paper a number of possible explanations are discussed. They not only deserve but are definitely in need of systematic investigation.

Do SSRIs or antidepressants in general increase suicidality? WPA Section on Pharmacopsychiatry: consensus statement

In the past few years several papers have reported critically on the risk of suicidal thoughts and behaviour associated with antidepressants, primarily SSRIs. The risk-benefit ratio of antidepressant (AD) treatment has been questioned especially in children and adolescents. The critical publications led to warnings being issued by regulatory authorities such as the FDA, MHRA and EMEA and stimulated new research activity in this field. However, potential harmful effects of antidepressants on suicidality are difficult to investigate in empirical studies because these have several methodological limitations. Randomised controlled trials (RCTs) are the most reliable way to test the hypothesis that AD have such side effects. In addition to meta-analyses of RCTs, complementary research methods should be applied to obtain the most comprehensive information. We undertook a comprehensive review of publications related to the topics ADs, suicide, suicidality, suicidal behaviour and aggression. Based on this comprehensive review we conclude that ADs, including SSRIs, carry a small risk of inducing suicidal thoughts and suicide attempts, in age groups below 25 years, the risk reducing further at the age of about 30-40 years. This risk has to be balanced against the well-known beneficial effects of ADs on depressive and other symptoms (anxiety, panic, obsessive-compulsive symptoms), including suicidality and suicidal behaviour. According to the principles of good clinical practice, decision making should consider carefully the beneficial effects of AD treatment as well as potentially harmful effects and attempt to keep the potential risks of AD treatment to a minimum. It is the major problem facing efforts to identify the possible 'suicidal effects' of antidepressants.

Assessing the role of drugs in suicidal ideation and suicidality

The emergence of suicidal ideation and suicide-related behaviour in patients receiving drug treatment is of concern because of the overall burden of these conditions and the possible link with completed suicide. Observational studies have been useful in generating hypotheses of causality but are confounded by the association between various disease states and increased suicide-related behaviour and completed suicide. The demonstration of causality requires experimental studies, especially randomised controlled trials, and meta-analyses. Unfortunately, the lack of uniform requirements for defining, detecting and recording suicidal ideation, suicide-related behaviour and completed suicide creates difficulties in comparing studies. Nevertheless, there is evidence of an association between SSRIs and other newer antidepressant drugs and treatment-emergent suicidal ideation and suicide-related behaviour in both children and adults; however, an increase in completed suicide as a result of treatment with SSRIs and other newer antidepressant drugs has not been demonstrated. Atomoxetine has also been associated with treatment-emergent suicidality, based on the results of a meta-analysis. Although similar associations have been proposed for some antiepileptic drugs, isotretinoin and interferon-alpha, they are yet to be supported by evidence from randomised controlled trials or meta-analyses.

Is there evidence for negative effects of antidepressants on suicidality in depressive patients? A systematic review

The role of antidepressants in suicide prevention is a major public health question given the high prevalence of both depression and depression-related suicidality. Therefore all available means should be utilised to clarify the influence of antidepressants on suicidality, especially in view of the ongoing intensive debate about possible suicidality-inducing effects of antidepressants that may outweigh their traditionally hypothesised beneficial effects. This paper gives a systematic and comprehensive review of the empirical data which might indicate that antidepressants have negative effects on suicidality. First, principal methodological issues related to this research question are discussed. Thereafter, the results of controlled trials and epidemiological and cohort studies are presented. Altogether, there seems to be only a small amount of evidence from different research approaches that antidepressants, not only serotonin reuptake inhibitors (SSRIs), might induce, aggravate or increase the risk of suicidal ideation and suicide attempts. As to suicide, there are no hints in this direction. TCAs have a higher risk of fatal outcome in overdose compared to SSRIs, which, in case of mono-intoxication, carry almost no risk of lethal consequences. The ongoing discussion about suicidality-inducing effects should not prevent physicians from prescribing SSRIs and other antidepressants to their patients if they are clinically indicated. However, they should take into account potential risks and manage them by good clinical practice.

The national suicide prevention strategy for England: the reality of a national strategy for the nursing profession

Suicide is recognized as a global phenomenon and many countries now have national suicide prevention strategies. International guidance on suicide prevention and accepted epidemiological and treatment-based research underpins healthcare policy relating to suicide reduction. There has been an established comprehensive strategy in England since 2002. However, the rate of suicide continues to be a concern and nurses hold a key role in the implementation of national, regional and local policy into practice. The aim of this paper is to consider the current implications of the national suicide prevention strategy in England for nursing. This discussion paper draws upon both empirical evidence-based literature, governmental guidance and policy-related documentation. The national suicide prevention strategy for England currently continues to have a multifaceted impact on the nursing profession. This ranges from clinical practice issues such as risk assessment through to broader public health responsibilities. If nurses and allied health professionals are to be effective in their role within suicide prevention, they will need to be supported in building awareness of the wider context of the national policy. In particular, this will mean working effectively and collaboratively with the voluntary sector, service users and other non-medical agencies.

Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness

BACKGROUND

Suicidal ideation is likely to represent a phase preceding suicidal acts among most suicidal patients with major depressive disorder (MDD). Factors predicting reversal of the suicidal process are unknown. Our aim was to test the hypothesis that a decline in suicidal ideation is preceded by a decline in hopelessness among patients with MDD.

METHOD

Of the 269 Vantaa Depression Study patients with DSM-IV MDD, 103 patients scored > or = 6 points at baseline on the Scale for Suicidal Ideation (SSI). Seventy of these patients were followed-up weekly either until they scored zero points on the SSI, or up to 26 weeks.

RESULTS

The median duration for a decline of suicidal ideation to zero was 2.2 months after baseline. The level of baseline suicidal ideation, depressive symptoms, and the presence of any personality disorder predicted duration of suicidal ideation. A decline in both depression (BDI) and hopelessness (HS) independently predicted a decline in suicidal ideation.

LIMITATIONS

Due to study design, we do not know if suicidal ideation relapsed after the first time the patient reached zero score in the SSI.

CONCLUSIONS

Among patients with major depressive disorder having suicidal ideation, the decline in suicidal ideation is independently predicted by preceding declines in the levels of both depressive symptoms as well as hopelessness. The findings are consistent with possible causal roles of declines in depression and hopelessness in reversing the suicidal process.

Did regulators fail over selective serotonin reuptake inhibitors?

Controversy over the safety of antidepressants has shaken public confidence. Were mistakes made and could they have been avoided?

Long-term treatment and suicidal behavior in severe depression: ECT and antidepressant pharmacotherapy may have different effects on the occurrence and seriousness of suicide attempts

Our objective in this article is to assess the relation between long-term treatments of depressive episodes and attempted or completed suicide in patients who had had a severe depression at index admission. A blind record evaluation of 96 suicides with a primary severe depression and matched controls has been performed. Out of those, 57 and 33, respectively, had made suicide attempts. Occurrence of attempt was less common after electroconvulsive therapy (ECT). However, seriousness of suicide attempt appeared to be reduced in those with at least 4 weeks of antidepressant medication compared to no treatment and ECT. The theory of a suicidal syndrome independent of depression seems supported. Continuation treatment after ECT is recommended.

ACNP Task Force report on SSRIs and suicidal behavior in youth

This Task Force report by the American College of Neuropsychopharmacology evaluates the safety and efficacy of selective serotonin reuptake inhibitor (SSRIs) antidepressants for depressed youth under 18 years. The report was undertaken after regulatory agencies in the United States and United Kingdom raised concerns in 2003 about the possibility that treatment of depression in children and adolescents with SSRIs may increase the risk of suicidal thinking or suicide attempts.

Why do we need new and better antidepressants?

The range of available antidepressants is reviewed in relation to mechanisms of action and the evidence of efficacy in general and efficacy in severe depression in particular. In studies investigating efficacy in major depressive disorder, not all antidepressants have been shown to have clear-cut efficacy in severe depression. Here, the minimum standards for the necessary methodology to investigate efficacy in severe depression are reviewed and the methods that are needed to establish efficacy as a superior antidepressant or as an antidepressant with a faster than expected response are suggested. A review of the mechanisms of action of different antidepressants is accompanied by a critical review of the properties of an antidepressant likely to achieve either efficacy in severe depression or the status of a superior antidepressant.

Citalopram and suicidality in adult major depression and anxiety disorders

The suicide-related data on citalopram from controlled clinical trials in depression and anxiety disorders were analysed. Safety data from placebo-controlled and relapse prevention citalopram trials in depression/major depressive disorder (MDD) and anxiety were searched for specific events relating to fatal suicide, non-fatal self-harm or suicidal thoughts. Efficacy data (item 10, suicidal thoughts, on the Montgomery-Asberg Depression Rating Scale [MADRS]) were also analysed. In the clinical trial database, the number of adverse events (fatal suicide, non-fatal self-harm or suicidal thoughts) was low, both during the first 2 weeks of treatment and during the full treatment period, with no statistically significant differences between citalopram and placebo. There was one fatal suicide during treatment (after 12 weeks of double-blind treatment in a relapse-prevention trial) for a patient treated with citalopram (incidence: 0.4%; rate: 0.010) and none on placebo. Citalopram was significantly more efficacious than placebo in lowering suicidal thoughts, based on efficacy rating (MADRS, item 10). There was no indication from this review of clinical trial data that citalopram may increase the risk of suicide in patients with MDD or anxiety. However, the patients in these clinical trials represent a selected group, as those patients with a significant risk of suicide were excluded at trial onset.

Treatment of depression in children and adolescents

Depressive disorders during youth occur frequently, are chronic and recurrent, and are associated with significant functional impairment, morbidity, and mortality. Two psychotherapeutic approaches-cognitive behavioural therapy and interpersonal therapy-are each better than wait-list or treatment-as-usual approaches. Several antidepressants have proven efficacious compared with placebo; however, more than half the studies comparing antidepressant treatment with placebo in children and adolescents with depression have not shown any benefit of the active compounds. Suicide rates are decreasing overall in adolescents, and there seems to be a correlation between the use of selective serotonin reuptake inhibitors (SSRIs) and a decrease in completed suicide. However, there was a signal for increase in suicide attempts and suicidal ideation in patients on acute antidepressant treatment when all antidepressants were assessed as a single group. Thus, there is substantial debate about the best approach to treat this serious disorder. Here, we discuss the treatment options for depression in children and adolescents.

Antidepressant drug use & the risk of suicide

There have been longstanding concerns about the propensity of antidepressants to precipitate suicidality in vulnerable individuals. To investigate this further, first we have analyzed all clinical trials, and in particular trials submitted to regulators for evidence on the relative risk of antidepressants versus placebo for this hazard. Second, we have compiled current epidemiological evidence germane to the issue. Third, we have constructed a model (Investigative Medication Routine; IMR) to shed light on the interactions between drug uptake, patient numbers on treatment and suicidal events. The clinical trial data gives rise to a relative risk of suicide on antidepressants over placebo of the order of a 2.0-2.5 times greater risk with treatment. These figures are supported by epidemiological findings. Investigative Medication Routine translates such findings into estimates of likely adverse outcomes, and explains why apparently increasing consumption of antidepressants would not be expected to lead to increased national suicide rates. From this data, we conclude that there is a clear signal that suicides and suicidal acts may be linked to antidepressant usage. It would seem likely that explicit warnings and monitoring in the early stages of treatment could greatly minimize these hazards.

Suicide Prevention

Abstract. Because of the almost complete absence of randomized controlled trials demonstrating the effectiveness of specific treatments, there is sometimes a degree of pessimism about our ability to prevent suicidal behaviors. However, the methodological challenges to produce such research are formidable and may never be overcome. Therefore, a pragmatic review of evidence-based methods of suicide prevention is required. This review of recent studies using a variety of research strategies, both nonpharmacological and pharmacological, particularly at the community level, provides persuasive data that suicide prevention is possible. This is achievable by the application of broad community and professional education programs, as well as by the optimum management of mental disorders.

Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy

BACKGROUND

The nosologic status of agitated depression is unresolved. Are they unipolar (UP) or bipolar (BP)? Are they mixed states? Even more controversial is the notion that antidepressants might play some role in the suicidality of such patients (Akiskal and Mallya, 1987) [Akiskal, H.S., Mallya, G., 1987. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol Bull. 23, 68-73].

METHODS

After excluding all patients with history of hypomanic episodes occurring outside the frame of a major depressive episode (MDE), even those with a shorter duration of hypomanic symptoms than stipulated in DSM-IV, the remaining consecutive 254 unipolar major depressive disorder (MDD) private adult (> 21 years old) outpatients were interviewed (off psychoactive drugs for 2 weeks) with the Structured Clinical Interview for DSM-IV (SCID-CV), the Hypomania Interview Guide (HIGH-C), and the Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed, with > or = 3 such symptoms required for a diagnosis of depressive mixed state (DMX). Agitated depression was defined as an MDE with HIGH-C psychomotor agitation score > or = 2. Logistic regression was used to study associations and control for confounding variables.

RESULTS

In this strictly defined unipolar sample, agitated depression was present in 19.7%. Compared with its non-agitated counterpart, it had significantly fewer recurrences, less chronicity, higher rate of family history for bipolar disorder, and DMX; and, among the intra-depressive non-euphoric hypomanic symptoms (in decreasing order of frequency), distractibility, racing/crowded thoughts, irritable mood, talkativeness, and risky behavior. The most striking finding was the robust association between agitated depression and DMX (OR = 36.9). Furthermore, patients with psychomotor agitation had significantly higher rate of weight loss and suicidal ideation. Of DMX symptoms, we found an association between suicidal ideation, psychomotor activation, and racing thoughts. Agitated depression was tested by forward stepwise logistic regression versus all variables significantly different in the pairwise comparisons, yielding DMX, talkativeness, and suicidal ideation as the independent significant positive predictors.

LIMITATIONS

No suicidal ideation scale was used.

CONCLUSIONS

Agitated depression emerges as a distinct affective syndrome with weight loss, pressure of speech, racing thoughts and suicidal ideation. Psychomotor activation and racing thoughts during MDD independently predicted suicidal ideation. In this "unipolar" MDD sample, agitated depression had a strong clustering of intra-episode non-euphoric hypomanic symptoms (i.e. DMX) which, coupled with its association with bipolar family history, support its link with the bipolar spectrum. Agitated depression is therefore best regarded as "pseudo-unipolar." These findings overall accord with classical German concepts of agitated depression as a mixed state. Given that these patients are typically activated along the lines of risk-taking behavior, Kraepelin's rubric of "excited (mixed) depression" appears to us the preferred terminology over "agitated depression".

CLINICAL IMPLICATIONS

The data reported herein, placed in the setting of the literature reviewed in the discussion suggest that the reports of increased risk of suicidal ideation and/or behavior in some depressed patients treated by antidepressant monotherapy or combinations thereof might be attributed to baseline psychomotor activation/agitation as part of an unrecognized bipolar mixed state. Whether antidepressants induce de novo suicidality in MDD cannot be answered without adequately powered prospective double-blind studies, unlikely to be conducted because of ethical constraints. Nonetheless, we submit that agitated, activated, or otherwise excited depressions (which we consider as depressive mixed states) overlap considerably with the so-called antidepressant "activation syndrome." Furthermore, the rare occurrence of suicidality on antidepressants should not obscure the fact that the advent of the new antidepressants is associated with worldwide decline in suicide rates. We finally wish to point out that our formal nosology (i.e. DSM-IV and ICD-10), in its failure to recognize the bipolar nature of depressive mixed states, thereby fails to shield pseudo-unipolar patients from antidepressant monotherapy, which is inappropriate for such patients.

Pharmacotherapy of suicidal behavior in bipolar disorder

Patients with Bipolar Disorder (BD) are at particularly high risk for both attempted and completed suicides. The period of highest risk for completed suicide is during the 2 years following discharge from a hospitalization. To date, pharmacological studies of suicidal behavior in BD have been quite limited. While strong evidence has been found regarding the anti-suicidal effects of lithium, evidence for such properties in other commonly prescribed medications for BD, including anticonvulsants, SSRIs and anti-psychotics, has been largely unexplored. Considering the high risk of suicidal acts in patients with BD, further research on the pharmacotherapy of suicidal behavior is crucial.

Antidepressants and suicidal behaviour in unipolar depression

OBJECTIVE

To compare the rates of suicidal behaviour during vs. after discontinuation of treatment with antidepressants, and to determine the comparative rates of suicidal behaviour for patients maintained on tricyclic (TCA) vs. selective serotonin reuptake inhibitor (SSRI) antidepressants.

METHOD

Charts were reviewed for 521 patients with major depressive disorder and/or dysthymic disorder. Periods of active treatment or discontinuation with SSRIs or TCAs were determined. Rates of completed suicide, suicide attempts, and hospitalization for suicidality were analyzed.

RESULTS

There was greater than a five-fold increase in risk for suicidal behaviour after discontinuation of antidepressant treatment (P < 0.0001). The rates of suicidal behavior during treatment with SSRIs or TCAs were similar.

CONCLUSION

Suicidal behaviour in unipolar depressed patients treated with antidepressants increases substantially after medication discontinuation. This effect occurred in both patients who were maintained on SSRIs and TCAs. The findings support a possible protective effect on suicidal behaviour for both SSRIs and TCAs.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Antidepressants in bipolar disorder: the case for caution

The 2002 American Psychiatric Association (APA) guidelines for the treatment of bipolar disorder recommended more conservative use of antidepressants. This change in comparison with previous APA guidelines has been criticized, especially from some groups in Europe. The Munich group in particular has published a critique of assumptions underlying the conservative recommendations of the recent APA treatment guidelines. In this paper, we re-examine the argument put forward by the Munich group, and we demonstrate that indeed, conceptually and empirically, there is a strong rationale for a cautious approach to antidepressant use in bipolar disorder, consistent with, and perhaps even more strongly than, the APA guidelines. This rationale is based on support for the following four propositions: (i) The risk of antidepressant induced mood-cycling is high, (ii) Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, whereas lithium has, (iii) Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression and have been shown to be less effective than mood stabilizers in preventing depressive relapse in bipolar disorder and (iv) Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. We therefore draw three conclusions from this interpretation of the evidence: (i) There are significant risks of mania and long-term worsening of bipolar illness with antidepressants, (ii) Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases and (iii) Antidepressants should be discontinued after recovery from the depressive episode, and maintained only in those who repeatedly relapse after antidepressant discontinuation (a minority we judge to represent only about 15-20% of bipolar depressed patients).

Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors

BACKGROUND

There has been a long-standing controversy about the possibility that selective serotonin reuptake inhibitor (SSRI) antidepressants might induce suicidality in some patients.

METHODS

Starting from the clinical studies that gave rise to this issue, this paper reviews an unselected cohort of randomized clinical trials (RCTs), a series of meta-analyses undertaken to investigate aspects of the problem, studies in recurrent brief depressive disorders, epidemiological studies and healthy volunteer studies using SSRIs to shed light on this issue.

RESULTS

The original clinical studies produced evidence of a dose-dependent link, present on a challenge, dechallenge and rechallenge basis, between SSRIs and both agitation and suicidality. Meta-analyses of RCTs conducted around this time indicate that SSRIs may reduce suicidal ideation in some patients. These same RCTs, however, yield an excess of suicides and suicide attempts on active treatments compared with placebos. This excess also appears in the best-controlled epidemiological studies. Finally, healthy volunteer studies give indications that SSRIs may induce agitation and suicidality in some individuals.

CONCLUSIONS

The data reviewed here, which indicate a possible doubling of the relative risk of both suicides and suicide attempts on SSRIs compared with older antidepressants or non-treatment, make it difficult to sustain a null hypothesis, i.e. that SSRIs do not cause problems in some individuals to whom they are given. Further studies or further access to data are indicated to establish the magnitude of any risk and the characteristics of patients who may be most at risk.

Role of selective serotonin reuptake inhibitors in psychiatric disorders: a comprehensive review

The selective serotonin reuptake inhibitors (SSRIs) have emerged as a major therapeutic advance in psychopharmacology. As a result, the discovery of these agents marks a milestone in neuropsychopharmacology and rational drug design, and has launched a new era in psychotropic drug development. Prior to the SSRIs, all psychotropic medications were the result of chance observation. In an attempt to develop a SSRI, researchers discovered a number of nontricyclic agents with amine-uptake inhibitory properties, acting on both noradrenergic and serotonergic neurons with considerable differences in potency. A given drug may affect one or more sites over its clinically relevant dosing range and may produce multiple and different clinical effects. The enhanced safety profile includes a reduced likelihood of pharmacodynamically mediated adverse drug-drug interactions by avoiding affects on sites that are not essential to the intended outcome. SSRIs were developed for inhibition of the neuronal uptake pump for serotonin (5-HT), a property shared with the TCAs, but without affecting the other various neuroreceptors or fast sodium channels. The therapeutic mechanism of action of SSRIs involves alteration in the 5-HT system. The plethora of biological substrates, receptors and pathways for 5-HT are candidates to mediate not only the therapeutic actions of SSRIs, but also their side effects. A hypothesis to explain these immediate side effects is that 5-HT is increased at specific 5-HT receptor subtypes in discrete regions of the body where the relevant physiologic processes are regulated. Marked differences exist between the SSRIs with regard to effects on specific cytochrome P450 (CYP) enzymes, and thus the likelihood of clinically important pharmacokinetic drug-drug interactions. Although no clear relationship exists between the clinical efficacy, plasma concentration of SSRIs, nor any threshold that defines toxic concentrations, but therapeutic drug monitoring (TDM) may be useful in special populations, such as in elderly patients, poor metabolizers (PM) of sparteine (CYP2D6) or mephenytoin (CYP2C19), and patients with liver and kidney impairment. Several meta-analyses have reviewed the comparative efficacy of TCAs and SSRIs, and concluded that both TCAs and SSRIs have similar efficacy in the treatment of depression. SSRIs have demonstrated better efficacy and tolerability in the treatment of obsessive compulsive disorder (OCD). They have also been found to be effective in the treatment for social anxiety disorder both in reducing total levels of social anxiety and in improving overall clinical condition. The benefit of SSRIs in anorexia nervosa (AN) is apparently short-term unless medication is given in the context of nutritional or behavioral therapy. No single antidepressant can ever be recommended for every patient, but in a vast majority of patients, SSRIs should be considered as one of the first-line drugs in the treatment of depression.

In the grip of the python: conflicts at the university-industry interface

When the University of Toronto withdrew a contract it held with me in December 2000, it initiated a sequence of events that led to a public letter to the University from senior figures in the world psychopharmacology community protesting against the infringement of academic freedom involved and a first ever legal action, undertake by this author, seeking redress for a violation of academic freedom. The issues of academic freedom surrounding this case have been intertwined with a debate about the possibility that the selective serotonin reuptake inhibitor (SSRI) group of antidepressants have the potential to trigger suicidality in a subgroup of patients. Whether the SSRIs do trigger suicidality or not, exploration of this issue has given rise to a number of worrying sets of observations. First, in my view, there is evidence that pharmaceutical companies have miscoded raw data on suicidal acts and suicidal ideation. Second, this author also maintains that there is a growing body of examples of ghostwriting of articles in the therapeutics domain. Many of the tensions evident in this case, therefore, can be linked to company abilities to keep clinical trial data out of the public domain--this is the point at which the pharmaceutical python gets a grip on academia.

Focus on paroxetine

This review of paroxetine is based on Medline and PsycLit searches and a manual search of the available research literature. It aims to cover the pharmacology of this frequently prescribed SSRI antidepressant in terms of its indications, efficacy and adverse effects. Overall, paroxetine is a well-tolerated and safe first-line SSRI antidepressant with anxiolytic qualities. It has been found useful in depression, anxiety and other conditions such as obsessive compulsive disorder and post-traumatic stress disorder. The antidepressant has some advantages over earlier tricyclic medication in terms of a lack of cardiovascular side-effects and relative safety in overdose. Cessation of use, however, is associated with withdrawal or discontinuation symptoms and patients should be counselled as to how these might be avoided. A 3- or 4-week graded withdrawal regimen, perhaps with concomitant fluoxetine to cover serotonergic discontinuation symptoms, may be advisable.

Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry

These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/ case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.

A meta-analysis of the efficacy and tolerability of paroxetine versus tricyclic antidepressants in the treatment of major depression

This meta-analysis examined efficacy and tolerability data from 39 randomized, double-blind, parallel-group studies comparing paroxetine (n = 1924) with clomipramine (n = 141) or other tricyclic antidepressants (TCAs; n = 1693) in the treatment of major depression. Paroxetine had comparable antidepressant efficacy to TCAs, including clomipramine, as assessed by response rates based on a < or = 50% reduction in Hamilton Rating Scale for Depression (HAMD) total score (58-66%) and a HAMD total score < or = 8 (38-48%) at endpoint, and absolute improvements in HAMD total score (mean change 12.3-14.5). Absolute improvements in HAMD anxiety factor scores were similar between paroxetine and clomipramine (mean change 2.3 versus 2.4, P = 0.566), but paroxetine was statistically significantly more effective on this measure than other TCAs (mean change 2.3 versus 2.1, P = 0.028). The proportion of patients who experienced adverse events with > 1% incidence was statistically significantly lower with paroxetine than with clomipramine (64% versus 77%, P = 0.02) or other TCAs (64% versus 71%, P < 0.001). The incidence of patient withdrawals due to adverse events was also statistically significantly lower with paroxetine than with clomipramine (17% versus 27%, P = 0.014), but an advantage seen for paroxetine over other TCAs (17% versus 20%, P = 0.130) did not reach statistical significance. These findings demonstrate that paroxetine has comparable efficacy to and better tolerability than TCAs, including clomipramine, and is therefore an appropriate treatment strategy for depression, particularly in the common clinical situation where concomitant anxiety symptoms are present.

Anxiety disorders: a review of tricyclic antidepressants and selective serotonin reuptake inhibitors

OBJECTIVE

Anxiety disorders are the most common mental health disorders. While the older tricylic antidepressants (TCAs) are efficacious in the treatment of many anxiety disorders, recent studies with fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have emphasized the role of serotonin in the aetiology of these conditions.

METHOD

We reviewed the efficacy, safety and tolerability of TCAs and SSRIs in the treatment of the most common anxiety disorders, specifically, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder.

RESULTS

Both the TCA and SSRI antidepressants are effective in treating a wide variety of anxiety disorders. SSRIs, due to their greater safety and tolerability, should be the preferred choices in treating anxiety disorders in those instances where TCAs and SSRIs are considered equally effective. In the cases of OCD and social phobia, SSRIs are almost always preferable given that the TCAs do not appear effective in these disorders.

CONCLUSION

Further research is needed on the naturalistic long-term use of the TCAs and SSRIs in the treatment of anxiety disorders.

Suicide by antidepressant intoxication identified at autopsy in Vienna from 1991-1997: the favourable consequences of the increasing use of SSRIs

In the area of Vienna, any person dying under questionable circumstances is examined at the Institute of Forensic Medicine, where the cause of death is determined by means of autopsy and chemical analysis. Our study on fatal intoxications was performed in the period between 1991 and 1997, when selective serotonin reuptake inhibitors (SSRIs) were establishing themselves on the market, reaching the top of prescription statistics. Tricyclic antidepressants (TCAs) were involved in 30 single- and 127 multiple-substance intoxications, with amitriptyline and doxepin being the most frequently used drugs. SSRIs were involved in five multiple-substance intoxications. The f-value, which refers to the number of deaths per million defined daily doses prescribed, was found to be significantly (P</=0.001) higher in TCAs than in SSRIs. The f-value for the total group of all antidepressants declined significantly (P</=0.05) during the observation period of 7 years. In conclusion, SSRIs turned out to be less toxic than TCAs, and the increasing use of new antidepressants did not coincide with an increased number of deaths caused by these drugs.

Suicide in the course of the treatment of depression

Five different mechanisms have been proposed whereby antidepressant treatment might lead to suicide: first by simply ameliorating depressions more rapidly; second by an action intrinsic to the specific antidepressant effects; third by toxicity in overdose; fourth by side-effects of specific antidepressants; and finally by virtue of treatment inefficacy. Evidence from randomized control trials (RCT), controlled case studies and epidemiological studies on this question is reviewed and it is concluded that antidepressants can be implicated in some cases of suicide during treatment. Modifications of clinical trial methods and pharmacogenetic studies would yield a richer data set to explore this issue further.

Suicide and suicidal behaviours: implications for mental health services

OBJECTIVE

To examine what is known about engaging and maintaining suicidal individuals in treatment and what can be learned from the randomized, controlled trials of psychosocial interventions concerning the reduction of suicidal behaviours.

METHOD

Review of the relevant literature.

RESULTS

Treatment follow-through is low among those who attempt suicide. The evidence to date is inconclusive as to whether psychosocial interventions can reduce the repetition of suicidal behaviour.

CONCLUSIONS

Certain groups may benefit from psychosocial interventions. Future research must overcome several methodological issues. As treatment relies on adequate follow-through, changes in the delivery of care may enhance treatment effectiveness.

Implications of the severity of social phobia

This paper presents a post hoc analysis of a recent large, 12-week, placebo-controlled trial of paroxetine in the treatment of social phobia, which analyzes subgroups of patients classified as suffering from severe (Liebowitz Social Anxiety Scale [LSAS] total score > or = 82, n = 85) or moderate (LSAS total score 52-81, n = 78) social phobia. With respect to the reduction in LSAS total score, the paroxetine-placebo difference was greater in patients in the severe subgroup (20.0, P < 0.001) than those in the moderate subgroup (13.7, P < 0.02). Likewise, for the number of patients rated as 'very much' or 'much' improved according to their Clinical Global Impressions improvement scores, the paroxetine-placebo difference was greater in the severe subgroup (34.2%, P < 0.001) than in the moderate subgroup (29.1%, P < 0.02). In conclusion, paroxetine is effective compared with placebo in both moderate and severe social phobia, and the response is more clear cut in patients with more severe symptoms.

Paroxetine. An update of its pharmacology and therapeutic use in depression and a review of its use in other disorders

Paroxetine is a potent and selective inhibitor of the neuronal reuptake of serotonin (5-hydroxytryptamine; 5-HT), which was previously reviewed as an antidepressant in Drugs in 1991. Since then, more comparative trials with other antidepressants have become available, and its use in the elderly and as long term maintenance therapy has been investigated. Paroxetine has also been studied in several other disorders with a presumed serotonergic component, primarily obsessive compulsive disorder (OCD) and panic disorder. In short term clinical trials in patients with depression, paroxetine produced clinical improvements that were significantly greater than those with placebo and similar to those achieved with other agents including tricyclic antidepressants (TCAs), maprotiline, nefazodone and the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine and sertraline. Long term data suggest that paroxetine is effective in preventing relapse or recurrence of depression in patients treated for up to 1 year. In the elderly, the overall efficacy of paroxetine was at least as good as that of comparator agents. In short term clinical trials involving patients with OCD or panic disorder, paroxetine was significantly more effective than placebo and of similar efficacy to clomipramine. Limited long term data show that paroxetine is effective in maintaining a therapeutic response over periods of 1 year (OCD) and up to 6 months (panic disorder). Preliminary data suggest that paroxetine has potential in the treatment of social phobia, premenstrual dysphoric disorder and chronic headache. Like the other SSRIs, paroxetine is better tolerated than the TCAs, causing few anticholinergic adverse effects. The most commonly reported adverse event associated with paroxetine treatment is nausea, although this is generally mild and subsides with continued use. Fewer withdrawals from treatment due to adverse effects occurred with paroxetine treatment than with TCAs. The adverse events profile of paroxetine appears to be broadly similar to that of other SSRIs, although data from comparative trials are limited. Serious adverse effects associated with paroxetine are very rare. In conclusion, paroxetine is effective and well tolerated, and suitable as first-line therapy for depression. It also appears to be a useful alternative to other available agents for the treatment of patients with OCD or panic disorder.