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Lynskey MT, Thurgur H, Athanasiou-Fragkouli A, Schlag AK, Nutt DJ. Suicidal Ideation in Medicinal Cannabis Patients: A 12-Month Prospective Study. Arch Suicide Res 2024:1-15. [PMID: 39045855 DOI: 10.1080/13811118.2024.2356615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To document the prevalence and correlates of suicidal ideation (SI) among individuals seeking cannabis-based medicinal products (CBMPs); to test whether SI declines or intensifies after three months of CBMP treatment and to document 12-month trajectories of depression in those reporting SI and other patients. METHOD Observational data were available for 3781 patients at entry to treatment, 2112 at three months and 777 for 12 months. Self-reported depressed mood and SI were assessed using items from the PHQ-9. Additional data included sociodemographic characteristics and self-reported well-being. RESULTS 25% of the sample reported SI at treatment entry and those with SI had higher levels of depressed mood (mean = 17.4 vs. 11.3; F(1,3533) = 716.5, p < .001) and disturbed sleep (mean = 13.8 vs. 12.2, F(1,3533) = 125.9, p < .001), poorer general health (mean = 43.6 vs. 52.2, F(1,3533) = 118.3, p < .001) and lower quality of life (mean = 0.44 vs. 0.56 (F(1,3533) = 118.3, p < .001). The prevalence of SI reduced from 23.6% to 17.6% (z = 6.5, p < .001) at 3 months. Twelve-month follow-up indicated a substantial reduction in depressed mood with this reduction being more pronounced in those reporting SI (mean (baseline) = 17.7 vs. mean (12 months) = 10.3) than in other patients (mean (baseline) = 11.1 vs. mean (12 months) = 7.0). CONCLUSIONS SI is common among individuals seeking CBMPs to treat a range of chronic conditions and is associated with higher levels of depressed mood and poorer quality of life. Treatment with CBMPs reduced the prevalence and intensity of suicidal ideation.
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Amendola S, Plöderl M, Hengartner MP. Suicide Rates and Prescription of Antidepressants. CRISIS 2024; 45:225-233. [PMID: 38353035 DOI: 10.1027/0227-5910/a000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Background: Previous ecological studies reported that increasing antidepressant prescriptions were associated with decreasing suicide rates. Aim: To determine whether antidepressant prescription prevalence is negatively associated with suicide rates (i.e., as antidepressant prescribing increases, suicide rates decrease) between 1999 and 2020. Method: The study protocol was pre-registered on the Open Science Framework (https://osf.io/978sk/). Publicly available data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiological Research (CDC WONDER) and Medical Expenditure Panel Survey (MEPS) were used. Results: Overall, both the antidepressant prescription prevalence and the suicide rate were increasing from 1990 to 2020 in the United States. Positive trends for both outcomes were also evident when analyses were stratified according to sex and/or race/ethnicity. Pearson's correlation analyses consistently found positive associations between antidepressant prescription prevalence and suicide rates. Limitations: Trends and their associations were examined at the population level. The results cannot clarify the causal nature of the association observed. Conclusion: The results of our analysis consistently demonstrated positive trends for both antidepressant prescription prevalence and suicide rates over time as well as positive associations between them. These findings update those from previous studies and are at odds with the notion that, at a population level, more antidepressant prescriptions would lead to lower suicide rates. However, it needs to be acknowledged that ecological studies provide insufficient evidence to infer causality.
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Affiliation(s)
- Simone Amendola
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Martin Plöderl
- Department of Inpatient Psychotherapy and Crisis Intervention, University Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
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Lagerberg T, Matthews AA, Zhu N, Fazel S, Carrero JJ, Chang Z. Effect of selective serotonin reuptake inhibitor treatment following diagnosis of depression on suicidal behaviour risk: a target trial emulation. Neuropsychopharmacology 2023; 48:1760-1768. [PMID: 37507510 PMCID: PMC10579366 DOI: 10.1038/s41386-023-01676-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
There is concern regarding the impact of selective serotonin reuptake inhibitors (SSRIs) on suicidal behaviour. Using the target trial framework, we investigated the effect on suicidal behaviour of SSRI treatment following a depression diagnosis. We identified 162,267 individuals receiving a depression diagnosis aged 6-59 years during 2006-2018 in Stockholm County, Sweden, after at least 1 year without antidepressant dispensation. Individuals who initiated an SSRI within 28 days of the diagnosis were assigned as SSRI initiators, others as non-initiators. Intention-to-treat and per-protocol effects were estimated; for the latter, individuals were censored when they ceased adhering to their assigned treatment strategy. We applied inverse probability weighting (IPW) to account for baseline confounding in the intention-to-treat analysis, and additionally for treatment non-adherence and time-varying confounding in the per-protocol analysis. The suicidal behaviour risk difference (RD), and risk ratio (RR) between SSRI initiators and non-initiators were estimated at 12 weeks. In the overall cohort, we found an increased risk of suicidal behaviour among SSRI initiators (intention-to-treat RR = 1.50, 95% CI = 1.25, 1.80; per-protocol RR = 1.69, 95% CI = 1.20, 2.36). In age strata, we only found evidence of an increased risk among individuals under age 25, with the greatest risk among 6-17-year-olds (intention-to-treat RR = 2.90, 95% CI = 1.72, 4.91; per-protocol RR = 3.34, 95% CI = 1.59, 7.00). Our finding of an increased suicidal behaviour risk among individuals under age 25 reflects evidence from RCTs. We found no evidence of an effect in the high-risk group of individuals with past suicidal behaviour. Further studies with information on a wider array of confounders are called for.
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Affiliation(s)
- Tyra Lagerberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.
| | - Anthony A Matthews
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nanbo Zhu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Seena Fazel
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Syed O, Jancic P, Fink AB, Knezevic NN. Drug Safety and Suicidality Risk of Chronic Pain Medications. Pharmaceuticals (Basel) 2023; 16:1497. [PMID: 37895968 PMCID: PMC10609967 DOI: 10.3390/ph16101497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/13/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023] Open
Abstract
Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.
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Affiliation(s)
- Osman Syed
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL 60515, USA
| | - Predrag Jancic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
| | - Adam B. Fink
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Harborview Medical Center, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA
| | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
- Department of Surgery, University of Illinois, Chicago, IL 60612, USA
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Plöderl M, Amendola S, Hengartner MP. Observational studies of antidepressant use and suicide risk are selectively published in psychiatric journals. J Clin Epidemiol 2023; 162:10-18. [PMID: 37544615 DOI: 10.1016/j.jclinepi.2023.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/15/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To investigate if observational studies showing favorable results for antidepressants on suicidal behavior (reduced risk) are preferably and more easily published in psychiatric journals and cited more often compared to studies with unfavorable results (increased risk). STUDY DESIGN AND SETTING Prespecified secondary analysis, including 27 original studies selected through a systematic review of observational studies reporting associations between the use of newer antidepressant drugs and suicide risk. RESULTS Independent of study quality, studies reporting favorable results were more frequently published in psychiatric than nonpsychiatric journals and were more often conducted by lead authors with financial conflicts of interest (fCOI). Within psychiatric journals, lead authors with fCOI published in journals with a higher impact factor (IF) and ranking. Within psychiatric journals, favorability of results also correlated with citation frequency, IF, and journal ranking, but these associations became weaker and inconclusive after adjusting for study quality. Results for ease of publishing were inconclusive. CONCLUSION Studies reporting unfavorable results (increased suicide risk with antidepressant exposure) are less likely to be published in psychiatric journals. Lead authors with fCOI report more favorable results, and their studies are published in the most prestigious psychiatric journals. This may create a biased evidence base and an unbalanced dissemination and appraisal of findings within psychiatry.
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Affiliation(s)
- Martin Plöderl
- Department of Inpatient Psychotherapy and Crisis Intervention, University Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Simone Amendola
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
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Selective serotonin reuptake inhibitors and suicidal behaviour: a population-based cohort study. Neuropsychopharmacology 2022; 47:817-823. [PMID: 34561608 PMCID: PMC8882171 DOI: 10.1038/s41386-021-01179-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
There is concern that selective serotonin reuptake inhibitor (SSRI) treatment may increase the risk of suicide attempts or deaths, particularly among children and adolescents. However, debate remains regarding the nature of the relationship. Using nationwide Swedish registers, we identified all individuals aged 6-59 years with an incident SSRI dispensation (N = 538,577) from 2006 to 2013. To account for selection into treatment, we used a within-individual design to compare the risk of suicide attempts or deaths (suicidal behaviour) in time periods before and after SSRI-treatment initiation. Within-individual incidence rate ratios (IRRs) of suicidal behaviour were estimated. The 30 days before SSRI-treatment initiation was associated with the highest risk of suicidal behaviour compared with the 30 days 1 year before SSRI initiation (IRR = 7.35, 95% CI 6.60-8.18). Compared with the 30 days before SSRI initiation, treatment periods after initiation had a reduced risk-the IRR in the 30 days after initiation was 0.62 (95% CI 0.58-0.65). The risk then declined over treatment time. These patterns were similar across age strata, and when stratifying on history of suicide attempts. Initiation with escitalopram was associated with the greatest risk reduction, though CIs for the IRRs of the different SSRI types were overlapping. The results do not suggest that SSRI-treatment increases the risk for suicidal behaviour in either youths or adults; rather, it may reduce the risk. Further research with different study designs and in different populations is warranted.
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Plöderl M, Hengartner MP. Learning about the course of suicidal behavior but not about the effects of SSRIs. Neuropsychopharmacology 2022; 47:803. [PMID: 34750569 PMCID: PMC8882168 DOI: 10.1038/s41386-021-01224-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/12/2021] [Accepted: 10/21/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Martin Plöderl
- Department for Crisis Intervention and Suicide Prevention and Department for Clinical Psychology, University Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Paracelsus Medical University, Salzburg, Austria.
| | - Michael P. Hengartner
- grid.19739.350000000122291644Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
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Carter G, Sperandei S, Chitty KM, Page A. Antidepressant treatment trajectories and suicide attempt among Australians aged 45 years and older: A population study using individual prescription data. Suicide Life Threat Behav 2022; 52:121-131. [PMID: 34693551 DOI: 10.1111/sltb.12812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/29/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Meta-analyses show antidepressant initiation has increased risk of suicidal behavior <25 years, no difference 25-64 years and reduced risk 65+ years. Estimating risks from RCTs has limitations and real-world population estimates are uncommon. METHODS A self-controlled case series reporting incidence rate ratio (IRR) between exposed and control periods for antidepressants associated with suicide attempt, in Australian older age adults. We included all cases with suicide attempt [hospital data for ICD codes (X60-X84)] and any antidepressant use (n = 689) by participants in the "45 and Up Study". RESULTS For all antidepressants the IRR for suicide attempt was elevated across all exposures, declining from 7.44 (95%CI 5.57-9.94) during the first 30 days, to 2.21 (1.73-2.81) at 91+ days. All four antidepressant sub-groups had higher IRRs for the first 30 day exposure: 2.43 (1.37-4.29) for TCAs, 4.06 (2.78-5.93) for SSRIs, 4.15 (2.65-6.50) for other antidepressants, and 4.92 (3.30-7.34) for SNRIs. Increased IRR persisted for 61- to 90-day exposures for SSRIs 2.42 (1.18-4.98) and SNRIs 2.66 (1.34-5.27). CONCLUSION Some older adults have increased risk of suicide attempt with antidepressant exposure, which may persist for months. Clinical guidelines should recommend a period of monitoring for treatment-emergent suicidal thoughts and behaviors in older adult patients.
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Affiliation(s)
- Gregory Carter
- Faculty of Medicine and Health Science, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sandro Sperandei
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Kate M Chitty
- School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
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Amendola S, Plöderl M, Hengartner MP. Did the introduction and increased prescribing of antidepressants lead to changes in long-term trends of suicide rates? Eur J Public Health 2021; 31:291-297. [PMID: 33236104 PMCID: PMC8071590 DOI: 10.1093/eurpub/ckaa204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Ecological studies have explored associations between suicide rates and antidepressant prescriptions in the population, but most of them are limited as they analyzed short-term correlations that may be spurious. The aim of this long-term study was to examine whether trends in suicide rates changed in three European countries when the first antidepressants were introduced in 1960 and when prescription rates increased steeply after 1990 with the introduction of the serotonin reuptake inhibitors (SSRIs). Methods Data were extracted from the WHO Mortality Database. Suicide rates were calculated for people aged 10–89 years from 1951–2015 for Italy, 1955–2016 for Austria and 1951–2013 for Switzerland. Trends in suicide rates stratified by gender were analyzed using joinpoint regression models. Results There was a general pattern of long-term trends that was broadly consistent across all three countries. Suicide rates were stable or decreasing during the 1950s and 1960s, they rose during the 1970s, peaked in the early 1980s and thereafter they declined. There were a few notable exceptions to these general trends. In Italian men, suicide rates increased until 1997, then fell sharply until 2006 and increased again from 2006 to 2015. In women from all three countries, there was an extended period during the 2000s when suicide rates were stable. No trend changes occurred around 1960 or 1990. Conclusions The introduction of antidepressants around 1960 and the sharp increase in prescriptions after 1990 with the introduction of the SSRIs did not coincide with trend changes in suicide rates in Italy, Austria or Switzerland.
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Affiliation(s)
- Simone Amendola
- Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Martin Plöderl
- Department of Crisis Intervention and Suicide Prevention, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland.,Medical Faculty, University of Zurich, Zurich, Switzerland
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Hengartner MP, Amendola S, Kaminski JA, Kindler S, Bschor T, Plöderl M. Suicide risk with selective serotonin reuptake inhibitors and other new-generation antidepressants in adults: a systematic review and meta-analysis of observational studies. J Epidemiol Community Health 2021; 75:jech-2020-214611. [PMID: 33685964 DOI: 10.1136/jech-2020-214611] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/25/2020] [Accepted: 02/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is ongoing controversy whether antidepressant use alters suicide risk in adults with depression and other treatment indications. METHODS Systematic review of observational studies, searching MEDLINE, PsycINFO, Web of Science, PsycARTICLES and SCOPUS for case-control and cohort studies. We included studies on depression and various indications unspecified (including off-label use) reporting risk of suicide and/or suicide attempt for adult patients using selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants relative to non-users. Effects were meta-analytically aggregated with random-effects models, reporting relative risk (RR) estimates with 95% CIs. Publication bias was assessed via funnel-plot asymmetry and trim-and-fill method. Financial conflict of interest (fCOI) was defined present when lead authors' professorship was industry-sponsored, they received industry-payments, or when the study was industry-sponsored. RESULTS We included 27 studies, 19 on depression and 8 on various indications unspecified (n=1.45 million subjects). SSRI were not definitely related to suicide risk (suicide and suicide attempt combined) in depression (RR=1.03, 0.70-1.51) and all indications (RR=1.19, 0.88-1.60). Any new-generation antidepressant was associated with higher suicide risk in depression (RR=1.29, 1.06-1.57) and all indications (RR=1.45, 1.23-1.70). Studies with fCOI reported significantly lower risk estimates than studies without fCOI. Funnel-plots were asymmetrical and imputation of missing studies with trim-and-fill method produced considerably higher risk estimates. CONCLUSIONS Exposure to new-generation antidepressants is associated with higher suicide risk in adult routine-care patients with depression and other treatment indications. Publication bias and fCOI likely contribute to systematic underestimation of risk in the published literature. REGISTRATION Open Science Framework, https://osf.io/eaqwn/.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Simone Amendola
- Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Roma, Italy
| | - Jakob A Kaminski
- Department of Psychiatry and Psychotherapy, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Simone Kindler
- Psychotherapist in Private Practice, Winterthur, Switzerland
| | - Tom Bschor
- Department of Psychiatry and Psychotherapy, University Hospital, Technical University of Dresden, Dresden, Germany
| | - Martin Plöderl
- Department of Crisis Intervention and Suicide Prevention, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
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Difficulties that unexpected results face to be accepted: suicide and the moon. Mol Psychiatry 2021; 26:4566-4567. [PMID: 33526824 PMCID: PMC8589661 DOI: 10.1038/s41380-021-01028-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/29/2020] [Accepted: 01/11/2021] [Indexed: 11/08/2022]
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