Suicides by violent means in individuals taking SSRIs and other antidepressants: a postmortem study in Sweden, 1992-2004

Psychotic depression and deaths due to suicide

BACKGROUND

The purpose of this study was to establish the risk of suicide associated with incident psychotic depression (PD) compared to incident non-psychotic severe depression (NPD).

METHODS

This cohort study used routine data from nationwide health registers in Finland. Eligible participants were aged 18-59 years at the index diagnosis. Causes of death were defined by the International Classification of Diseases, 10th revision codes. The follow-up time was up to five years. Adjusted Cox regression models were used to analyse risk of death by method of suicide.

RESULTS

We included 17,331 individuals with incident PD and 85,989 individuals with incident NPD. Most of the deaths due to suicides occurred within the first two years after the index diagnosis. Compared to NPD, PD was associated with an overall two-fold increased risk of suicide (adjusted hazard ratio, (aHR) 2.19, 95 % confidence interval (CI) 1.95, 2.46), after adjusting for psychiatric comorbidities. In PD, the highest relative risks were for impact-related suicides (aHR 3.03, 95%CI 2.23, 4.13) and for suffocation-related suicides (aHR 2.72, 95%CI 2.23, 3.30), whereas the lowest relative risk was for intentional poisonings (aHR 1.66, 95%CI 1.37, 2.02).

LIMITATIONS

Information on all potential confounders is not available in studies using routine data.

CONCLUSIONS

Psychotic symptoms doubled the risk of suicides over and above of the risk that was associated with severe depression, after controlling for comorbid psychiatric disorders. The severity of suicidal ideation may be higher in PD than in NPD, which then leads to more lethal methods of self-harm.

Evaluating Prevalence and Patterns of Prescribing Medications for Depression for Patients With Obesity Using Large Primary Care Data (Canadian Primary Care Sentinel Surveillance Network)

Introduction: Depression is a serious disorder that brings a tremendous health and economic burden. Many antidepressants (AD) have obesogenic effects, increasing the population of obese patients at increased risk for a more severe disease course and poor treatment response. In addition, obese patients with depression may not be receiving the recommended standard of care due to "obesity bias." It is important to evaluate prescribing pharmacological treatment of depression in patients with obesity. Objectives: To describe the prevalence and patterns of AD prescribing for patients with depression and comorbid obesity compared with normal weight patients, and to examine the association of prescribing prevalence with obesity class. Methods: Study sample of adult patients (>18 years old) with depression was extracted from the national Canadian Primary Care Sentinel Surveillance Network (CPCSSN) Electronic Medical Records database for 2011-2016. Measures were prescribing of at least one AD (outcome) and body mass index (BMI) to categorize patients into weight categories (exposure). Data were analyzed cross-sectionally using descriptive statistics and mixed effects logistic regression model with clustering on CPCSSN networks and adjusting for age, sex, and the comorbidities. Results: Of 120,381 patients with depression, 63,830 patients had complete data on studied variables (complete cases analysis). Compared with normal weight patients, obese patients were more likely to receive an AD prescription (adjusted Odds Ratio [aOR] = 1.17; 95% Confidence Interval [CI]: 1.12-1.22). Patients with obesity classes II and III were 8% (95% CI: 1.00, 1.16) and 6% (95% CI: 0.98, 1.16) more likely, respectively, to receive AD. After imputing missing data using Multiple Imputations by Chained Equations, the results remained unchanged. The prevalence of prescribing >3 AD types was higher in obese category (7.27%, [95% CI: 6.84, 7.73]) than in normal weight category (5.6%; [95% CI: 5.24, 5.99]). Conclusion: The association between obesity and high prevalence of AD prescribing and prescribing high number of different AD to obese patients, consistent across geographical regions, raises a public health concern. Study results warrant qualitative studies to explore reasons behind the difference in prescribing, and quantitative longitudinal studies evaluating the association of AD prescribing patterns for obese patients with health outcomes.

The concept of violent suicide, its underlying trait and neurobiology: A critical perspective

Suicide is one of the leading causes of death and represents a significant public health problem world-wide. Individuals who attempt or die by suicide represent a highly heterogeneous population. Recently, efforts have been made to identify sub-populations and variables to categorize them. A popular dichotomy in suicide research of the past years is violent versus non-violent suicide - based on the method. This dichotomy is important given that there is an association between method of attempted suicide and risk of subsequent death by suicide. The differentiation concerning suicide methods is also critical regarding preventive efforts. In this review, we have tried to approach the concept of violent suicide from different perspectives, including a discussion about its definition and overlapping categories. In addition, we have critically discussed aggression as underlying trait, the question of intent to die, and sociodemographic, environmental, neuropsychological, and neurobiological factors potentially associated with violent suicide.

Premature Death Among Primary Care Patients With a History of Self-Harm

PURPOSE

Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves.

METHODS

During 2001-2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice.

RESULTS

We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1-4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3-86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%-7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%-1.5%) for suicide.

CONCLUSIONS

Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.

Serum triglycerides, but not cholesterol or leptin, are decreased in suicide attempters with mood disorders

BACKGROUND

Many peripheral biomarkers, including low cholesterol and its fractions, have been examined to identify suicidal behavior. Herein, we assessed serum lipid profile and some proteins putatively associated with suicidal behavior in subjects with mood disorder (bipolar disorder or major depressive disorder) with a recent suicide attempt and with no lifetime history of suicide attempts.

METHODS

Fifty subjects had presented an episode of attempted suicide during the last 15 days, and 36 subjects had no history of any suicide attempt. We measured total cholesterol, HDL, LDL and triglycerides as well as serum leptin, brain-derived neurotrophic factor (BDNF), S100B and C-reactive protein (CRP).

RESULTS

Individuals that had attempted suicide presented decreased body mass index (BMI) and waist circumference. After adjusting for these confounders, we found that triglycerides were decreased in attempted suicide subjects. We found no differences among total cholesterol, LDL, and HDL or leptin, S100B, CRP and BDNF.

LIMITATIONS

This is a cross-sectional study, and we cannot therefore assess whether a decrease in triglycerides caused a mood episode with suicidal ideation that led to a suicide attempt or if the presence of a mood episode originated a loss of appetite and consequent loss of weight, therefore decreasing triglyceride levels.

CONCLUSIONS

These results do not support the hypothesis that lower levels of cholesterol are associated with suicidal behavior in a mood disorder sample. However, our data support the idea that adiposity is differentiated in these patients (reduced BMI, waist circumference and serum triglycerides), which could lead to an altered communication between the adipose tissue and brain.

National study of suicide method in violent criminal offenders

BACKGROUND

Gaining a greater knowledge of the mechanisms and means by which violent offenders die by suicide can inform tailored preventive strategies.

METHODS

Using interlinked national Danish registry data we constructed a nested case-control study dataset of all adult suicides during 1994-2006: N=9708 cases and N=188,134 age and gender matched living controls. Completely ascertained International Classification of Diseases 10th revision cause-specific mortality codes were examined, with all criminal charges since 1980, and covariate information on psychiatric treatment and socio-demographics. Self-poisonings were classified as 'nonviolent' suicide and all other methods as being 'violent' ones.

RESULTS

Compared with the general population, risk among male and female violent offenders was strongly and significantly elevated for suicide by either a violent or a nonviolent method, although the relative risk was greater for nonviolent suicide. These patterns were also observed among nonviolent offenders, albeit with smaller effect sizes. Risk was especially raised for self-poisoning with narcotics & hallucinogens. We could only examine the full range of suicide methods in male violent offenders. In these men, hanging was the most frequently used method, although risk was markedly and significantly elevated virtually across the entire range of regularly used suicide methods.

LIMITATIONS

We lacked sufficient statistical power for undertaking a detailed profiling of specific suicide methods among female violent offenders.

CONCLUSIONS

Our findings indicate that comprehensive and broadly-based preventive approaches are needed for tackling the markedly raised risk of suicide by both violent and nonviolent means in this population. Their high relative risk for self-poisoning by illicit or illegal drugs underlines the importance of access to means and of prevailing subculture.

Exposure to prescription drugs labeled for risk of adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide, 2006-2009

Prescription drugs for many indications are labeled with warnings for potential risk of suicidal ideation or behavior. Exposures to prescription drugs labeled for adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide between 2006 and 2009 are described. Air Force registry data were linked to administrative prescription data. Descriptive statistics illustrate utilization: 89 personnel had a prescription history, 35 filled at least one prescription labeled with a warning, 26 had antidepressants on hand at death, and 2 died by drug overdose. Most airmen were not exposed to any prescriptions labeled for risk of suicidal ideation or behavior prior to death by suicide.

Economic conditions and suicide rates in New York City

Extant analyses of the relation between economic conditions and population health were often based on annualized data and were susceptible to confounding by nonlinear time trends. In the present study, the authors used generalized additive models with nonparametric smoothing splines to examine the association between economic conditions, including levels of economic activity in New York State and the degree of volatility in the New York Stock Exchange, and monthly rates of death by suicide in New York City. The rate of suicide declined linearly from 8.1 per 100,000 people in 1990 to 4.8 per 100,000 people in 1999 and then remained stable from 1999 to 2006. In a generalized additive model in which the authors accounted for long-term and seasonal time trends, there was a negative association between monthly levels of economic activity and rates of suicide; the predicted rate of suicide was 0.12 per 100,000 persons lower when economic activity was at its peak compared with when it was at its nadir. The relation between economic activity and suicide differed by race/ethnicity and sex. Stock market volatility was not associated with suicide rates. Further work is needed to elucidate pathways that link economic conditions and suicide.

Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years' data

CONTEXT

A US Food and Drug Administration advisory has warned that antidepressants may be associated with an increased risk of suicidal thoughts and behaviors in adolescents. This prompted a meta-analysis of trials in adults that found no overall increase in risk, but individual agents could not be studied.

OBJECTIVE

To assess the risk of suicide and suicide attempts associated with individual antidepressant agents.

DESIGN

Cohort study of incident users of antidepressant agents.

SETTING

Population-based health care utilization data of all residents of British Columbia, Canada, aged 18 years and older between January 1, 1997, and December 31, 2005.

PATIENTS

British Columbia residents who had antidepressant therapy initiated and had a recorded diagnosis of depression.

INTERVENTION

Initiation of various antidepressant medications.

MAIN OUTCOME MEASURES

Combined suicide death or hospitalization due to self-harm.

RESULTS

In a population of 287,543 adults aged 18 years and older with antidepressant therapy initiated, we observed outcome rates ranging from 4.41/1000 person-years to 9.09/1000 person-years. Most events occurred in the first 6 months after treatment initiation. After extensive propensity score adjustment, we found no clinically meaningful variation in the risk of suicide and suicide attempt between antidepressant agents compared with fluoxetine hydrochloride initiation: citalopram hydrobromide, hazard ratio = 1.00 (95% confidence interval, 0.63-1.57); fluvoxamine maleate, hazard ratio = 0.98 (95% confidence interval, 0.63-1.51); paroxetine hydrochloride, hazard ratio = 1.02 (95% confidence interval, 0.77-1.35); and sertraline hydrochloride, hazard ratio = 0.75 (95% confidence interval, 0.53-1.05). Compared with selective serotonin reuptake inhibitors as a drug class, other classes including serotonin-norepinephrine reuptake inhibitors, tricyclic agents, and other newer and atypical agents had a similar risk. Restriction to patients with no antidepressant use in the past 3 years further reduced apparent differences between groups.

CONCLUSIONS

Our finding of equal event rates across antidepressant agents supports the US Food and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent.

An intercalation mechanism as a mode of action exerted by psychotropic drugs: results of altered phospholipid substrate availabilities in membranes?

Patients respond differently to psychotropic drugs, and this is currently a controversial theme among psychiatrists. The effects of 16 psychotropics on cell membrane parameters have been reported. These drugs belong to three major groups used in therapeutic psychiatry: antipsychotics, antidepressants, and anxiolytic/hypnotics. Human platelets, lacking dopamine (D(2)) receptors (proposed targets of most psychotropics), have been used as a cell model. Here we discuss the effects of these drugs on three metabolic phenomena and also results from Langmuir experiments. Diazepam, in contrast to the remaining drugs, had negligible effects on metabolic phenomena and had no effects in Langmuir experiments. Psychotropic drugs may work through intercalation in membrane phospholipids. It is possible that the fluidity of membranes, rich in essential fatty acids, the content being influenced by diet, could be a contributing factor to the action of psychotropics. This might in turn explain the observed major differences in therapeutic response among patients.

Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies

BACKGROUND

It is unclear whether the use of selective serotonin reuptake inhibitors (SSRIs) and other antidepressant drugs reduce the risk of suicide in people with depression. We explored the association between exposure to SSRIs and risk of suicide completion or attempt.

METHODS

We conducted a systematic review of observational studies that reported completed or attempted suicide in depressed individuals who were exposed to SSRIs compared with those who were not exposed to antidepressants. We assessed the overall risk of completed or attempted suicide.

RESULTS

Eight studies involving more than 200 000 patients with moderate or severe depression were included in the meta-analysis. Although exposure to SSRIs increased the risk of completed or attempted suicide among adolescents (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.51-2.44), the risk was decreased among adults (OR 0.57, 95% CI 0.47-0.70). Among people aged 65 or more years, exposure to SSRIs had a protective effect (OR 0.46, 95% CI 0.27-0.79). Sensitivity analyses did not change these findings. In particular, for studies that used completed suicide as an outcome, exposure to SSRIs was associated with increased risk among adolescents (OR 5.81, 95% CI 1.57-21.51) and decreased risk among adults (OR 0.66, 95% CI 0.52-0.83) and older people (OR 0.53, 95% CI 0.26-1.06).

INTERPRETATION

Based on data from observational studies, use of SSRIs may be associated with a reduced risk of suicide in adults with depression. Among adolescents, use of SSRIs may increase suicidality.

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.