Suicide risk with selective serotonin reuptake inhibitors and other new-generation antidepressants in adults: a systematic review and meta-analysis of observational studies

[Changes in the perception of benefits and risks of antidepressive pharmacotherapy]

Antidepressive pharmacotherapy has undergone various phases in its history. The euphoria of the early years on the relief of depressive symptoms was followed by a long period of clinical experience and intensive scientific work resulting in a more balanced perspective. Current debates circle around the actual effectiveness, especially with respect to long-term treatment, the prevention of suicide and the sequelae of discontinuation of an antidepressant. The evaluation of antidepressants as a group and often also the risk-benefit ratio of an individual treatment change over time. Antidepressants are typical for many forms of psychiatric treatment which, in a term from Hanfried Helmchen, are just as Janus-faced as psychiatry in a general sense is as a science and as a clinical discipline.

Unveiling potential adverse events associated with escitalopram oxalate: A real-world analysis based FDA adverse event reporting system database

OBJECTIVE

The study aimed to conduct a multidimensional evaluation of potential adverse events (AEs) of escitalopram oxalate based on the FDA adverse event reporting system (FAERS) database.

METHODS

This study utilized the reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma-poisson shrinker (MGPS) to mine and analyze data from the FAERS database from the first quarter of 2004 to the second quarter of 2023.

RESULTS

There was a total of 19,854 AE reports related to escitalopram oxalate, extracting 625 preferred terms (PTs), and covering 27 system organ classes (SOCs). The results showed that the number of reports by females was significantly higher than males, accounting for 57.68%. The reporting number was higher in 2018 and 2019, accounting for 9.50% and 10.18% of the total reports, respectively. The main reporters were consumers and other health professionals, accounting for 26.99% and 26.75% respectively. The majority of the reports were primarily from the United States. Newly emerging AE signals such as intentional overdose (n = 691, ROR 8.51, PRR 8.45, IC 3.05, Empirical Bayesian Geometric Mean (EBGM) 8.35), suicide attempt (n = 665, ROR 8.58, PRR 8.52, IC 3.06, EBGM 8.42), serum serotonin (n = 5, ROR 1044.78, PRR 1044.71, IC 2.56, EBGM 392.39), anti-actin antibody positive (n = 5, ROR 626.87, PRR 626.83, IC 2.56, EBGM 313.91), among others, were not mentioned in the drug's label.

CONCLUSION

While escitalopram oxalate has clear benefits in the treatment of depression and other mental health disorders, the presence of AEs also suggests risks associated with its use. Particularly concerning are risks of suicide and changes in serum serotonin levels.

Academic procrastination, loneliness, and academic anxiety as predictors of suicidality among university students

Suicide is a major public health concern, and university students are at higher risk of suicide than any other age group. The purpose of this study was to examine the prediction power of loneliness, academic anxiety, and academic procrastination on suicidality among university students. A cross-sectional, correlational design was used to recruit 403 university students using the electronic survey format in Jordan. Data were collected regarding loneliness, academic anxiety, academic procrastination, and suicidality. A two-step multiple hierarchical regression analysis was performed. Only 17.1% (n = 69) of students were at risk of suicide, low to moderate level of loneliness, moderate level and moderate to high level of academic procrastination of academic anxiety. The model that included the sociodemographic and the psychological factors was significant (F18,390 = 12.3, p < 0.001) where the total variance in suicidality was 37.3% (R2 = 0.373). Being a working student, being on psychotropic medication, romantic and family relationships domains of loneliness, and academic anxiety were found to be predictors of suicidality (p < 0.05). Suicide is a significant problem among university students. Mental health professionals and policymakers need to enhance the use and access to mental health services and seek psychological counselling to combat the increasingly observed phenomenon of suicide among young people.

Suicide Rates and Prescription of Antidepressants

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.

Drug-induced psychiatric disorders: A pharmacovigilance update

The psychiatric risks associated with drugs are sometimes one of the few restrictions on the use of certain drug classes, such as corticosteroids in patients with a history of severe psychotic episodes associated with this drug class. In this non-exhaustive review, we propose to deal with the most recent issues concerning psychiatric disorders induced by drugs and encountered in doctors' clinical practice. Firstly, we look at depressive disorders and suicide risks, secondly at psychotic and manic disorders and thirdly at anxiety and sleep disorders. While lot of drugs are associated with psychiatric disorders, the confounding by indication represents an important methodological gap since information on the psychiatric profile of patients is not always available. This is particularly the case for serotonin reuptake inhibitors and esketamine used as antidepressants. Recent pharmacovigilance concerns of psychiatric disorders emerged with montelukast, orexin receptor antagonists or cystic fibrosis transmembrane regulator (CFTR) modulators.

Is combined antidepressant medication (ADM) and psychotherapy better than either monotherapy at preventing suicide attempts and other psychiatric serious adverse events for depressed patients? A rare events meta-analysis

Antidepressant medication (ADM)-only, psychotherapy-only, and their combination are the first-line treatment options for major depressive disorder (MDD). Previous meta-analyses of randomized controlled trials (RCTs) established that psychotherapy and combined treatment were superior to ADM-only for MDD treatment remission or response. The current meta-analysis extended previous ones by determining the comparative efficacy of ADM-only, psychotherapy-only, and combined treatment on suicide attempts and other serious psychiatric adverse events (i.e. psychiatric emergency department [ED] visit, psychiatric hospitalization, and/or suicide death; SAEs). Peto odds ratios (ORs) and their 95% confidence intervals were computed from the present random-effects meta-analysis. Thirty-four relevant RCTs were included. Psychotherapy-only was stronger than combined treatment (1.9% v. 3.7%; OR 1.96 [1.20-3.20], p = 0.012) and ADM-only (3.0% v. 5.6%; OR 0.45 [0.30-0.67], p = 0.001) in decreasing the likelihood of SAEs in the primary and trim-and-fill sensitivity analyses. Combined treatment was better than ADM-only in reducing the probability of SAEs (6.0% v. 8.7%; OR 0.74 [0.56-0.96], p = 0.029), but this comparative efficacy finding was non-significant in the sensitivity analyses. Subgroup analyses revealed the advantage of psychotherapy-only over combined treatment and ADM-only for reducing SAE risk among children and adolescents and the benefit of combined treatment over ADM-only among adults. Overall, psychotherapy and combined treatment outperformed ADM-only in reducing the likelihood of SAEs, perhaps by conferring strategies to enhance reasons for living. Plausibly, psychotherapy should be prioritized for high-risk youths and combined treatment for high-risk adults with MDD.

Effect of selective serotonin reuptake inhibitor treatment following diagnosis of depression on suicidal behaviour risk: a target trial emulation

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.

Drug Safety and Suicidality Risk of Chronic Pain Medications

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.

Observational studies of antidepressant use and suicide risk are selectively published in psychiatric journals

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.

Risk of repeated suicide attempt after redeeming prescriptions for antidepressants: a register-based study in Denmark

BACKGROUND

It remains unclear how SSRIs and other antidepressants are associated with the risk of repeated suicide attempts. We aimed to analyse the association between redeemed antidepressant prescriptions and the risk of repeated suicide attempts, hypothesising that antidepressant treatment is associated with increased risk of repeated suicide attempts.

METHODS

The study was based on Danish register data and a validated cohort of 1842 suicide attempts. We used three Cox regression models (crude, adjusted and propensity score matched) to analyse the data; these models included both static and dynamic time-dependent factors.

RESULTS

1842 individuals attempted suicide in the study period, with a total of 210 repeated attempts. Individuals redeeming antidepressant prescriptions were more likely to repeat a suicide attempt. All crude models showed all antidepressants to be significant risk factors (HR around 1.39), whereas all adjusted models showed all antidepressants to be insignificant risk factors.

CONCLUSION

We found no significant increased risk of repeated suicide attempts in individuals redeeming a prescription for any antidepressant (or only SSRIs) when considering the individuals' baseline risk of repetition. This study is based on validated suicide attempts, register data, and strong epidemiology designs, but it still has some limitations, and the results should be replicated and confirmed in other studies.

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

The Effect of Herbal Medicine on Suicidal Behavior: A Protocol for Systematic Review and Meta-Analysis

Suicide is an important social and medical problem worldwide, including in countries that use traditional East Asian medicine (TEAM). Herbal medicine (HM) has been reported to be effective against several suicide-related conditions. This systematic review aimed to investigate the efficacy and safety of HM in reducing suicidal behavior including suicidal ideation, attempts, or completed suicide. We conduct a comprehensive search in 15 electronic bibliographic databases from inception to September 2022. All types of prospective clinical studies-including randomized controlled clinical trials (RCTs)-involving HM without or with routine care are included. The primary outcomes of this review are validated measures of suicidal ideation including the Beck scale for suicidal ideation. The revised Cochrane's risk of bias tool and other tools including the ROBANS-II tool are used to assess the methodological quality of RCTs and non-RCTs, respectively. A meta-analysis is performed using RevMan 5.4 in cases of homogeneous data from controlled studies. The results of the systematic review provide high-quality evidence to determine the efficacy and safety of HM for suicidal behavior. Our findings are informative for clinicians, policymakers, and researchers, aimed at reducing suicide rates, especially in countries that use TEAM.

Gap between the Scientificization and Utilization of Korean Medicine for Depressive Disorder in South Korea with the Highest Suicide Rate among OECD Countries

In South Korea, with the highest suicide rate among Organization for Economic Co-operation and Development countries, doctors of both Korean medicine (KM) and Western medicine (WM) are licensed in the national healthcare system. The beneficial effects of complementary and integrative medicine, including KM, for depressive disorders, a major cause of suicide, have been reported in some clinical studies. Longitudinal change (2012-2021) of KM and WM use for depressive disorders and the attempts to scientificize KM in the context of depressive disorders were investigated. Specifically, clinical practice guidelines (CPGs) and national R&D projects of KM in the treatment of depressive disorders were investigated. The use of KM treatment for patients with a depressive disorder appears to be gradually decreasing in South Korea (annual number of patients in 2012 and 2021: 3607 and 2151 (-40.37%)), while the use of WM treatment is increasing (662,947 and 989,909 (+49.32%)). With the support of the government, KM CPG for depressive disorders and some R&D projects on KM for depressive disorders are being implemented. Our findings highlight the gap between the accumulation of clinical evidence, or the government's efforts to promote the evidence-based use of KM for depressive disorders, and its practical use in South Korea.

Telehealth-Supported Decision-making Psychiatric Care for Suicidal Ideation: Longitudinal Observational Study

Background

Suicide is a leading cause of death in the United States, and suicidal ideation (SI) is a significant precursor and risk factor for suicide.

Objective

This study aimed to examine the impact of a telepsychiatric care platform on changes in SI over time and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission.

Methods

Participants included 8581 US-based adults (8366 in the treatment group and 215 in the control group) seeking treatment for depression, anxiety, or both. The treatment group included patients who had completed at least 12 weeks of treatment and had received a prescription for at least one psychiatric medication during the study period. Providers prescribed psychiatric medications for each patient during their first session and received regular data on participants. They also received decision support at treatment onset via the digital platform, which leveraged an empirically derived proprietary precision-prescribing algorithm to give providers real-time care guidelines. Participants in the control group consisted of individuals who completed the initial enrollment data and completed surveys at baseline and 12 weeks but did not receive care.

Results

Greater feelings of hopelessness, anhedonia, and feeling bad about oneself were most significantly correlated (r=0.24-0.37) with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI (r=0.13-0.14). In terms of demographic variables, advancing age and education were associated with less SI at baseline (r=−0.16) and 12 weeks (r=−0.10) but less improvement over time (r=−0.12 and −0.11, respectively). Although not different at baseline, the SI expression was evident in 34.4% (74/215) of the participants in the control group and 12.32% (1031/8366) of the participants in the treatment group at 12 weeks. Although the participants in the treatment group improved over time regardless of various demographic variables, participants in the control group with less education worsened over time, after controlling for age and depression severity. A model incorporating the treatment group, age, sex, and 8-item Patient Health Questionnaire scores was 77% accurate in its classification of complete remission. Those in the treatment group were 4.3 times more likely (odds ratio 4.31, 95% CI 2.88-6.44) to have complete SI remission than those in the control group. Female participants and those with advanced education beyond high school were approximately 1.4 times more likely (odds ratio 1.38, 95% CI 1.18-1.62) to remit than their counterparts.

Conclusions

The results highlight the efficacy of an antidepressant intervention in reducing SI, in this case administered via a telehealth platform and with decision support, as well as the importance of considering covariates, or subpopulations, when considering SI. Further research and refinement, ideally via randomized controlled trials, are needed.

Therapeutic and Prophylactic Effects of Amphotericin B Liposomes on Chronic Social Defeat Stress-Induced Behavioral Abnormalities in Mice

Recently, innate immune system stimulants, such as lipopolysaccharide (LPS) and macrophage-colony stimulating factor (M-CSF), were reported to prevent and reverse chronic stress-induced behavioral abnormalities, suggesting that innate immune stimulation could be a potential strategy for the treatment and prevention of mental disorders. Amphotericin B liposome is a clinically available antifungal medication that can stimulate macrophages and microglia. We hypothesize that amphotericin B liposome may be used to prevent and reverse behavioral abnormalities triggered by chronic stress. As expected, our results showed that a single injection of amphotericin B liposome (1 mg/kg) immediately after stress cessation reversed the decrease in time spent in the interaction zone in the social interaction test (SIT) and the increase in immobility time in the tail suspension test (TST) and forced swimming test (FST) in mice caused by chronic social defeat stress (CSDS). In addition, a single injection of amphotericin B liposomes (1 mg/kg) 1 day before stress exposure was found to prevent the CSDS-induced decrease in time spent in the interaction zone in the SIT and the increase in immobility time in the TST and FST in mice. Pretreatment with minocycline to inhibit the innate immune response was able to abolish the reversal effect of post-stress injection of amphotericin B liposomes on CSDS-induced behavioral abnormalities and the prophylactic effect of pre-stress injection of amphotericin B liposomes on CSDS-induced behavioral abnormalities. These results demonstrate that amphotericin B liposomes have both therapeutic and prophylactic effects on chronic stress-induced behavioral abnormalities in mice by mobilizing the innate immune response.

Antidepressant treatment trajectories and suicide attempt among Australians aged 45 years and older: A population study using individual prescription data

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.

Observing time effect of SSRIs on suicide risk and suicide-related behaviour: a network meta-analysis protocol

INTRODUCTION

Suicide is a serious problem worldwide and 90% cases are associated with pre-existing or underlying mental illness. As a common treatment for depressive symptoms that suicidal people may receive, selective serotonin reuptake inhibitors (SSRIs) have been linked to a possible increase in suicide rates. Studies focusing on SSRIs and suicide have produced inconsistent results, suggesting that use of SSRIs decreases, increases, has no effect on suicide rates, or that the effect of SSRIs on suicide is age-dependent. This protocol of network meta-analysis aims to precisely evaluate the time effects of SSRIs by observing weekly changes of suicidality in the first 2 months of the treatment, and consequently, to explore whether the effect of the SSRIs on suicide varies depending on the stages of the treatment; if so, we will identify the turning point.

METHODS AND ANALYSIS

We will search in the following databases: PubMed, Web of science, China National Knowledge Infrastructure and Wanfang Data, from dates of inception to 9 July 2021, with language restricted to English and Chinese. Studies focusing on the time effect of SSRIs on suicide will be retrieved. Then, the study selection process will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, and the quality assessment will be conducted with Cochrane Collaboration's tool. Two researchers will work independently on data extraction using a standardised data extraction spreadsheet. Any disagreement between two researchers will be discussed and determined by a third researcher.

ETHICS AND DISSEMINATION

This work does not require ethics approval as it will be based on published studies. This review will be published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021244779.

Functional gastrointestinal disorders as predictors of suicidal ideation. An observational study

BACKGROUND/OBJECTIVES

Suicidal ideation (SI), a symptom of depression, is known to be associated with irritable bowel syndrome (IBS) but is not known to be associated with other functional gastrointestinal disorders (FGIDs). However, the source of this association is discussed. It could be related to a possible abnormal biochemical pathway implicating neurotransmitters common to both disorders like serotonin or pain and an ill-being associated with a chronic disorder of unknown etiology. The present study aims to search for the FGIDs associated with suicidal ideation.

DESIGN

Observational study.

METHODS

A total of 1469 patients with FGIDs (71% of women) were included in the present study. They filled the Rome III questionnaire, Beck depression inventory, and state and trait anxiety questionnaires. Data were analyzed using analysis of variance with Bonferroni correction and logistic regression analysis.

RESULTS

Suicidal ideation was reported by 15% of patients, associated with increased scales of depression (P < 0.001), state (P = 0.006), and trait anxiety (P = 0.021). Clinically, these patients reported a higher prevalence of IBS-diarrhea subtype (P = 0.045), fecal incontinence (P = 0.020), soiling (P = 0.016), and difficult defecation (P = 0.005), and higher perceived severity for constipation, diarrhea, bloating, and abdominal pain (P < 0.001 for all scales).

CONCLUSIONS

This study shows that only functional bowel and functional anorectal disorders are associated with suicidal ideation. This result must be taken into account in the management of these patients.

Did the introduction and increased prescribing of antidepressants lead to changes in long-term trends of suicide rates?

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.

On the Relationship between Classic Psychedelics and Suicidality: A Systematic Review

Use of classic psychedelics (e.g., psilocybin, ayahuasca, and lysergic acid diethylamide) is increasing, and psychedelic therapy is receiving growing attention as a novel mental health intervention. Suicidality remains a potential safety concern associated with classic psychedelics and is, concurrently, a mental health concern that psychedelic therapy may show promise in targeting. Accordingly, further understanding of the relationship between classic psychedelics and suicidality is needed. Therefore, we conducted a systematic review of the relationship between classic psychedelics (both non-clinical psychedelic use and psychedelic therapy) and suicidality. We identified a total of 64 articles, including 41 articles on the association between non-clinical classic psychedelic use and suicidality and 23 articles on the effects of psychedelic therapy on suicidality. Findings on the association between lifetime classic psychedelic use and suicidality were mixed, with studies finding positive, negative, and no significant association. A small number of reports of suicide and decreased suicidality following non-clinical classic psychedelic use were identified. Several cases of suicide in early psychedelic therapy were identified; however, it was unclear whether this was due to psychedelic therapy itself. In recent psychedelic therapy clinical trials, we found no reports of increased suicidality and preliminary evidence for acute and sustained decreases in suicidality following treatment. We identify some remaining questions and provide suggestions for future research on the association between classic psychedelics and suicidality.