Comparison of antidepressant classes and the risk and time course of suicide attempts in adults: propensity matched, retrospective cohort study

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.

Antidepressant use and risk of self-harm among people aged 40 years or older: A population-based cohort and self-controlled case series study

BACKGROUND

Studies on the association between antidepressants and self-harm in adults were mostly conducted over a decade ago and have inconsistent findings. We aimed to compare self-harm risks by antidepressant classes among people aged 40 years or older with depression.

METHODS

Individuals aged ≥40 years with depression who initiated antidepressant treatment between 2001 and 2015 were retrieved from the Hong Kong Clinical Data Analysis & Reporting system, and were followed up until December 31, 2016. We conducted self-controlled case series (SCCS) analyses to estimate the incidence rate ratio (IRR) of self-harm comparing the pre-exposure (90 days before the first antidepressant use), index exposure (the first antidepressant use), and subsequent exposure (subsequent antidepressant use) periods to nonexposed periods. We applied Cox proportional hazard regressions to estimate the hazard ratio (HR) of self-harm comparing five antidepressant classes (tricyclic and related antidepressant drugs [TCAs], selective serotonin reuptake inhibitors [SSRIs], noradrenergic and specific serotonergic antidepressants [NaSSAs], serotonin-norepinephrine reuptake inhibitors [SNRIs], and others).

FINDINGS

A total of 48,724 individuals were identified. SCCS analyses (N = 3,846) found that the increased self-harm risk occurred during the pre-exposure (IRR: 22.24; 95% CI, 20.25-24.42), index exposure (7.03; 6.34-7.80), and subsequent exposure periods (2.47; 2.18-2.79) compared to the unexposed period. Cohort analyses (N = 48,724) found an association of higher self-harm risks in short-term (one year) for NaSSAs vs. TCAs (HR, 2.13; 95% CI, 1.53-2.96), SNRIs vs. TCAs (1.64; 1.01-2.68), and NaSSAs vs. SSRIs (1.75; 1.29-2.36) in the 40-64 years group. The higher risk remained significant in long-term (> one year) for NaSSAs vs. TCAs (1.55; 1.26-1.91) and NaSSAs vs. SSRIs (1.53; 1.26-1.87). In the 65+ group, only short-term differences were observed (SSRIs vs. TCAs [1.31; 1.03-1.66], SNRIs vs. SSRIs [0.44; 0.22-0.87], and SNRIs vs. NaSSAs [0.43; 0.21-0.87]).

INTERPRETATION

Within-person comparisons did not suggest that antidepressant exposure is causally associated with an increased risk of self-harm in people with depression. Between-person comparisons revealed differences in self-harm risks between certain pairs of antidepressant classes. These findings may inform clinicians' benefit-risk assessments when prescribing antidepressants.

FUNDING

Nil.

Association between mirtazapine use and serious self-harm in people with depression: an active comparator cohort study using UK electronic health records

Background

Studies report an increased risk of self-harm or suicide in people prescribed mirtazapine compared with other antidepressants.

Objectives

To compare the risk of serious self-harm in people prescribed mirtazapine versus other antidepressants as second-line treatments.

Design and setting

Cohort study using anonymised English primary care electronic health records, hospital admission data and mortality data with study window 1 January 2005 to 30 November 2018.

Participants

24 516 people diagnosed with depression, aged 18–99 years, initially prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine, a different SSRI, amitriptyline or venlafaxine.

Main outcome measures

Hospitalisation or death due to deliberate self-harm. Age–sex standardised rates were calculated and survival analyses were performed using inverse probability of treatment weighting to account for baseline covariates.

Results

Standardised rates of serious self-harm ranged from 3.8/1000 person-years (amitriptyline) to 14.1/1000 person-years (mirtazapine). After weighting, the risk of serious self-harm did not differ significantly between the mirtazapine group and the SSRI or venlafaxine groups (HRs (95% CI) 1.18 (0.84 to 1.65) and 0.85 (0.51 to 1.41) respectively). The risk was significantly higher in the mirtazapine than the amitriptyline group (3.04 (1.36 to 6.79)) but was attenuated after adjusting for dose.

Conclusions

There was no evidence for a difference in risk between mirtazapine and SSRIs or venlafaxine after accounting for baseline characteristics. The higher risk in the mirtazapine versus the amitriptyline group might reflect residual confounding if amitriptyline is avoided in people considered at risk of self-harm.

Clinical implications

Addressing baseline risk factors and careful monitoring might improve outcomes for people at risk of serious self-harm.

Risk of Suicidal Behaviors and Antidepressant Exposure Among Children and Adolescents: A Meta-Analysis of Observational Studies

OBJECTIVES

Although several studies have reviewed the suicidal risk of antidepressants, the conclusions remain inconsistent. We, therefore, performed a meta-analysis of observational studies to address the association between exposure to antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and the risk of suicide and suicide attempt in children and adolescents.

METHODS

MEDLINE and Embase were searched from January 1990 to April 2021. Seventeen cohort and case-control studies were identified that reported suicide or suicide attempt in children and young adults (aged 5-25 years) who were exposed to any antidepressants. We extracted the estimates and corresponding 95% confidence intervals (CIs) from each publication.

RESULTS

The results showed that antidepressant exposure significantly increased the risk of suicide and suicide attempt when compared with no antidepressant usage among children and adolescents. The pooled relative risk (RR) was 1.38 (95% CI: 1.16-1.64; I ² = 83.1%). Among the antidepressants, SSRI use was associated with an increased risk of suicide and suicide attempt, and the pooled RR was 1.28 (95% CI: 1.09-1.51; I ² = 68.8%). In subgroup analysis, the attempted suicidal risk of antidepressant and SSRI was significantly increased (RR = 1.35, 95% CI: 1.13-1.61; I ² = 86.2% for all antidepressants; and RR = 1.26, 95% CI: 1.06-1.48; I ² = 73.8% for SSRIs), while the completed suicidal risk of antidepressant and SSRI was not statistically significant (RR = 2.32, 95% CI: 0.82-6.53; I ² = 6.28% for all antidepressants; and RR = 1.88, 95% CI: 0.74-4.79; I ² = 52.0% for SSRIs). In addition, the risk of suicide and suicide attempt between SSRIs and other antidepressants was similar (RR 1.13, 95% CI: 0.87-1.46, I ² = 32.4%).

CONCLUSION

The main findings of this meta-analysis provide some evidence that antidepressant exposure seems to have an increased suicidal risk among children and young adults. Since untreated depression remains one of the largest risk factors for suicide and the efficacy of antidepressants is proven, clinicians should evaluate carefully their patients and be cautious with patients at risk to have treatment emergence or worsening of suicidal ideation (TESI/TWOSI) when prescribing antidepressants to children and young patients.

Effects of somatic treatments on suicidal ideation and completed suicides

OBJECTIVE

This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide.

METHODS

Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides.

RESULTS

Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term.

CONCLUSIONS

Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.

Relationship between suicide rate and antidepressant prescription: An ecological study in the People's Republic of China

OBJECTIVES

The objective of this study was to estimate the features of suicide rate and its association with antidepressant prescriptions during the past decade in China.

METHODS

Official data on suicides were obtained and stratified by four age groups, gender, urban/rural areas, and regions (East, Central, and West). The annual antidepressant prescriptions were expressed in pills per 100 persons calculated as the volume of prescriptions divided by the total population. Negative binomial regression was carried out to examine the association between suicide and other variables.

RESULTS

Suicide rates in each stratum typically decreased from 2008 to 2015, while annual antidepressant prescriptions were generally increased by the year. The suicide rate increased with age and was greater in adult males than in females; higher in the central area and greater in rural than in urban areas. Suicide rates are negatively associated with antidepressant prescriptions including selective serotonin reuptake inhibitors (Incidence rate ratio [IRR] 0.983, 95% confidence interval [CI] 0.983-0.983), serotonin-norepinephrine reuptake inhibitors (IRR 0.951, 95% CI 0.951-0.951), tricyclic antidepressant (IRR 0.925, 95% CI 0.925-0.925) and total antidepressants (IRR 0.990, 95% CI 0.990-0.990) during 2008-2012.

CONCLUSION

Suicide varied among different studied stratum. Suicide rates are negatively associated with antidepressant prescriptions.

Measuring suicide risk in the elderly with non-institutionalized depression: an integrative review

OBJECTIVE

Analyze the state of the art about instruments, at national and international levels, for assessing the risk of suicide in elderly people with depression assisted in the community.

METHODS

Integrative review of 38 complete articles, published in journals indexed in the databases: US National Library of Medicine (PubMed Central), Scopus, CINAHL and Web of Science, located using controlled descriptors combined with Boolean operators: elderly OR aged OR older OR elder OR geriatric AND depression AND suicide AND risk assessment.

RESULTS

Six instruments were found, all international and published in the English language, in order to identify suicidal behavior and ideation in the elderly. Of these, two are specific scales for assessing the risk of suicide in the elderly in the community: 5-item GDS subscale and Geriatric Suicide Ideation Scale.

FINAL CONSIDERATIONS

With the scarcity of national instruments to assess such risk, research is recommended to cross-culturally adapt one of these scales to the Brazilian Portuguese language.

Incidence of suicidal behaviour and violent crime following antidepressant medication: a Danish cohort study

OBJECTIVE

To examine the incidence of suicidal and violent behaviour following initiation of antidepressant medication.

METHOD

Cohorts of 997 911 conscripts and 95 794 patients with a first-time affective disorder were followed for purchase of antidepressant medication, suicide, suicide attempts and conviction for violent crime in Danish registries between 1997 through 2015. Incidence of outcomes was estimated for the first 28 days, 28-365 days or later after initiation of antidepressants or study entry.

RESULTS

Of 16.5% of conscripts and 73.7% of patients with affective disorders initiated antidepressant medication. Incidence of suicide was 3-4 times higher during the first 28 days after initiation compared to the rates in the following year in both cohorts. A similar trend was seen among the untreated patients with affective disorders, whereas suicide incidence was stable at a low level among conscripts not treated with antidepressants. Incidence of attempted suicide was highest during the 28 days before and after initiation of antidepressants, while rates of violent crime were similar before and after initiation. These trends in incidence were independent of class of antidepressant.

CONCLUSION

Higher rates of suicidal behaviour in the weeks following initiation of antidepressant medication probably reflect disease severity and a delay in mood response.

A Review of Telemental Health as a Modality to Deliver Suicide-Specific Interventions for Rural Populations

Introduction: Despite recent advancements in the development of new suicide prevention interventions, suicide rates continue to rise in the United States. As such, suicide prevention efforts must continue to focus on expanding dissemination of suicide-specific interventions. Methods: This review explores telemental health through two-way synchronous clinical video telehealth (CVT) technologies as one approach to improving access to suicide-specific interventions. Results: Studies were reviewed if (1) the modality of interest was telemental health by CVT and (2) management, assessment, or intervention of suicidal thoughts or behaviors was discussed. A total of 22 studies were included. Conclusions: Findings from the limited existing studies are synthesized, and recommendations are provided for future research, clinical, and educational advancements.

[Antidepressants and Suicidality: A Contradiction?]

Antidepressants and Suicidality: A Contradiction? Abstract. In 2004, the European and American authorities released a black-box warning on antidepressants indicating an association with an increased risk of suicidality (suicidal ideation and behavior) in young people. Until today, this issue remained controversial. The present review gives an overview on the relationship between antidepressant therapy and the risk of suicide and suicidality, respectively: there is no evidence of an increased risk of suicide, but of an increased rate of suicidality during the first period after starting an antidepressant treatment in young patients. Importantly, this risk was not higher than before treatment initiation. However, an intensified supervision is needed especially during the first weeks of treatment. Finally, the risk posed by untreated depression is far greater than a risk associated with antidepressant treatment.

Effects of selective serotonin reuptake inhibitors on rating-scale-assessed suicidality in adults with depression

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) have been claimed to elicit or aggravate suicidal ideation. Aims To explore the effect of SSRIs on the suicidality item of the Hamilton Rating Scale for Depression (HRSD).

METHOD

We undertook a patient-level mega-analysis of adults with depression participating in industry-sponsored studies of sertraline, paroxetine or citalopram, comparing patients on an SSRI (n = 5681) with those on placebo (n = 2581) with respect to HRSD-rated suicidality. Separate analyses were conducted for young adults (age 18-24; n = 537) and adults (age ≥25; n = 7725).

RESULTS

Among adults, the reduction in mean rating of suicidality was larger and the risk for aggravation of suicidality lower in patients receiving an SSRI from week 1 and onwards. In young adults, SSRI treatment neither reduced nor increased suicidality ratings relative to placebo at the end-point.

CONCLUSIONS

The net effect of SSRIs on suicidality appears beneficial in people above the age of 24 and neutral in those aged 18-24. Declaration of interest F.H. has received speaker's fees from Servier. E.E. has previously been on the advisory boards and/or received speaker's honoraria and/or research grants from Eli Lilly, GlaxoSmithKline, Servier and Lundbeck.

Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment

Suicidal behavior is strongly associated with depression, especially if accompanied by behavioral activation, dysphoria, or agitation. It may respond to some treatments, but the design of scientifically sound, ethical trials to test for therapeutic effects on suicidal behavior is highly challenging. In bipolar disorder, and possibly also unipolar major depression, an underprescribed medical intervention with substantial evidence of preventive effects on suicidal behavior is long-term treatment with lithium. It is unclear whether this effect is specifically antisuicidal or reflects beneficial effects of lithium on depression, mood instability, and perhaps aggression and impulsivity. Antisuicidal effects of anticonvulsant mood stabilizers (carbamazepine, lamotrigine, valproate) appear to be less than with lithium. Further evaluation is needed for potential antisuicidal effects of atypical antipsychotics with growing evidence of efficacy in depression, particularly acute bipolar depression, while generally lacking risk of inducing agitation, mania, or mood instability. Short-term and long-term value and safety of antidepressants are relatively secure for unipolar depression but uncertain and poorly tested for bipolar depression; their effects on suicidal risk in unipolar depression may be age-dependent. Sedative anxiolytics are virtually unstudied as regards suicidal risks. Adequate management of suicidal risks in mood disorder patients requires comprehensive, clinically skillful monitoring and timely interventions.

Clinical Characteristics Associated with Suicide Attempts in Clinical Settings: A Comparison of Suicidal and Non-Suicidal Depressed Inpatients

INTRODUCTION

Both psychiatrists and psychiatric nurses are involved in the psychiatric management of suicidal inpatients. One-to-one observation by qualified nurses and the accommodation of the patient in a room close to the infirmary are usually recommended. Suicidal risk should be reassessed periodically to check response to treatment.

AIM

To compare the severity of depressive symptoms in depressed inpatients admitted after an attempted suicide and those admitted for any other reason and to assess the severity of suicide attempts and the management of suicidal risk in clinical settings.

MATERIALS AND METHODS

We divided the sample into two subgroups: patients with a diagnosis of depression admitted because of a recent suicide attempt and depressed patients with no recent history of attempted suicide. Socio-demographic and clinical data were gathered; assessments included the Montgomery-Asberg Depression Rating Scale and the Nurses' Global Assessment of Suicide Risk (NGASR).

RESULTS

Forty-six patients were recruited over a 1-year period: 20 were admitted to the hospital following a suicide attempt; the other 26 had not attempted suicide and were admitted for other depression-related reasons. Multivariate analysis revealed a correlation between use of antidepressants and recent attempted suicide. Attempting suicide was not related to the severity of depressive symptoms. In the recent suicide attempt subgroup, NGASR suicide risk levels were lower at discharge than at admission. Patients with a recent history of attempted suicide had a higher number of suicide attempts in their clinical history than patients with no recent history of attempted suicide.

CONCLUSION

There were no correlations between psychiatric diagnosis, severity of depressive symptoms, and recent suicide attempt. Antidepressant therapy protected against suicide attempts. History of suicide attempts was one of the best predictors of recent attempted suicide. A more thorough understanding of the complex phenomenon of suicide and the reasons for suicidal behavior is needed.