Antidepressant prescription and suicide rates: effect of age and gender

A Population-Level Study Concerning the Assumed Association Between Suicide Rates and Antidepressant Consumption in Hungary

BACKGROUND

It has been claimed that the advent of modern antidepressants has reduced the suicide rate.

AIMS

To examine the correlation between the suicide rate and the prescription of antidepressants.

METHOD

A dynamic regression was employed to analyze a 73-month-long, monthly time series between 2010 and 2016 in Hungary. The independent variable was the Defined Daily Dose value for the number of antidepressant (AD) prescriptions filled each month.

RESULTS

The models failed to show a significant association between the prescription of antidepressants and age- and sex-specific monthly suicide rates.

CONCLUSIONS

The prescription of antidepressants in Hungary has had no impact on suicide rates.

Population heterogeneity in associations between hormonal contraception and antidepressant use in Sweden: a prospective cohort study applying intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

OBJECTIVES

From a reproductive justice framework, we aimed to investigate how a possible association between hormonal contraceptive (HC) and antidepressants use (as a proxy for depression) is distributed across intersectional strata in the population. We aimed to visualise how intersecting power dynamics may operate in combination with HC use to increase or decrease subsequent use of antidepressants. Our main hypothesis was that the previously observed association between HC and antidepressants use would vary between strata, being more pronounced in more oppressed intersectional contexts. For this purpose, we applied an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy approach.

DESIGN

Observational prospective cohort study using record linkage of national Swedish registers.

SETTING

The population of Sweden.

PARTICIPANTS

All 915 954 women aged 12-30 residing in Sweden 2010, without a recent pregnancy and alive during the individual 1-year follow-up.

PRIMARY OUTCOME MEASURE

Use of any antidepressant, meaning being dispensed at least one antidepressant (ATC: N06A) during follow-up.

RESULTS

Previously mentally healthy HC users had an OR of 1.79 for use of antidepressants compared with non-users, whereas this number was 1.28 for women with previous mental health issues. The highest antidepressant use were uniformly found in strata with previous mental health issues, with highest usage in women aged 24-30 with no immigrant background, low income and HC use (51.4%). The largest difference in antidepressant use between HC users and non-users was found in teenagers, and in adult women of immigrant background with low income. Of the total individual variance in the latent propensity of using antidepressant 9.01% (healthy) and 8.16% (with previous mental health issues) was found at the intersectional stratum level.

CONCLUSIONS

Our study suggests teenagers and women with immigrant background and low income could be more sensitive to mood effects of HC, a heterogeneity important to consider moving forward.

Suicide along the Australian coast: Exploring the epidemiology and risk factors

Suicide is an increasing global concern with multiple risk factors, yet location-based understanding is limited. In Australia, surf lifesavers (SLS) and lifeguards patrol the coast, performing rescues and assisting injured people, including people who suicide. This study is a descriptive epidemiological analysis of Australian coastal suicide deaths. The results will be used to inform training and support surf lifesaving personnel and suicide prevention organisations. This is a population-based cross-sectional study of suicide deaths at Australian coastal locations (between 1 January 2005 and 31 December 2019). Data were sourced from the National Coronial Information System and SLS Australia's Incident Report Database. Analyses explored decedent, incident, and risk factors by sex and method. Across the study period, there were 666 coastal suicide deaths (71.0% male, 43.4% jumping from high places [X80]). Males were more likely to suicide by other means (hanging, self-poisoning, firearm discharge; n = 145, 83.8%), compared to females who were more likely to suicide by drowning ([X71]; n = 77, 37.7%). In one third (n = 225, 38.3%) toxicology was a contributing factor. The risk of coastal suicides was 10.3 times higher during the seven-days prior to their birthday (p<0.001). Evidence of mental ill health was reported in 61.4% (n = 409) of cases and evidence of suicidal behaviour was reported for 37.4% of decedents (n = 249), more prevalent in females. SLS responded in 10.7% (n = 71) of coastal suicides (most jumps from high places; n = 36, 50.7%). Coastal suicides differ to national trends suggesting that location-based differences should be considered during development of preventative and protective measures, especially at a community level. Accessibility, availability, perceived lethality and symbolic qualities are proposed to influence suicide location decisions. These results will guide support and education strategies for surf lifesaving personnel, contributes to established, ongoing suicide surveillance efforts (including hot-spot identification) and add to the limited literature exploring place-based suicide.

Antidepressant Use and Suicide Rates in Adults Aged 75 and Above: A Swedish Nationwide Cohort Study

Background: The treatment of depression is a main strategy for suicide prevention in older adults. We aimed to calculate suicide rates by antidepressant prescription patterns in persons aged ≥ 75 years. A further aim was to estimate the contribution of antidepressants to the change in suicide rates over time.

Methods: Swedish residents aged ≥ 75 years (N = 1,401,349) were followed between 2007 and 2014 in a national register-based retrospective cohort study. Biannual suicide rates were calculated for those with selective serotonin reuptake inhibitor (SSRI) single use, mirtazapine single use, single use of other antidepressants and use of ≥ 2 antidepressants. The contribution of antidepressants to the change in biannual suicide rates was analyzed by decomposition analysis.

Results: There were 1,277 suicides. About one third of these were on an antidepressant during their last 3 months of life. In the total cohort, the average biannual suicide rate in non-users of antidepressants was 13 per 100,000 person-years. The corresponding figure in users of antidepressants was 34 per 100,000 person-years. These rates were 25, 42 and 65 per 100,000 person-years in users of SSRI, mirtazapine and ≥ 2 antidepressants, respectively. In the total cohort, antidepressant users contributed by 26% to the estimated increase of 7 per 100,000 in biannual suicide rates. In men, biannual suicide rates increased by 11 suicides per 100,000 over the study period; antidepressant users contributed by 25% of the change. In women, those on antidepressant therapy accounted for 29% of the estimated increase of 4.4 per 100,000.

Conclusion: Only one third of the oldest Swedish population who died by suicide filled an antidepressant prescription in their last 3 months of life. Higher suicide rates were observed in mirtazapine users compared to those on SSRIs. Users of antidepressants accounted for only one quarter of the increase in the suicide rate. The identification and treatment of suicidal older adults remains an area for prevention efforts.

Trajectories of Depressive Symptomatology and Loneliness in Older Adult Sexual Minorities and Heterosexual Groups

OBJECTIVES

This article examines whether sexual minority men and women experience greater increases in depressive symptoms and loneliness with age compared to heterosexual men and women.

METHODS

Using three waves of data from sexual minority (n_Men = 87 and n_Women = 62) and heterosexual (n_Men = 1,297 and n_Women = 1,362) older adults in the National Social Life, Health, and Aging Project, we used latent growth curve modeling to test whether change in depressive symptoms and loneliness varies across sexual orientation and whether annual household income and family support accounted for this change.

RESULTS

Although differences in the growth trajectories of depressive symptoms and loneliness across sexual orientation were not observed, gender differences were. Annual household income and family support more strongly influenced initial depressive symptoms and loneliness in sexual minority men and women than in heterosexual men and women.

CONCLUSIONS

Trajectories of depressive symptoms and loneliness in older adulthood do not vary by sexual orientation. Economic and family resources may allow sexual minorities to cope effectively with depressive symptoms and loneliness.

CLINICAL IMPLICATIONS

Clinicians should be cautious about assuming that older sexual minority group members are more susceptible to depressive symptoms and loneliness than heterosexual groups by virtue of their sexual preference.

Availability and use of mental health services in European countries: Influence on national suicide rates

BACKGROUND

Previous research suggests significant increases in suicide mortality rates in European countries following the economic crisis of 2008. However, the relationship between national differences in availability and use of mental health services and suicide rates has not been extensively examined yet.

MATERIALS AND METHODS

Data on mental health services and socioeconomic variables were derived from Eurostat for the years 2000-2013 for ten European countries. The national health care variables consisted of suicide mortality rate (SMR), average length of hospital stay and number of hospitalizations due to affective disorder or any psychiatric disorder, number of psychiatric beds and number of prescribed antidepressants. Economic variables included the gross domestic product (GDP), the gross domestic product per 1000 inhabitants (Real GDP), the rate of unemployment and the GINI-coefficient as a measurement for the equality of wealth distribution. Mixed models were used to investigate the potential influence of the onset of the economic crisis in 2008 on each of the psychiatric variables. Multivariable regression analyses were used to assess the influence on suicide mortality rates.

RESULTS

In this study, a significant change in slope starting from 2008 was revealed for the number of psychiatric beds, hospitalizations due to affective disorder or any psychiatric disorder and for prescribed antidepressants. Furthermore, a significant step change for hospitalizations due to affective disorder was observed in 2008. SMR exhibited a significant step change in 2008 for males and females as well as a significant change in slope from 2008 onwards for males only. Contrary to our hypothesis, most variables showed no statistically significant influence on SMR. Only a higher number of available psychiatric beds was significantly associated with higher suicide mortality rates. This effect, however, was only significant for females and did not remain significant after correcting for economic variables. Less than 10% of suicide mortality rate variability could be explained by a model including all variables, further corroborating the multifactorial etiology of suicide.

LIMITATIONS

Since administrative registry data was used, the results should be interpreted with caution. Results might not be applicable to countries not included.

CONCLUSION

While significant changes in the psychiatric variables, as well as SMR, were observed, no statistically significant influence on SMR remained after correcting for country, time and economic variables. Our study suggests the necessity of a more comprehensive international data gathering effort. Further research is needed to identify populations at risk of suicide.

The Indirect Effect of Perceived Criticism on Suicide Ideation and Attempts

The effect of perceived criticism from others is one potentially important risk factor for suicide that has received scant attention, despite decades of research on the role of criticism in the treatment and course of mental illnesses such as schizophrenia and mood disorders. This study analyzed the effect of perceived criticism's association with suicidal ideation and attempts as well as its connection with the suicide related constructs thwarted belongingness and perceived burdensomeness as described in the Interpersonal Theory of Suicide. Fifty participants (66% female, M_Age = 18.7), 18 of whom had previously made one or more suicide attempts, completed a battery of self-report assessments as well as two in-person, structured clinical interviews. Analyses demonstrated that perceived parental criticism is a significant indicator of suicide ideation (β = .297, p = .003) and attempts (β = .373, p < .001) and that perceived criticism from close friends is a significant indicator of suicide attempts (β = .297, p = .006). Perceived criticism has a strong indirect effect on suicide ideation and attempts through its effect on thwarted belongingness, but not perceived burdensomeness, while controlling for mental illnesses. Some limitations of this study include the cross-sectional design and the use of a relatively small, restricted age sample. Treatment designed to mitigate perceived criticism and thwarted belongingness may be an important component in combatting suicidal ideation and attempts, particularly among young adults.

Antidepressant sales and regional variations of suicide mortality in Germany

Suicides account for over one million deaths per year worldwide with depression among the most important risk factors. Epidemiological research into the relationship between antidepressant utilization and suicide mortality has shown heterogeneous and contradictory results. Different methodological approaches and limitations could at least partially explain varying results. This is the first study assessing the association of suicide mortality and antidepressant sales across Germany using complex statistical approaches in order to control for possible confounding factors including spatial dependency of data. German suicide counts were analyzed on a district level (n = 402) utilizing ecological Poisson regressions within a hierarchical Bayesian framework. Due to significant spatial effects between adjacent districts spatial models were calculated in addition to a baseline non-spatial model. Models were adjusted for several confounders including socioeconomic variables, quality of psychosocial care, and depression prevalence. Separate analyses were performed for Eastern and Western Germany and for different classes of antidepressants (SSRIs and TCAs). Overall antidepressant sales were significantly negatively associated with suicide mortality in the non-spatial baseline model, while after adjusting for spatially structured and unstructured effects the association turned out to be insignificant. In sub-analyses, analogue results were found for SSRIs and TCAs separately. Suicide risk shows a distinct heterogeneous pattern with a pronounced relative risk in Southeast Germany. In conclusion, the results reflect the heterogeneous findings of previous studies on the association between suicide mortality and antidepressant sales and point to the complexity of this hypothesized link. Furthermore, the findings support tailored suicide preventive efforts within high risk areas.

Suicide in older adults: the role of emotions and cognition

Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.

Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study

AIM

To investigate the influence of socioeconomic factors, mental health service availability, and prevalence of mental disorders on regional differences in the suicide rate in Slovenia.

METHODS

The effects of different socioeconomic factors, mental health service availability, and mental disorders factors on suicide rates from 2000-2009 were analyzed using a general linear mixed model (GLMM). Pearson correlations were used to explore the direction and magnitude of associations.

RESULTS

Among socioeconomic factors, unemployment rate ranked as the most powerful predictor of suicide and an increase of one unit in the unemployment rate increased regional suicide rate by 2.21 (β=2.21, 95% confidence intervals [CI]=1.87-2.54, P<0.001). On the other hand, higher marriage/divorce ratio was negatively related to the suicide rate and an increase of one unit in marriage/divorce ratio reduced regional suicide rate by 1.16 (β=-1.16, 95% CI=-2.20 to -0.13, P<0.031). The most influential mental health service availability parameter was higher psychiatrist availability (4 psychiatrists and more working at outpatient clinics per 100 000 inhabitants), which was negatively correlated with the suicide rate and reduced regional suicide rate by 2.95 (β=-2.95, 95% CI=-4.60 to -1.31, P=0.002). Another negatively correlated factor was the antidepressant/anxiolytic ratio higher than 0.5, which reduced the regional suicide rate by 2.32 (β=-2.32, 95% CI=-3.75 to -0.89, P=0.003). Among mental health disorders, only the prevalence of alcohol use disorders was significantly related to the regional suicide rates and an increase of one unit in the prevalence of alcohol use disorders per 1000 inhabitants increased the regional suicide rate by 0.02 (β=0.02, 95% CI=0.01- 0.03, P=0.008).

CONCLUSIONS

Besides unemployment, which was a very strong predictor of suicide rates, unequal availability of mental health services and quality of depressive disorder treatment may contribute to variations in suicide rates in different regions.

Dialectical behavior therapy training to reduce clinical burnout in a public behavioral health system

There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to clients with BPD in order to enhance the quality of patient care.

Age-related response to redeemed antidepressants measured by completed suicide in older adults: a nationwide cohort study

OBJECTIVE

To examine if the suicide rate of older adults prescribed antidepressants varies with age and to assess the proportion of older adults who died by suicide that had recently been prescribed antidepressants.

METHODS

A population-based cohort study using a nationwide linkage of individual-level records was conducted on all persons aged 50+ living in Denmark during 1996-2006 (1,215,524 men and 1,343,568 women). Suicide rates by treatment status were calculated using data on all antidepressant prescriptions redeemed at pharmacies.

RESULTS

Individual-level data covered 9,354,620 and 10,720,639 person-years for men and women, respectively. Men aged 50-59 who received antidepressants had a mean suicide rate of 185 (95% confidence interval [CI]: 160-211) per 100,000, whereas for those aged 80+ the rate was 119 (95% CI: 91-146). For women, the corresponding values were 82 (95% CI: 70-94) and 28 (95% CI: 20-35). Logistic regression showed a 2% and 3% decline in the rate for men and women, respectively, considered in treatment with antidepressants, with each additional year of age. An opposite trend was found for persons not in treatment. Fewer persons aged 80+ dying by suicide had received antidepressant prescriptions during the last months of life than younger persons.

CONCLUSION

An age-dependent decline in suicide rate for antidepressant recipients was identified. One reason could be that older adults respond better to antidepressants than younger age groups. Still, the increasing gap with age between estimated prevalence of depression and antidepressant prescription rate in persons dying by suicide underscores the need for assessment of depression in the oldest old.

Factors associated with temporal and spatial patterns in suicide rates across U.S. states, 1976-2000

Using pooled cross-sectional time-series data for the 50 U.S. states over a 25-year period, this article examines how well four conceptual groups of social correlates-demographic, economic, social, and cultural factors-are associated with the 1976-2000 patterns in overall suicide rates and suicide by firearms and other means. Unlike past research that typically considers only one dimension, this analysis differentiates between spatial and temporal variation in suicide rates to determine whether and how social correlates operate differently in these two contexts. Results indicate that suicide rates correspond closely to social correlates. Within U.S. states, lower overall suicide rates between 1976 and 2000 were associated with demographic change (e.g., larger numbers of foreign-born) as well as with fewer numbers of Episcopalians. Across U.S. states, variation in overall suicide rates over the period was related to demographic (percentage male), economic (per capita income), social (percentage divorced), and cultural (alcohol consumption and gun ownership) factors. However, findings differ importantly by type of suicide, and across time and space. Reasons for these distinct patterns are discussed.

Suicide in Hungary-epidemiological and clinical perspectives

Annual suicide rates of Hungary were unexpectedly high in the previous century. In our narrative review, we try to depict, with presentation of the raw data, the main descriptive epidemiological features of the Hungarian suicide scene of the past decades. Accordingly, we present the annual suicide rates of the period mentioned and also data on how they varied by gender, age, urban vs. rural living, seasons, marital status, etc. Furthermore, the overview of trends of other factors that may have influenced suicidal behavior (e.g., alcohol and tobacco consumption, antidepressant prescription, unemployment rate) in the past decades is appended as well. Based on raw data and also on results of the relevant papers of Hungarian suicidology we tried to explain the observable trends of the Hungarian suicide rate. Eventually, we discuss the results, the possibilities, and the future tasks of suicide prevention in Hungary.

Antidepressant use and method of suicide in the United States: variation by age and sex, 1998-2007

This study examines the association between antidepressant use and suicide rates, by sex, age, and method of suicide, between 1998 and 2007 in the United States. Overall suicide rates for the young and elderly declined but rates for the middle-aged increased. All age groups experienced increases in antidepressant use. The elderly exhibited the largest increase in antidepressant usage and biggest declines in suicide rates. Firearm suicides for men and women declined but suicide by drug poisoning rose, particularly for women. For young males and elderly males and females, better treatment of severe depression may have contributed to declining suicide rates. However, rising rates of prescription drug use are associated with higher levels of suicide by drug poisoning.

Tobacco consumption and antidepressant use are associated with the rate of completed suicide in Hungary: an ecological study

The suicide rate of Hungary is the highest in the world averaged over the last century but it has shown a very pronounced decrease since 1987. To explore the background of this decrease we investigated the associations between some known suicide-related factors (i.e. tobacco use, antidepressant use and alcohol consumption at the population level) and the suicide rate between 1985 and 2008. The total number of man-hours worked per year by psychiatrists in the outpatient service system and real GDP growth were also monitored in our study. A time series analysis model was constructed to investigate the associations between the above variables and the suicide rate. In the unadjusted model annual tobacco consumption was significantly associated with the suicide rate in a positive manner, while antidepressant use and man-hours were significantly associated with the suicide rate in a negative manner. After adjustment, the associations remained significant only for tobacco consumption and antidepressant use. Neither alcohol consumption nor real GDP growth was associated with the suicide rate in any models. Our results from group-level data confirmed the role of smoking in suicidal behavior previously suggested mainly by studies using individual-level data and also corroborated the results of previous ecological studies concerning the inverse association between antidepressant use and suicide rate. These findings and the results of previous studies - investigating the relationship between smoking and the risk of suicidal behavior at the individual-level - may suggest that programs to prevent tobacco use or to address the widespread recognition and treatment of depression may also prevent suicidality.

Antidepressants and Suicide Risk: A Comprehensive Overview

The annual worldwide suicide rate currently averages approximately 13 per 100,000 individuals per year (0.013% per year), with higher average rates for men than for women in all but a few countries, very low rates in children, and relatively high rates in elderly men. Suicide rates vary markedly between countries, reflecting in part differences in case-identification and reporting procedures. Rates of attempted suicide in the general population average 20-30 times higher than rates of completed suicide, but are probably under-reported. Research on the relationship between pharmacotherapy and suicidal behavior was rare until a decade ago. Most ecological studies and large clinical studies have found that a general reduction in suicide rates is significantly correlated with higher rates of prescribing modern antidepressants. However, ecological, cohort and case-control studies and data from brief, randomized, controlled trials in patients with acute affective disorders have found increases, particularly in young patients and particularly for the risk of suicide attempts, as well as increases in suicidal ideation in young patients. whether antidepressants are associated with specific aspects of suicidality (e.g., higher rates of completed suicide, attempted suicide and suicidal ideation) in younger patients with major affective disorders remains a highly controversial question. In light of this gap this paper analyzes research on the relationship between suicidality and antidepressant treatment.

Gender differences in antidepressant use-related seasonality change in suicide mortality in Hungary, 1998-2006

OBJECTIVES

Studies show that the seasonality of suicide (spring/early summer peak, winter low) is mainly the consequence of the seasonal incidence of depression-related suicides. The aim of the present study was to analyse the relationship between increasing antidepressant utilization and national suicide rate of Hungary between 1998 and 2006, with particular regard to seasonal patterns and gender differences.

METHODS

Time trend analysis (ARIMA) had been applied to investigate the correlation between the trend of antidepressant prescription and both of suicide rates and seasonality index.

RESULTS

During the 9 years of the study period there was a significant (P<0.001) correlation between the steadily increasing antidepressant prescription (113%) and continuous decline in total national suicide rate (23%) as well as both in females and males (21 and 23%, respectively), but this relationship was 8-fold stronger in males. Increasing antidepressant utilization was associated with significantly decreased seasonality of suicides only among males.

CONCLUSIONS

The results suggest that decreasing seasonality of suicides could be a good marker of lowering rate of depression-related suicides in the population particularly among males.

Suicidality and suicide in older people

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

Preliminary spatiotemporal analysis of the association between socio-environmental factors and suicide

BACKGROUND

The seasonality of suicide has long been recognised. However, little is known about the relative importance of socio-environmental factors in the occurrence of suicide in different geographical areas. This study examined the association of climate, socioeconomic and demographic factors with suicide in Queensland, Australia, using a spatiotemporal approach.

METHODS

Seasonal data on suicide, demographic variables and socioeconomic indexes for areas in each Local Government Area (LGA) between 1999 and 2003 were acquired from the Australian Bureau of Statistics. Climate data were supplied by the Australian Bureau of Meteorology. A multivariable generalized estimating equation model was used to examine the impact of socio-environmental factors on suicide.

RESULTS

The preliminary data analyses show that far north Queensland had the highest suicide incidence (e.g., Cook and Mornington Shires), while the south-western areas had the lowest incidence (e.g., Barcoo and Bauhinia Shires) in all the seasons. Maximum temperature, unemployment rate, the proportion of Indigenous population and the proportion of population with low individual income were statistically significantly and positively associated with suicide. There were weaker but not significant associations for other variables.

CONCLUSION

Maximum temperature, the proportion of Indigenous population and unemployment rate appeared to be major determinants of suicide at a LGA level in Queensland.

Effect of milnacipran on suicidality in patients with mild to moderate depressive disorder

The presence of suicidal manifestations (thoughts and behavior) was studied in a cohort of 30 patients with mild to moderate depression during a 6-week treatment with the serotonin-norepinephrine reuptake inhibitor, milnacipran. At baseline mild suicidal thoughts were present in 46.7% of patients, the mean Hamilton Depression Rating Score (HDRS(17)) was 23.9 +/- 1.8 and the mean suicidality score on the Beck Scale for Suicidal Ideation (BSS) was 4.9 +/- 4.9. Suicidal thoughts decreased progressively throughout the study in parallel with other depressive symptoms. At no time during treatment was there any indication of an increased suicidal risk. Notably, the items retardation and psychic anxiety on the HDRS(17) decreased in parallel. This may possibly explain the lack of any "activation syndrome", which is occasionally observed at the early stages of therapy with some antidepressants and may be linked to a temporary increase in suicidal ideation. To our knowledge this is the first detailed report of suicidality during treatment with milnacipran.