Date: 31 Jul 2008

Do SSRIs or antidepressants in general increase suicidality?

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In the past few years several papers have reported critically on the risk of suicidal thoughts and behaviour associated with antidepressants, primarily SSRIs. The risk-benefit ratio of antidepressant (AD) treatment has been questioned especially in children and adolescents. The critical publications led to warnings being issued by regulatory authorities such as the FDA, MHRA and EMEA and stimulated new research activity in this field. However, potential harmful effects of antidepressants on suicidality are difficult to investigate in empirical studies because these have several methodological limitations. Randomised controlled trials (RCTs) are the most reliable way to test the hypothesis that AD have such side effects. In addition to meta-analyses of RCTs, complementary research methods should be applied to obtain the most comprehensive information. We undertook a comprehensive review of publications related to the topics ADs, suicide, suicidality, suicidal behaviour and aggression. Based on this comprehensive review we conclude that ADs, including SSRIs, carry a small risk of inducing suicidal thoughts and suicide attempts, in age groups below 25 years, the risk reducing further at the age of about 30–40 years. This risk has to be balanced against the well-known beneficial effects of ADs on depressive and other symptoms (anxiety, panic, obsessive-compulsive symptoms), including suicidality and suicidal behaviour. According to the principles of good clinical practice, decision making should consider carefully the beneficial effects of AD treatment as well as potentially harmful effects and attempt to keep the potential risks of AD treatment to a minimum. It is the major problem facing efforts to identify the possible ‘suicidal effects’ of antidepressants.

WPA Section on Pharmacopsychiatry: Hans-Jürgen Möller (Section Chairman); Ulrik Malt (Section Secretary); Bernd Saletu (Section Treasurer), A. Carlo Altamura, David S. Baldwin, David Baron, Michael Bauer, R.H. Belmaker, Pierre Blier, Patrice Boyer, William E. Bunney, Graham Burrows, Wolfang Fleischhacker, Daniel Flores, Wagner F. Gattaz, Guy Goodwin, Gerardo Heinze, Ian Hindmarch, Hans Hippius, Cyril Hoschl, Siegfried Kasper, Per Kragh-Sorensen, Juan J. Lopez-Ibor, Ulrik Malt, Bruno Millet, Sung Kil Min, Jaime Monti, Bruno Muller-Oerlinghausen, Franz Muller-Spahn, David J. Nutt, Ahmed Okasha, Jean Pierre Olie, Eugene S. Paykel, Giorgio Racagni, Perry Renshaw, Raben Rosenberg, Bruce Singh, Dan J. Stein, Rajiv Tandon, Marcio Versiani, Eduard Vieta, Joseph Zohar