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Treatment Decreased Suicide Risks
Sondegard L, et al.
Archives of Suicide Research   2007;11:163-175
Simon G, et al.
American Journal of Psychiatry   2006;163:41-47
Simon G, Savarino J.
American Journal of Psychiatry   2007;164:1029-1034
Posted: September 2007  

Contrary to the research that prompted the FDA black box warning, several studies have shown no increase in suicide rates with antidepressant therapy. A recent study found suicide risk declined with each successive antidepressant prescription filled. Another large study has found the highest suicide risk in the month before antidepressant therapy was initiated followed by a marked decline in risk with continued treatment. In order to clarify the reasons for the decrease in suicidality, a longitudinal study was conducted of suicidality in patients with depression who began treatment with medication or psychotherapy.

Methods:   Patients, aged = 7 years, with new-onset treatment for depression with psychotherapy or an antidepressant drug were identified from the claims data of a large HMO. The data were used to identify patients who attempted suicide from 90 days before to 180 days after treatment was initiated.

Results:   More than 109,000 patients received treatment for depression. About 55% of treatment episodes began with an antidepressant prescribed by a primary care physician, 40% with psychotherapy, and 5% with an antidepressant prescribed by a psychiatrist. Although overall rates of suicide attempts differed among the 3 groups, all showed a similar time pattern. Attempts increased in the months before treatment, reaching a steep peak in the month before starting treatment, dropping almost as sharply after the onset of treatment, and continuing to decline thereafter. Overall rates were highest in patients prescribed an antidepressant by a psychiatrist and lowest in those treated in primary care, probably reflecting the fact that high-risk patients are most often referred for specialty care.

In more than 23,000 patients under 25 years of age, overall suicide attempt rates were about twice as high as in older patients, but the time pattern was the same.

Discussion:   The striking similarity in results across treatment groups suggests that the decrease in attempted suicide reflects an improvement in depression and suicidal ideation when beginning treatment, not a specific effect of medication or psychotherapy. Although these findings offer some reassurance that SSRIs do not cause suicidality, they do not rule out the possibility for increased suicide risk in a subgroup of vulnerable patients.