A study of more than 200,000 veterans adds to the evidence that treating
depression reduces suicide attempts, even among young adults.
The results contrast with findings by the U.S. Food and Drug Administration
(FDA) that suicidality rises after treatment in young people aged 18 to 25.
Those findings led the agency to expand its black-box warning recently
(Psychiatric News, June 1).
"The risk of suicide attempt among patients treated with an SSRI was
about one-third that of patients who were not treated with an SSRI,"
wrote the authors in the July American Journal of Psychiatry.
Their conclusions held for all age groups, they said. "In contrast to
the FDA's findings, our analysis of the VA data indicates that these
protective effects also apply to patients in the 18- to-25-year-old age
Using data from the Veterans Health Administration, researchers led by
Robert Gibbons, Ph.D., director of the Center for Health Statistics and a
professor of biostatistics and psychiatry at the University of Illinois at
Chicago, examined the relationship between antidepressant treatment and
suicide attempts in a group of 226,866 veterans with depression. These
patients had experienced depressive or unipolar mood disorders in 2003 or
2004, had at least six months of follow-up, and had no history of such
disorders or antidepressant treatment from 2000 to 2002.
Outcomes were based on suicide-related diagnostic codes in patient records,
but not cause-of-death information.
About 26 percent of the patients (59,432) were not treated with
antidepressant medications. The rest were treated with SSRIs, newer non-SSRIs
(like bupropion, mirtazapine, nefazadone, or venlfaxine), or tricyclic
antidepressants. Some had received combined treatment.
SSRI treatment, alone or in combination, resulted in a rate of 364 suicide
attempts per 100,000 patients. The rate for all other patients, with or
without treatment, was 1,057 per 100,000. More specifically, the rate for
patients taking SSRIs was 123 per 100,000, compared with 335 per 100,000 among
untreated patients, an odds ratio of 0.37 (see
FIG1). Rates of suicide
attempts were cut nearly in half after treatment began.
"Our analyses of VA data are consistent with the hypothesis that
treatment with SSRIs lowers the risk for suicide attempt in adults with
depression and do not support the hypothesis that SSRIs increase the risk of
suicidal behavior in adults," the researchers concluded.
Their data on the 18- to-25-year-old cohort throws some light on the FDA's
analysis and its decision to expand its black-box warning to those patients,
Gibbons and his colleagues said.
The attempted-suicide rate in this VA age cohort treated with SSRIs was 477
per 100,000, close to the FDA's finding of 551 per 100,000. However, the VA
study found a rate of 1,368 per 100,000 attempts among untreated depressed 18-
to-25-year-old patients, compared with the FDA rate of 269 per 100,000.
The difference between this study and the FDA's number may be due to the
selection of patients with lower risk of suicide attempts who were enrolled in
the controlled randomized trials on which the agency based its analysis.
Clinical trials more congruent with real-world patients and contexts should
enroll subjects that include more of the high-risk patients found in clinical
practice, said David Brent, M.D., a professor of psychiatry, pediatrics, and
epidemiology at the University of Pittsburgh School of Medicine, in an
accompanying editorial.(see related article Suicide Attempts Decline With
Psychotherapy or Antidepressants.)
"Only by empanelling depressed patients at significant suicide risk
into randomized trials and then systematically assessing the impact of
treatment on suicidality and depression will we be able to delineate the
effects of antidepressants and psychotherapy on depression and suicide
risk," Brent said.
"Relationship Between Antidepressants and Suicide Attempts: An
Analysis of the Veterans Health Administration Data Sets" is posted at<http://ajp.psychiatryonline.org/cgi/content/full/164/7/1044>.▪