Research report
Antidepressants and suicide mortality

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Abstract

Background: This paper presents a nationwide analysis of suicide mortality in Finland from 1990 to 1995, when the total use of antidepressants, especially that by selective serotonin reuptake inhibitors (SSRIs) expanded in the country. Methods: Suicide rate was analysed by various methods including that by intake of antidepressants. Various antidepressants were compared by calculating fatal toxicity indices (FTI) by relating number of fatal poisonings by a drug to its consumption. Results: The expanded use of antidepressants coincided with an increased number of deaths caused by these drugs. The proportion of suicides committed by use of antidepressants among all suicides increased from 5.6% to 8.4%. The total suicide rate, however, declined significantly. This was mainly accounted for by the reduced suicide rates by hanging and carbomonoxide poisoning, which outnumbered the increased figures of suicides by poisoning. On the whole, 82% of suicides by antidepressants were committed by use of tricyclics. Use of doxepin and amitriptyline remained steady, and their FTIs were constantly high. The lowest FTIs were associated with fluoxetine, citalopram, mianserin and moclobemide. Limitations: The method ignores causality between the increased use of SSRIs and suicide mortality. Various factors affecting risk of suicide or choice of a method remain outside the scope of the data. Conclusion: The increased use of SSRIs coincided with a significant decline in suicide mortality. However, suicides by use of antidepressants showed an upward trend. Therefore, in suicide prevention, risks and benefits of antidepressants should be considered in choosing treatment for depressive patients.

Introduction

Adequate treatment with antidepressants is often useful in the treatment of moderately and severely depressed patients (Paykel and Priest, 1992). Depressive disorders have been found to be significant risk factors for suicide (Barraclough et al., 1974, Rich et al., 1986, Henriksson et al., 1993). Many recent studies, however, have revealed unidentification and undertreatment of depression among suicide victims (Mendelson and Rich, 1993, Henry, 1994, Isometsä et al., 1994a, Marzuk et al., 1995), and in suicide prevention, therapeutic failure rather than toxicity of antidepressants have been emphasized (Isacsson et al., 1994, Montgomery and Kasper, 1995). Therefore, much attention has been paid to the recognition of depressive disorders and the education of general practitioners, who have a great responsibility for identifying suicide risk, and who also prescribe the majority of antidepressants (Paykel and Priest, 1992, Isometsä et al., 1994b, Donoghue and Tylee, 1996, Rutz et al., 1997).

During the last ten years, several new antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and a selective monoamine oxidase inhibitor, moclobemide, has been introduced in Europe. While one of the major problems with tricyclic antidepressants is their toxicity in overdose (Cassidy and Henry, 1987, Vuori et al., 1989, Kapur et al., 1992), the new antidepressants have been claimed to be as effective as tricyclics (Young et al., 1987, Song et al., 1993, Anderson and Tomenson, 1994, Paykel, 1995) but better tolerated (Anderson and Tomenson, 1995) and less toxic (Freemantle et al., 1994, Henry et al., 1995).

The aim of the present study is to analyse suicide mortality by various methods with a focus on suicides by intake of antidepressants in a period when the use of these drugs more than doubled. Antidepressants are compared by assessing fatality toxicity indices for various antidepressants.

Section snippets

Suicide mortality

The basic data were obtained from the Finnish official statistics on mortality between 1990 and 1995 (Central Statistical Office of Finland, 1991–1996). Suicides were analysed by various methods of suicide (E950-E959) according to the 9th revision of the International Classification of Diseases (WHO, 1977). Suicides by intake of antidepressants were listed separately. Suicide rates were calculated per 100 000 population.

Comparison of various antidepressants

To compare fatality risks of various antidepressants all deaths from drug

Suicide rates by various methods

The total suicide mortality decreased significantly over the study period (Table 2). Suicide rate by poisoning including that by antidepressants, was the only method, which showed an upward trend. This effect was compensated by declined suicide rates by other methods, especially by significantly reduced rates by hanging and carbonmonoxide poisoning.

Suicides by antidepressants among all suicides

Among all suicides over the study period (n=8628), 6.3% were committed by use of antidepressants, with an increasing trend from 5.6% (CI 95%

Antidepressants and suicide rate

In the present study, the expanded use of antidepressants coincided with an increased number of deaths and an upward trend in the suicide rate by these drugs. The increased number of suicides by antidepressants involved mainly tricyclics rather than SSRIs or moclobemide, which showed the largest increase in consumption. Thus, it seems that the possible benefit of the increased use of new antidepressants does not result in a reduced number of suicides by tricyclics, not even by any

Conclusion

In the present study, the expanded use of antidepressants was accompanied by an increase in the number of deaths caused by these drugs, but however, it also coincided with the significantly reduced total suicide mortality. The declined suicide rates by hanging and carbomonoxide poisoning, in particular, compensated the increased figures of suicides by use of drugs including antidepressants. According to fatal outcomes in relation to consumption, the present study suggests substantial

Acknowledgements

This study was supported by Paulo Foundation, Finland.

References (51)

  • J. Cassidy et al.

    Fatal toxicity of antidepressant drugs in overdose

    Br. Med. J.

    (1987)
  • Central Statistical Office of Finland, 1991–1996. Causes of death 1990–1995, Painatuskeskus Oy,...
  • Danish University Antidepressant Group, 1990. Paroxetine: a selective serotonin reuptake inhibitor showing better...
  • Danish University Antidepressant Group, 1993. Moclobemide: a reversible MAO-A inhibitor showing weaker antidepressant...
  • J. Donoghue et al.

    The treatment of depression: prescribing patterns of antidepressants in primary care in the UK

    Br. J. Psychiatry

    (1996)
  • M. Fava et al.

    Suicidality and fluoxetine: is there relationship?

    J. Clin. Psychiatry

    (1991)
  • N. Freemantle et al.

    Prescribing selective serotonin reuptake inhibitors as strategy for prevention of suicide

    Br. Med. J.

    (1994)
  • Gardner, M., Altman, D., 1992. Calculating confidence intervals for proportions and their differences. In: Gardner M....
  • M. Heikkinen et al.

    Social factors in suicide

    Br. J. Psychiatry

    (1995)
  • M. Henriksson et al.

    Mental disorders and comorbidity in suicide

    Am. J. Psychiatry

    (1993)
  • J. Henry

    Antidepressants and overdose toxicity

    Hum. Psychopharmacol.

    (1994)
  • J. Henry et al.

    Relative mortality from overdose of antidepressants

    Br. Med. J.

    (1995)
  • M. Hotopf et al.

    Are SSRIs a cost-effective alternative to tricyclics

    Br. J. Psychiatry

    (1996)
  • M. Hotopf et al.

    Discontinuation rates of SSRIs and tricyclic antidepressants: a meta-analysis and investigation of heterogenity

    Br. J. Psychiatry

    (1997)
  • G. Isacsson et al.

    Use of antidepressants among people committing suicide in Sweden

    Br. Med. J.

    (1994)
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