Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years' data.
BACKGROUND
A US Food and Drug Administration advisory has warned that antidepressants may be associated with an increased risk of suicidal thoughts and behaviors in adolescents. This prompted a meta-analysis of trials in adults that found no overall increase in risk, but individual agents could not be studied.


OBJECTIVE
To assess the risk of suicide and suicide attempts associated with individual antidepressant agents.


METHODS
Cohort study of incident users of antidepressant agents.


METHODS
Population-based health care utilization data of all residents of British Columbia, Canada, aged 18 years and older between January 1, 1997, and December 31, 2005.


METHODS
British Columbia residents who had antidepressant therapy initiated and had a recorded diagnosis of depression.


METHODS
Initiation of various antidepressant medications.


METHODS
Combined suicide death or hospitalization due to self-harm.


RESULTS
In a population of 287,543 adults aged 18 years and older with antidepressant therapy initiated, we observed outcome rates ranging from 4.41/1000 person-years to 9.09/1000 person-years. Most events occurred in the first 6 months after treatment initiation. After extensive propensity score adjustment, we found no clinically meaningful variation in the risk of suicide and suicide attempt between antidepressant agents compared with fluoxetine hydrochloride initiation: citalopram hydrobromide, hazard ratio = 1.00 (95% confidence interval, 0.63-1.57); fluvoxamine maleate, hazard ratio = 0.98 (95% confidence interval, 0.63-1.51); paroxetine hydrochloride, hazard ratio = 1.02 (95% confidence interval, 0.77-1.35); and sertraline hydrochloride, hazard ratio = 0.75 (95% confidence interval, 0.53-1.05). Compared with selective serotonin reuptake inhibitors as a drug class, other classes including serotonin-norepinephrine reuptake inhibitors, tricyclic agents, and other newer and atypical agents had a similar risk. Restriction to patients with no antidepressant use in the past 3 years further reduced apparent differences between groups.


CONCLUSIONS
Our finding of equal event rates across antidepressant agents supports the US Food and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent.
Schneeweiss
Sebastian
S
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02120, USA. schneeweiss@post.harvard.edu
Patrick
Amanda R
AR
Solomon
Daniel H
DH
Mehta
Jyotsna
J
Dormuth
Colin
C
Miller
Matthew
M
Lee
Jennifer C
JC
Wang
Philip S
PS
D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001955:British Columbia; D002423:Cause of Death; D015283:Citalopram / Q000009:adverse effects / Q000627:therapeutic use; D015331:Cohort Studies; D003866:Depressive Disorder / Q000188:drug therapy* / Q000401:mortality*; D005260:Female; D005473:Fluoxetine / Q000009:adverse effects / Q000627:therapeutic use; D016666:Fluvoxamine / Q000009:adverse effects / Q000627:therapeutic use; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017374:Paroxetine / Q000009:adverse effects / Q000627:therapeutic use; D016016:Proportional Hazards Models; D012306:Risk; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000523:psychology* / Q000706:statistics & numerical data*
D000928:Antidepressive Agents; D015283:Citalopram; D005473:Fluoxetine; D016666:Fluvoxamine; D017374:Paroxetine; D017367:Selective Serotonin Reuptake Inhibitors