title: An association between initiation of selective serotonin reuptake inhibitors and suicide - a nationwide register-based case-crossover study.
abstract: BACKGROUND
  Treatment with selective serotonin reuptake inhibitors (SSRI) is one of the most common treatments for depression. It is however not clear whether or not there is an increased short-term suicide risk during initiation with SSRI.
  
  
  METHODS
  A register-based nationwide case-crossover study including 5,866 suicides, 1,698 women and 4,168 men, from the Death Register 2007-2010 in Sweden. SSRI initiation was defined as a dispensed prescription of SSRI within 28 days prior to the date of suicide with no previous dispensed prescription of SSRI within 4 months prior that prescription. The control period took place one year earlier. Odds ratio (OR) was estimated using conditional logistic regression.
  
  
  RESULTS
  During the 28 day period prior to suicide 48 women and 138 men were exposed to SSRI initiation (while not being exposed in the control period) and 22 women and 43 men were exposed in the control period (while not being exposed in the case period). The OR for suicide after initiation with SSRI was 2.7 (95% CI: 1.6-44) for women, and 4.3 (95% CI: 3.0-6.1) for men. The highest OR was found 8-11 days after initiation with SSRI 9.7 (95% CI: 3.0-31.7) for women and men combined.
  
  
  CONCLUSIONS
  The main limitation in this study is confounding by indication, but the descriptive question is however not confounded by indication. Together with plausible biological mechanisms and previous clinical and epidemiological observations our findings, linking initiation of SSRI to increased short-term suicide risk, deserve further attention specifically in the clinical setting.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ; Department of Statistics, Monitoring, and Evaluation, National Board of Health and Welfare, Stockholm, Sweden.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Björkenstam
authors.forename: Jette
authors.initials: J
authors.lastname: Möller
authors.forename: Gunilla
authors.initials: G
authors.lastname: Ringbäck
authors.forename: Peter
authors.initials: P
authors.lastname: Salmi
authors.forename: Johan
authors.initials: J
authors.lastname: Hallqvist
authors.forename: Rickard
authors.initials: R
authors.lastname: Ljung
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D018592:Cross-Over Studies; D003863:Depression / Q000188:drug therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012042:Registries; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D012737:Sex Factors; D013405:Suicide / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D017367:Selective Serotonin Reuptake Inhibitors
references.citation: BMJ. 2009 Aug 11;339:b3066
references.pmid: 19671934
references.citation: Trends Pharmacol Sci. 2009 Apr;30(4):165-73
references.pmid: 19269045
references.citation: Arch Gen Psychiatry. 2006 Aug;63(8):865-72
references.pmid: 16894062
references.citation: Ann Med. 2005;37(6):404-12
references.pmid: 16203613
references.citation: Br J Psychiatry. 2001 May;178:465-8
references.pmid: 11331564
references.citation: Depress Anxiety. 2008;25(12):1014-9
references.pmid: 18781664
references.citation: Arch Gen Psychiatry. 2006 Mar;63(3):332-9
references.pmid: 16520440
references.citation: Neuropsychiatr Dis Treat. 2010 Sep 07;6:3-8
references.pmid: 20856596
references.citation: Am J Epidemiol. 1995 Jul 1;142(1):91-8
references.pmid: 7785679
references.citation: N Engl J Med. 2007 Jun 7;356(23):2343-6
references.pmid: 17485726
references.citation: Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):476-96
references.pmid: 17143567
references.citation: J Clin Psychiatry. 2011 May;72(5):580-6
references.pmid: 21658345
references.citation: Am J Epidemiol. 1991 Jan 15;133(2):144-53
references.pmid: 1985444
references.citation: Mol Psychiatry. 2010 May;15(5):473-500
references.pmid: 18982004
references.citation: Ann N Y Acad Sci. 2006 Nov;1086:134-43
references.pmid: 17185512
references.citation: Arch Suicide Res. 2011;15(2):93-112
references.pmid: 21541857
references.citation: Am J Psychiatry. 2010 Oct;167(10):1194-201
references.pmid: 20713498
references.citation: JAMA. 2004 Jul 21;292(3):338-43
references.pmid: 15265848
references.citation: Am J Psychiatry. 2007 Jul;164(7):1044-9
references.pmid: 17606656
references.citation: Am J Psychiatry. 2005 May;162(5):915-23
references.pmid: 15863793
references.citation: BMJ. 2009 Aug 11;339:b2880
references.pmid: 19671933
references.citation: Arch Gen Psychiatry. 2009 Dec;66(12):1341-52
references.pmid: 19996039
references.citation: J Clin Psychopharmacol. 1994 Jun;14(3):163-9
references.pmid: 8027412
references.citation: Hum Brain Mapp. 2009 Aug;30(8):2558-70
references.pmid: 19086022
references.citation: Arch Gen Psychiatry. 2012 Jun;69(6):580-7
references.pmid: 22309973
references.citation: Pharmacoepidemiol Drug Saf. 2007 Jul;16(7):726-35
references.pmid: 16897791
references.citation: J Health Econ. 2009 May;28(3):659-76
references.pmid: 19324439
references.citation: J Affect Disord. 2009 Dec;119(1-3):59-65
references.pmid: 19327843