BMJ  2005;330:389 (19 February), doi:10.1136/bmj.330.7488.389

Paper

Antidepressant treatment and the risk of fatal and non-fatal self harm in first episode depression: nested case-control study

¹ General Practice Research Database Division, Medicines and Healthcare products Regulatory Agency, London SW8 5NQ, ² Post-Licensing Division, Medicine and Healthcare products Regulatory Agency, ³ Wolfson Institute of Preventive Medicine, Queen Mary, University of London, ⁴ Department of Psychiatry, University of Edinburgh, Edinburgh, ⁵ Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, ⁶ Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Objective To compare the risk of non-fatal self harm and suicide in patients taking selective serotonin reuptake inhibitors (SSRIs) with that of patients taking tricyclic antidepressants, as well as between different SSRIs and different tricyclic antidepressants.

Design Nested case-control study.

Setting Primary care in the United Kingdom.

Participants 146 095 individuals with a first prescription of an antidepressant for depression.

Main outcome measures Suicide and non-fatal self harm.

Results 1968 cases of non-fatal self harm and 69 suicides occurred. The overall adjusted odds ratio of non-fatal self harm was 0.99 (95% confidence interval 0.86 to 1.14) and that of suicide 0.57 (0.26 to 1.25) in people prescribed SSRIs compared with those prescribed tricyclic antidepressants. We found little evidence that associations differed over time since starting or stopping treatment. We found some evidence that risks of non-fatal self harm in people prescribed SSRIs compared with those prescribed tricyclic antidepressants differed by age group (interaction P = 0.02). The adjusted odds ratio of non-fatal self harm for people prescribed SSRIs compared with users of tricylic antidepressants for those aged 18 or younger was 1.59 (1.01 to 2.50), but no association was apparent in other age groups. No suicides occurred in those aged 18 or younger currently or recently prescribed tricyclic antidepressants or SSRIs.

Conclusion We found no evidence that the risk of suicide or non-fatal self harm in adults prescribed SSRIs was greater than in those prescribed tricyclic antidepressants. We found some weak evidence of an increased risk of non-fatal self harm for current SSRI use among those aged 18 or younger. However, preferential prescribing of SSRIs to patients at higher risk of suicidal behaviour cannot be ruled out.

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