Clinical Review

Antidepressants and suicide: what is the balance of benefit and harm

BMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7456.34 (Published 01 July 2004) Cite this as: BMJ 2004;329:34
  1. David Gunnell, professor of epidemiology1 (d.j.gunnell@bristol.ac.uk),
  2. Deborah Ashby, professor of medical statistics2
  1. 1 Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  2. 2 Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London EC1M 6BQ
  1. Correspondence to: D Gunnell
  • Accepted 11 June 2004

Introduction

Prescribing of antidepressants has increased greatly in England and elsewhere in recent years.13 This increase has coincided with a fall in rates of suicide, leading some researchers to suggest a causal association.2 46 Meanwhile, others are concerned that antidepressants may precipitate suicidal behaviour.7 8 A recent review of evidence from paediatric trials by the Committee on Safety of Medicines in Britain led to most selective serotonin re-uptake inhibitors (SSRIs) being contraindicated in people aged younger than 18.9 So how safe are they? In this article, we assess the data on the risks and benefits.

Is increased prescribing linked to reduced suicide rates?

SSRIs and tricyclic antidepressants account for over 90% of antidepressant prescribing in Britain. Systematic reviews confirm that both these classes of antidepressant are effective in adults,10 although SSRIs are better tolerated by patients.11 The effectiveness of antidepressants in childhood and adolescence is less clear.12

As depression is the main psychiatric condition leading to suicide, it seems reasonable to infer that rises in antidepressant prescribing, which indicate improved management of depression, should have a beneficial effect on suicide rates. Indeed, an intervention to improve general practitioners' management of depression in a Swedish community resulted in increased antidepressant prescribing and a short term reduction in suicide.13

Summary points

Concern is growing that serotonin reuptake inhibitors (SSRIs) may precipitate suicidal behaviour, especially in children

Reassuringly, although antidepressant prescribing in Britain has more than doubled in the past 15 years, population suicide rates have fallen.

If the risks of SSRI associated suicidal behaviour seen in children were to apply to suicide in adults, the number of “antidepressant induced” suicides would be small enough to be masked by currently favourable suicide trends

Long term studies are required to assess the risks and benefits to population health of recent large scale rises …

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