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

Introduction

Prescribing of antidepressants has increased greatly in England and elsewhere in recent years.1^–3 This increase has coincided with a fall in rates of suicide, leading some researchers to suggest a causal association.2 4^–6 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