Intended for healthcare professionals

Primary Care

Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials

BMJ 2005; 330 doi: (Published 17 February 2005) Cite this as: BMJ 2005;330:396

SSRI use and non-fatal self harm

Demonstration of a causal link between Selective serotonin reuptake
inhibitors (SSRI) use and self-harm would have significant clinical
implications for health services. Indeed the extra monitoring might make
antidepressant use wholly impractical within a risk averse service.

Two findings stand out. First is the remarkably low reported
incidence of self-harm in these studies with estimates of 0.05 – 0.001 %.
Even during a short trial such a low incidence among patients with
significant depression is not credible. The surely unique finding that
rates of fatal and non-fatal self-harm are identical among placebo treated
patients further emphasises how unsustainable these reported figures must
be. It is perhaps unsurprising that in studies designed to evaluate self-
harm but efficacy there is gross underreporting of such acts.

It is likely that underreporting may be more common among placebo
treated patients. Although the methods of self-harm are not stated one
might speculate that overdose of trial tablets accounts for a number of
these reports. The trial treatments are unequal since SSRI’s will cause
physical effects (GI disturbance) that might prompt emergency attendance.
Placebo should provoke no such reaction and thus less need to report such
an act of self-harm.

Such data has not emerged to a barrage of opprobrium from the
pharmaceutical industry. Although popular and endorsed in recent NICE
guidelines SSRI’s no longer have novelty value and are rapidly losing
their patents. Data that discredits such old drugs may serve well in
marketing the new generation of antidepressants that will be launched in
coming years.

Competing interests:
previous receipt of research grant from Eli Lilly.

Competing interests: No competing interests

22 February 2005
Hugh M Jones
Consultant Psychiatrist
Lordship lane CMHT, London SE22 8HN