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August 3, 2007 — Patients with depression treated in two independent health care systems experienced overall drops in suicide attempts between the month prior to starting treatment with antidepressant medications and the month after treatment began.
The findings are based on records from a large prepaid health plan and from Veterans Health Administration databases, reflecting the clinical care of more than 330,000 patients. These two studies are reported in the July issue of the American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association.
The first study, "Suicide Attempts Among Patients Starting Depression Treatment With Medications or Psychotherapy," is presented by Gregory Simon, M.D., M.P.H., and James Savarino, Ph.D., of Group Health Cooperative — a mixed-model prepaid health plan with approximately 500,000 members in Washington State and Idaho. Among the 109,256 members treated for depression between 1996 and 2005, suicide attempts decreased during the first month of treatment and diminished further in subsequent months. This progressive decline occurred for both patients taking medication and those receiving psychotherapy. About 60 percent of the treatment episodes began with antidepressant prescriptions and about 40 percent began with psychotherapy visits.
The second study, involving veterans, is described in "The Relationship Between Antidepressants and Suicide: Results of Analysis of the Veterans Health Administration Datasets," by Robert Gibbons, Ph.D., Kwan Hur, Ph.D., J. John Mann, M.D., and colleagues at the University of Illinois at Chicago and the New York State Psychiatric Institute. The findings are based on 226,866 veterans diagnosed with depression during 2003-2004. The analysis, in addition to showing a decrease in suicide attempts once treatment began, also revealed a lower rate of suicide attempts in depressed veterans who took antidepressants compared to those who did not. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed antidepressants, and the rate of suicide attempts for patients taking SSRIs fell from 221 per 100,000 patients before treatment, to 123 per 100,000 after treatment began. The rate also fell after the beginning of treatment with medications known as non-serotonergic and tricyclic antidepressants.
The positive overall outcomes in the two studies were shared by the youngest patients. The adolescents and young adults studied by Simon and Savarino made approximately twice as many suicide attempts as the total group, but they showed a similar decline after beginning treatment. Gibbons et al. found that all age groups, including 18 to 25 year olds, experienced both a decline in suicide attempts with treatment and a lower incidence among depressed veterans receiving SSRIs, compared to those receiving no antidepressant treatment. The authors point out that large-scale studies do not exclude the possibility that depression treatment may precipitate suicidal thinking or behavior in vulnerable individuals.
The findings are reviewed in an editorial by David Brent, M.D., of the University of Pittsburgh. AJP Editor in Chief Robert Freedman, M.D., stated "These studies of treatment in actual clinical practice find a decrease in suicide attempts after treatment, regardless of whether the treatment is psychotherapy or drug therapy. Patients and their doctors are concerned because of the FDA's black-box warning that antidepressants can cause suicide attempts. The studies in this issue provide more evidence that this side effect is rare, compared to the overall decrease in suicide attempts that occurs when treatment is initiated. Furthermore, suicide attempts in the first month of treatment occur regardless of whether the treatment is psychotherapy or drug therapy, which suggests that these attempts are part of the natural evolution of symptoms in depression itself."