Viewpoint - SSRIs and young suicides

Dr Ben Wheeler discusses whether patterns of prescribing for SSRIs affect suicide mortality rates and self-harm.

The suggestion that SSRIs might have some association with an increase in suicidal behaviour has been around since their appearance in the late 1980s.

A 1992 Committee on Safety of Medicines report Current Problems (known as Drug Safety Update since June 2007) highlighted concerns following adverse drug reaction reports. As well as advising continued vigilance, it concluded that 'There is little to support the suggestion that fluoxetine induces suicidal or aggressive behaviour'.1

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UK findings show no link between reduced SSRI use and suicide

Guidance
Since that time, there has been continuing debate and research regarding the risk-benefit balance of SSRIs, especially in young people. There has also been intense media scrutiny of the issue, particularly with regard to paroxetine, which was the subject of several BBC Panorama programmes.2

By 2003, sufficient evidence on the effects of SSRIs on suicidal thoughts and behaviour in young people had accumulated for the MHRA to issue guidance that SSRIs (with the exception of fluoxetine) should not be prescribed to patients under the age of 18.3 Similar guidance was issued by pharmaceutical regulatory agencies worldwide.

Decline in prescribing
Since that guidance, concern has been raised that the decline in prescriptions of antidepressants to young people could result in untreated depression and consequent increases in suicidal behaviour.4

This concern was apparently realised in a high profile paper published in late 2007. Gibbons and colleagues5 analysed trends in prescribing and suicide mortality in the USA, and found that while suicide mortality rates among young people (aged 5 - 19) fell from 4.4 to 2.8 per 100,000 between 1988 and 2003, from 2003 to 2004 they increased to 3.2 per 100,000.

The authors associated this increase with decreases in SSRI prescriptions.

Suicide rates
We conducted a similar study, funded by the MHRA, to investigate trends in antidepressant prescribing and suicide in young people in the UK.6

As expected, we found that overall antidepressant prescriptions to young people rose substantially up until 2003, then fell by around 50 per cent in the two years following regulatory intervention, with these changes being driven by SSRI prescribing patterns.

However, we did not find any association between the very large changes in prescribing patterns and trends of either suicide mortality or hospital admissions for deliberate self-harm (DSH).

Between 1993 and 2005, suicide mortality for both young men and women – we looked at 12-17 year olds – decreased at a fairly steady rate. Admission rates for DSH increased steadily among young women, and stayed fairly constant for young men (data for 1999 to 2005).

There was no apparent change in these time-trends following the regulatory guidance in 2003. Our findings therefore contradict those of the US study, although recent updates suggest that US suicide mortality rates did not continue to increase, but fell from 2004 to 2005.7

Findings for the UK therefore suggest that reduced access to antidepressants in young people following regulatory intervention appears not to have had an adverse impact on suicide deaths or hospital admissions for DSH.

  • Dr Wheeler is a research fellow at the University of Bristol

References

1. Committee on Safety of Medicines. Safety of Fluoxetine (Prozac): Comparison with Fluvoxamine (Faverin). Current Problems 1992; 34.

2. Martin R M, May M, Gunnell D. Did intense adverse media publicity impact on prescribing of paroxetine and the notification of suspected adverse drug reactions? Analysis of routine databases, 2001-2004. Br J Clin Pharmacol 2006; 61(2):224-8.

3. Medicines and Healthcare products Regulatory Agency. Selective serotonin reuptake inhibitors (SSRIs): overview of regulatory status and CSM advice relating to major depressive disorder (MDD) in children and adolescents including a summary of available safety and efficacy data. 2003.

4. Murray M L, Thompson M, Santosh P J, Wong I C. Effects of the Committee on Safety of Medicines advice on antidepressant prescribing to children and adolescents in the UK. Drug Saf 2005; 28: 1,151-7

5. Gibbons R D, Brown C H, Hur K, et al. Early Evidence on the Effects of Regulators' Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents. Am J Psychiatry 2007; 164: 1,356-63.

6. Wheeler B W, Gunnell D, Metcalfe C, et al. The population impact on incidence of suicide and non-fatal self harm of regulatory action against the use of selective serotonin reuptake inhibitors in under 18s in the United Kingdom: ecological study. BMJ 2008; 336: 542-5.

7. Olfson M, Shaffer D. SSRI Prescriptions and the Rate of Suicide. Am J Psychiatry 2007; 164: 1, 907-8.

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