SSRIs and depression

Current situation

  • Depression is a common and debilitating condition.
  • SSRIs and tricyclic antidepressants account for over 90 per cent of antidepressant prescribing in UK.
  • Concerns over the safety of SSRIs have been raised, with some reports describing a possible association with suicides.

What is the evidence?

  • A review of published RCTs comparing SSRIs with either placebo or other treatments in patients with depression found an almost two-fold increase in the odds of fatal and non-fatal suicidal attempts in users of SSRIs (BMJ 2005; 330: 396).
  • A study of information from the General Practice Research Database found that the risk of non-fatal self-harm and suicide in patients with a new diagnosis of depression prescribed SSRIs or tricyclics were similar (BMJ 2005; 330: 389).
  • One study found the risk of suicidal behaviour after starting to take antidepressants to be similar for four antidepressants, including SSRIs and tricyclic antidepressants (JAMA 2004; 292: 338–43).
  • SSRIs have been shown to be associated with an increased risk of suicide during the first month of treatment compared with other antidepressants in older people (over 66 years) (Am J Psychiatry 2006; 163: 813–21). This increased risk was only apparent in the first month of treatment.
  • A study from Finland has shown that although antidepressants increase the risk of attempting suicide, the risk of completed suicide fell by 9 per cent (Arch Gen Psychiatry 2006; 63: 1,217–23).
  • A General Practice Research Database study using the found that patients prescribed venlafaxine for depression were two to three times more likely to commit suicide than those prescribed citalopram, fluoxetine or dothiepin (BMJ 2007; 334: 242). However, patients prescribed venlafaxine had more severe depression to start with, and were more likely to have attempted suicide in the past.

Implications for practice

  • The MHRA has advised that doctors prescribing SSRIs to patients should warn them first of the risks associated with stopping the treatment. 
  • Maintenance treatment with an SSRI for a year has been shown to reduce the risk of recurrence after effective initial treatment (J Clin Psych 2006; 67: 1,767–75).
  • One study showed that early benefits can be felt by depressed patients taking serotonin reuptake inhibitors in the first week of treatment (Arch Gen Psychiatry 2006; 63: 1,217–23).

Available guidelines

  • NICE recommends initial psychological treatment for patients with mild and moderate depression. Where antidepressants are prescribed for moderate or severe depression, SSRIs should be used.

Useful websites — MHRA — NICE

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners’ PasTest 2006

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