Clinical Question: Are suicide rates higher in depressed patients treated with tricyclic anti-depressants than in those taking selective serotonin reuptake inhibitors (SSRIs)?

Setting: Population-based

Study Design: Cohort (retrospective)

Synopsis: To minimize the risk of suicide, many clinicians prefer prescribing SSRIs for patients with depression. By analyzing the U.S. Food and Drug Administration database of all reported adverse drug events, the authors compared completed (successful) suicide rates in patients treated with SSRIs (e.g., fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine) and those treated with “other” antidepressants (e.g., nefazodone, mirtazapine, bupropion, venlafaxine, imipramine, amitriptyline, maprotiline, trazodone, mianserin, dothiepin).

Of 48,277 patients participating in clinical trials, 77 committed suicide. Based on patient-exposure years, similar rates of suicide were seen among patients randomized to treatment with an SSRI (0.59 percent; 95 percent confidence interval [CI], 0.31 to 0.87 percent), a standard comparison antidepressant (0.76 percent; 95 percent CI, 0.49 to 1.03 percent), and placebo (0.45 percent; 95 percent CI, 0.01 to 0.89 percent). The authors speculate that the low rate of suicide in patients treated with placebo was because of the short period of placebo use in these clinical trials. No clear differences in the method of suicide were observed for patients treated with any of the drug classes.

Study participants may not represent a routine clinical sample of patients with depression. Subjects were outpatients who had mild to moderate depression without suicidal ideations, comorbid psychiatric or medical illnesses, or substance abuse disorders. The length of time participants took medication in these studies was shorter than that in patients in clinical practice.

Bottom Line: Patients with depression were no more likely to successfully commit suicide while taking any particular class of antidepressants. Specifically, rates of suicide were not increased by treatment with tricyclic antidepressants. Fear of an increased risk of suicide should not be a reason to choose one type of antidepressant class over another. (Level of Evidence: 2b)