Clinical Question

Are some antidepressants safer than others regarding suicide risk?

Bottom Line

Mirtazapine (Remeron) and venlafaxine are associated with higher rates of completed suicide in primary care patients. Rates of suicide attempts and completion are similar with the use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. (Level of Evidence = 2b)

Synopsis

These U.K.-based researchers used Qresearch, a large primary care database of more than 12 million patients from 600 general practices, to identify 238,963 patients with a new diagnosis of depression. Most patients (87.7%) received a prescription for an antidepressant and most of these prescriptions (71.3%) were for an SSRI. The mean duration of treatment was 221 days. During the first five years of follow-up, the authors identified 198 cases of suicide and 5,243 cases of attempted suicide or self-harm. Suicide rates were higher in the first 28 days of treatment. Absolute risks of suicide over one year ranged from 0.02% for amitriptyline to 0.19% for mirtazapine. There was no difference in suicide rates or rates of attempted suicide/self-harm between patients treated with SSRIs and tricyclic and related antidepressants. Compared with citalopram (Celexa), rates of suicide were significantly increased with mirtazapine (hazard ratio [HR] = 3.70; 95% confidence interval [CI], 2.00 to 6.84) and venlafaxine (HR = 2.23; 95% CI, 1.14 to 4.39). Other studies have shown similar suicide rates between SSRIs and tricyclic antidepressants (Am J Psychiatry. 2003;160(4):790–792).

Study design: Cohort (retrospective)

Funding source: Government

Setting: Outpatient (any)

Reference: CouplandCHillTMorrissRArthurAMooreMHippisley-CoxJAntidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: cohort study using a primary care database. BMJ2015; 350: h517.