July 2, 2007 In a study of more than 100,000 patients treated for depression, suicide attempts declined during the first month of treatment--whether that treatment consisted of medication, psychotherapy, or both. The findings, published by Group Health researchers in the July American Journal of Psychiatry, show a similar pattern for populations of adolescents and young adults (up to age 24) as for older adults.
The study sheds new light on the "black box" advisory that the U.S. Food and Drug Administration (FDA) placed in 2004 and has revised since then, said Greg Simon, MD, MPH, the Group Health psychiatrist who led the study. The advisory--which has concerned many patients, families, and care providers--warns that suicidal behavior may emerge soon after people younger than 25 start treatment with newer antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). It was spurred by randomized placebo-controlled trials showing that starting to take an SSRI can make thoughts of suicide more common among some teens and young adults.
Dr. Simon's study is the first published research to compare the risk of suicide attempts before and after the start of treatment with not only antidepressants but also psychotherapy. It is based on computerized medical and pharmacy records for more than 109,000 patients who started treatment for depression at Group Health from 1996 to 2005.
In the study, suicide attempts were about twice as common among patients up to age 24 as among older adults. However, the time pattern was the same for both age groups, regardless of the type of treatment they received: Suicide attempts were most likely during the month before treatment started, falling by at least 50 percent in the month after treatment began, with steady declines thereafter.
At all time points--up to three months before and six months after starting treatment--patients who received their antidepressant prescription from a psychiatrist tended to be most likely to attempt suicide. Those who received it from their primary care doctor were least likely to attempt suicide, with levels in between for those who got individual psychotherapy from a therapist other than a psychiatrist. "That's not because seeing a psychiatrist makes you want to kill yourself," said Dr. Simon. Rather, he suggested, these results reflect the fact that people with severe depression, who tend to be more suicidal, are more likely to be referred to psychiatrists, while those with milder depression stick with their primary doctors.
"Our study indicates that there's nothing specific to antidepressant medications that would either make large populations of people with depression start trying to kill themselves--or protect them from suicidal thoughts," said Dr. Simon. "Instead, we think that, on average, starting any type of treatment--medication, psychotherapy, or both--helps most people of any age have fewer symptoms of depression, including thinking about suicide and attempting it." That said, he likened population-based studies--both observational studies such as this one and randomized controlled trials of medications--to "circumstantial evidence" about what happens to individual patients.
Like other psychiatrists, Dr. Simon has seen a few depressed patients start having suicidal thoughts while taking antidepressant medication despite never having thought about suicide before then. He hypothesizes that subgroups of people may be vulnerable to becoming more agitated or suicidal after taking these drugs. "We hope to learn how to identify these people in advance," he said.
Dr. Simon published an earlier paper showing that the risk of suicide attempts decreased in the weeks after patients started taking antidepressant medication. His new study strengthens his earlier conclusion that for populations of people, even teens and young adults, suicide attempts tend to be rarer right after starting antidepressant medication than beforehand. He echoed the FDA's recommendations that doctors regularly monitor their patients during treatment with antidepressants to ensure that they are receiving the right medication at a dose that helps them feel better. "If people feel agitated or suicidal, they should seek help from a doctor or therapist," he added.
The National Institute of Mental Health funded the study, whose other author is James Savarino, PhD, a programmer analyst at Group Health Center for Health Studies.
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