Antidepressants and Suicidal Risk

Only 5% of suicidal patients on the average use their prescribed antidepressant to commit suicide. Underprescription of antidepressants and failure of antidepressant therapy appear to be of greater practical importance than the toxicity of individual compounds. Prescribing less toxic agents, therefore, will not be of great advantage, especially if they are less efficacious. Several antidepressants including the selective serotonin reuptake inhibitors (SSRIs) may increase suicidal behavior by energizing depressed patients to act along preexisting suicidal thoughts or by inducing akathisia with associated self-destructive impulses. For acutely suicidal patients, the use of more sedating antidepressants is recommended. Clinical trials could not confirm a superiority of SSRIs over tricyclics in reducing the number of suicide attempts. There is evidence from large international data sources and a large multicenter controlled trial that lithium prophylaxis decreases the suicide risk and overall mortality in affective disorders. A suicide-preventing effect has not been demonstrated conclusively for antidepressants or non-lithium mood stabilizers.