Antidepressants and suicidality

Plöderl et al (2020) have produced the most definitive commentary yet on whether antidepressants are associated with increased suicide risk. Interestingly a twitter conversation (so twitter can be useful after all!) helped to produce this consensus statement. Further analysis of the data would apparently be possible if the FDA made a large dataset publicly available (I’m not sure why it isn’t).

Plöderl et al’s cautious conclusion is that “the analyses consistently hint at an elevated risk for suicide attempts and, less reliably, also for suicides in cohorts of adults”. They suggest this is “remarkable for drugs that are used to treat depressive symptoms”.

I agree that whether antidepressants are associated with increased suicidal risk is an important issue. However, I am perhaps not as surprised if this is the case, as Plöderl et al seem to be.

Doctors do need to be cautious about prescribing antidepressants. It can be an identity-altering experience (see previous post). People react to taking antidepressants in a multitude of ways. For example, some people may feel that a doctor is not taking them seriously by trying to palm them off with antidepressants and this may trigger a suicide attempt. Okay, they may well have been at high risk of suicide anyway, but how the doctor reacts to their presentation may well matter. We may all wish for a simple, quick, cheap, painless and complete cure if we’re feeling desperate, but reality may actually be more complex.

So, I think we do need to be clear, if there is an increased suicidal risk with antidepressants (and the evidence seems to confirm that there is, perhaps particularly in the first few weeks after initiating treatment with antidepressants), that this is probably related to the act of prescribing for people who are feeling desperate. As far as I’m aware, there is no evidence that there is any direct effect of antidepressants on the brain, for example, that increases suicidality.