Suicide risk and antidepressants: Beyond the controversy

Recently, the risk for suicide while on antidepressant medication became of great concern. Summarizing the literature, it seems that the majority of reports support the favourable effect of antidepressants on suicide rates in general, by diminishing the underlying depression. Some studies, however, suggest that the advantageous effect of antidepressants is partly abolished by its increased risk for suicide, especially in children. Therefore, in the present article, we propose a number of practical diagnostic and therapeutic measures to diminish the risk for suicide in patients on antidepressants. First, the age of the patient should be taken into account, since in children the effect of antidepressants over placebo is not as clear as in adults. Therefore, the indication for antidepressants in children should be restricted to those with severe depression, who cannot be treated by other means and the prescribing of antidepressants to children should be reserved to psychiatrists. Moreover, also in adults, it is important to take the severity and type of depression into account, since the effect of antidepressants in mild depression is less clear than in severe depression and the agitated, "pseudo-unipolar" type of depression requires a different treatment strategy. Therefore, the decision to prescribe antidepressants should be made by a physician who is experienced in estimating depression severity and type. Probably, the most rewarding measure to decrease suicide rates among depressed patients is adequate antidepressant treatment, since under-treatment seems to be a serious problem in depressed patients who commit suicide. During this treatment, safety must be ensured and psychosocial factors addressed. Furthermore, antidepressants should be used with low risk for suicide in overdose and, if necessary, benzodiazepines against agitation in the first weeks of treatment. Finally, debriefing strategies, ongoing support, and counselling following suicide should be available for both family and caregivers. Drug Dev. Res. 65:179-184, 2005. (c) 2005 Wiley-Liss, Inc.