Suicide Attempt Pattern Is the Same Regardless of Initial Treatment of Depression

July 10, 2007 — According to the results of a large observational study, the same pattern of suicide attempts occurs in patients who start depression treatment with initial psychotherapy or with antidepressant drugs prescribed by family physicians or by psychiatrists. The risk of making a suicide attempt is highest in the month prior to starting treatment and then declines steadily during the next 6 months.
The study is published in the July issue of the American Journal of Psychiatry.
Author Gregory E. Simon, MD, MPH, at the Center for Group Health Studies in Seattle, Washington, told Medscape, "We conclude that the risk pattern [for suicide attempts] has probably more to do with the natural process of what happens to people in their treatment, rather than anything specific about the treatment. People enter treatment when they are in a crisis. When they start treatment, whatever the treatment is, they feel better."
He explained that there has been a lot of recent controversy about suicide risk early in antidepressant treatment. In 2003, the US Food and Drug Administration required a "black box" warning be placed on antidepressant medications, based on their review of pediatric clinical trials that suicidal behavior may emerge soon after people younger than 25 years start taking selective serotonin reuptake inhibitors (SSRIs). Dr. Simon clarified that this warning did not advise that people should not take these drugs, but rather that a closer follow-up was necessary. However, as an unintended result, rates of treatment went down, and as described in an accompanying editorial by David Brent, MD, from the University of Pittsburgh School of Medicine, in Pittsburgh, Pennsylvania, rates of adolescent suicide rose in 2004 after a decade of decline.
Dr. Simon and co-author James Savarino, PhD, aimed to compare the time patterns in suicide attempts among outpatients starting depression therapy with medication or psychotherapy.
More Than 100,000 Cases of New Treatment of Depression
Simon and Savarino examined computerized claims records from the Group Health Cooperative health plan and identified 109,256 individuals who started treatment of depression from 1996 to 2005. They divided the patients into 3 groups depending on their initial therapy for depression: antidepressant drugs from a primary care clinician, antidepressant drugs from a psychiatrist, or initial psychotherapy.
The investigators looked at the incidence of suicide attempts or possible suicide attempts in the 90 days before or the 180 days after the initial antidepressant prescription or psychotherapy visit.
The incidence of suicide attempt was highest among patients receiving antidepressant medications from a psychiatrist, which was expected, Dr. Simon explained, because people who are more severely ill see psychiatrists rather than their family clinicians.
The time pattern of suicide attempt was identical in the 3 treatment groups. The highest incidence occurred in the month prior to the start of treatment, followed by a high incidence in initial month of treatment and a subsequent steady decline.
The results were the same after an analysis that excluded patients receiving both psychotherapy and medication.
Among young adults younger than 25 years, suicide attempts were about twice as common as in the total group, but the time pattern for suicide attempts for patients receiving any of the 3 treatments was the same as for the total group.
"The practical message is that this is not a reason to avoid treatment, but a recommendation that people should be followed more closely," said Dr. Simon.
Dr. Simon has disclosed receiving research grants from Eli Lilly, Pfizer, and Wyeth Pharmaceuticals and consulting fees from Wyeth Pharmaceuticals. Dr. Savarino has disclosed no relevant financial relationships.
"Suicidal Behavior Leads to Treatment" Not the Reverse
In an accompanying editorial, Dr. Brent writes that this "elegant" observational study, "while not proving that antidepressants and psychotherapy reduce suicide risk, [does] strongly support the converse conclusion: it is much more likely that suicidal behavior leads to treatment than that treatment leads to suicidal behavior."
We need to conduct clinical trials that include rather than exclude these high-risk patients, he adds, cautioning that, "In the meantime, the disturbing increase in the suicide rate in adolescents at a time when antidepressant treatment is becoming less frequent in this population should serve as a warning that the consequences of not receiving treatment for depression may be fatal."
Am J Psychiatry. 2007;164:989-991, 1029-1034.