Treating Suicidality in Depressive Illness. Part 2: Does Treatment Cure or Cause Suicidality?

By Sakinofsky, Isaac | Canadian Journal of Psychiatry, June 2007 | Go to article overview

Treating Suicidality in Depressive Illness. Part 2: Does Treatment Cure or Cause Suicidality?


Sakinofsky, Isaac, Canadian Journal of Psychiatry


ABSTRACT

Objective: To systematically review studies of treatment efficacy for suicidality in mood disorders. To consider the evidence for whether antidepressants may induce suicidality.

Method: Systematic review of the literature.

Results and Conclusions: There is fairly good evidence that lithium reduces completed suicide and attempt rates in people with bipolar disorder and recurrent unipolar depression. Antidepressants and psychological treatments may reduce suicidal ideation in depressed patients. Antidepressant trials do not, however, a priori target suicidality as an outcome, and inferences made are post hoc. For practical reasons, no adequate trials to date have tested the efficacy of treatment aimed at reducing completed suicide in people with depressive disorders. Antidepressants have been implicated in suicide in one metaanalysis (the elderly) and in one case-control study (youth), signalling the need for caution. However, most metaanalyses have found no significant excess of completed suicide among antidepressant users, compared with placebo groups, in adults and juveniles, but excess nonfatal suicidality is found more often in children and adolescents who take antidepressants (except fluoxetine). The controversy is ongoing.

RÉSUMÉ

Objectif : Mener une revue systématique des études sur l'efficacité du traitement de la suicidabilité dans les troubles de l'humeur. Examiner s'il y a des données probantes indiquant que les antidépresseurs peuvent induire la suicidabilité.

Méthode : Une revue systématique de la documentation.

Résultats et Conclusions : II y a d'assez bonnes données probantes indiquant que le lithium réduit les taux de suicide complété et de tentatives chez les personnes souffrant de trouble bipolaire et de dépression unipolaire récurrente. Les antidépresseurs et les traitements psychologiques peuvent réduire l'ideation suicidaire chez les patients déprimés. Cependant, les essais d'antidépresseurs ne ciblent pas a priori la suicidabilité comme résultat, et les inferences sont faites ultérieurement. Pour des raisons pratiques, aucun essai adéquat existant à ce jour n'a vérifié l'efficacité du traitement visant à réduire le suicide complété chez les personnes souffrant de troubles dépressifs. Les antidépresseurs ont été impliqués dans le suicide dans 1 méta-analyse (les personnes âgées) et 1 étude cas-témoin (les jeunes), indiquant le besoin de faire preuve de prudence. Toutefois, la plupart des méta-analyses n'ont observé aucun excès significatif de suicide complété chez les utilisateurs d'antidépresseurs comparés aux groupes placebo d'adultes et déjeunes, mais un excès de suicidabilité non fatale se trouve plus souvent chez les enfants et les adolescents qui prennent des antidépresseurs (sauf la fluoxétine). La controverse se poursuit.

(Can J Psychiatry 2007:52[6 Suppl 1]:85S-102S)

Key Words: suicide, treatment, antidepressants, electroconvulsive therapy, provocation

This paper is Part 2 of a review of the evidence for the treatment of suicidality in persons suffering from depressive illness. Part 1 deals with 2 major controversies that beset the treatment of suicidal behaviour in depressive illness today: first, whether suicide is undertreated or not and, second, whether epidemiologic studies support the contention that the rise in antidepressant prescriptions accounts for the decline in suicide rates observed in some countries. 'Part 2 deals with the grave charge that antidepressant treatment may actually cause suicidal ideation and actions (attempts, resulting in completed suicide or not). First, however, this paper reviews the evidence for the efficacy of treatment of suicidality (ideation, attempts, or completed suicide) in depression cases. The method is a systematic review of the literature as described in the first section of this compendium of papers (see "The Current Evidence Base for the Clinical Care of Suicidal Patients: Strengths and Weaknesses"). …

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