Antidepressants and Suicide Risk in the United States, 1985-1999

Michael F. Grunebaum, M.D.; Steven P. Ellis, Ph.D.; Shuhua Li, Ph.D.;Maria A. Oquendo, M.D.; and J. John Mann, M.D.

Background: The role of antidepressants in suicide prevention is a major public health question. An association was hypothesized between the increase in the use of non-tricyclic antidepressant medications in the United States and the decline in the suicide rate during the years 1985-1999.

Method: The relationships between the suicide, antidepressant prescription, unemployment, and alcoholic beverage consumption rates were studied using generalized linear models. Suicide rates by antidepressant overdose were compared in selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).

Results: From 1985 to 1999, the suicide rate fell 13.5%, with a greater decline among women, and antidepressant prescription rates increased over 4-fold, with the increase mostly due to SSRIs. Prescription rates for SSRIs and other second-generation antidepressants were both inversely associated with suicide rates (p = .03 and p = .02, respectively). In a multivariable analysis adjusting for unemployment and alcoholic beverage consumption rates, SSRI antidepressant prescription rates remained inversely associated with the national suicide rate (p = .03). Females received twice as many antidepressant prescriptions compared with males. The commonest prescription indication was mood disorders, the condition most often associated with suicide. SSRIs were associated with a lower risk of suicide by antidepressant overdose compared with TCAs.

Conclusion: The decline in the national suicide rate (1985-1999) appears to be associated with greater use of non-tricyclic antidepressants. Treatment of a greater proportion of mood disorders with SSRIs and other second-generation non-tricyclic antidepressants may further reduce the suicide rate. Controlled studies of the anti-suicidal properties of antidepressants are needed in high-risk depressed patient populations.

(J Clin Psychiatry 2004;65:1456-1462)

Received Aug. 25, 2003; accepted May 19, 2004. From the Department of Neuroscience, New York State Psychiatric Institute; and the Department of Psychiatry, the College of Physicians and Surgeons, Columbia University, New York, N.Y.

Supported by Public Health Service grant #MH62185 to the NIMH Conte Center for the Neuroscience of Mental Disorders: The Neurobiology of Suicidal Behavior. Part of the IMS data related to sex and indications for antidepressant prescriptions were obtained from Pfizer, but Pfizer was otherwise uninvolved in the project.

Dr. Mann has received an investigator-initiated grant from Pfizer unrelated to the current study.

Corresponding author and reprints: Michael F. Grunebaum, M.D., Department of Neuroscience, New York State Psychiatric Institute, 1051 Riverside Dr., Box 42, New York, NY 10032(e-mail: mfg14@Columbia.edu).