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Letter to the Editor

Reply to Suicidal Risk During Antidepressant Treatment

Susanne Stübner, MD; Renate Grohmann, MD; and Waldemar Greil, MD

Published: May 15, 2011

See the original letter

Dr Stübner and Colleagues Reply

To the Editor: We would like to thank Dr Baldessarini for his comments on our article.1

Dr Baldessarini stated that in our sample of 142,000 patients undergoing treatment with antidepressant drugs, the rate of suicidal behavior is far lower than would be expected in a clinical population of depressed patients and that it is even lower than in the general population. This discrepancy is a consequence of the method applied. Within a drug surveillance program, cases were included only on the condition that an observed adverse event is considered to be an adverse drug reaction. This means that in our study, suicidal ideation, suicidal attempts, and suicides had to be rated by the treating and drug monitoring psychiatrists as possible or probable adverse effects of the antidepressant medication.

Furthermore, Dr Baldessarini noticed that the ratio of suicide attempts to suicides is comparable to data in the literature, but the higher number of suicide attempts compared to suicidal ideation is in contrast to clinical and epidemiologic data. Since suicidal ideation is a very common symptom of depressive disorder, a causal relation to the medication has been assessed less often than in cases of suicide attempts in our naturalistic study.

In accordance with Dr Baldessarini’s suggestion that we should discriminate between suicidal ideation, suicidal attempts, and suicides and avoid the more general term suicidality, we have described suicidal behavior for all cases in detail.

In cases of suicidal behavior assumed to be triggered by antidepressants, emerging suicidal thoughts and impulses experienced as strange to the patients (ego-dystonic) as well as restlessness and impulsivity were observed as characteristic symptoms. During treatment with antidepressants, physicians should be aware of these symptoms to avoid suicidal behavior as a rare but serious adverse effect of medication.


1. Stübner S, Grohmann R, von Stralendorff I, et al. Suicidality as rare adverse event of antidepressant medication: report from the AMSP multicenter drug safety surveillance project. J Clin Psychiatry. 2010;71(10):1293-1307. PubMed doi:10.4088/JCP.09m05912blu

Susanne Stübner, MD

Renate Grohmann, MD

Waldemar Greil, MD

Author affiliations: Department of Psychiatry, Ludwig-Maximilan University of Munich, Germany. Potential conflicts of interest: Dr Grohmann is the project manager of the AMSP (Arzneimittelsicherheit in der Psychiatrie) program, which is supported by grants from multiple pharmaceutical companies as listed in full in the original article. Dr Greil is a recipient of research and educational grants from, as well as a member of speakers and advisory boards of, several pharmaceutical companies as listed in the original article. Dr Stübner reports no potential conflicts of interest relevant to this report. Funding/support: None reported.

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