Talking Points About Antidepressants and Suicide

Thomas A. M. Kramer, MD

In This Article

The Risks

It is important to directly acknowledge the suicide risk caused by these medications. It is real and well understood, at least by experienced psychopharmacologists. There are 2 mechanisms that we know about that cause these medications to potentially precipitate suicidality. One is extremely rare, and the other is milder but more common. The rare one is the potential for SSRIs to precipitate an akathisia. This movement disorder, usually associated with antipsychotic medications, has been reported as a rare side effect of SSRIs. This intense restlessness can be so dysphoric for patients that they might consider suicide rather than endure the restlessness. This is something that practitioners should warn patients about, and look for closely, as it is quite treatable with adjunctive medication.

The second mechanism involves the natural history of recovery from depression. Depression is a disorder with numerous symptoms, and when the disorder is treated effectively, the symptoms do not resolve all at the same time. Classically, the physical symptoms of depression (including lack of energy, difficulty concentrating, and sleeping and eating disturbances) resolve first and the subjective depressed mood resolves last. As a result, patients who are being treated for depression can have increased energy and increased functionality as they recover, while still struggling with subjectively depressed mood. This increases their suicide risk; they may have lacked the energy or the ability to attempt suicide prior to starting treatment, but as they begin to recover they regain ability and motivation before they have a subjective sense of improvement. As a result, patients are usually at greatest risk a week to 10 days after starting medication, and by 2-3 weeks later, that risk is resolved. Experienced clinicians understand this as a function of the disease, not the specific treatment, and are careful to watch for it and to instruct family and friends to also be aware of it. The problem may be exacerbated by the trend of primary care physicians treating depression. They usually see patients for 10- or 15-minute periods of time and very rarely more frequently than once a month.


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