Antidepressants and suicidality: History, the black-box warning, consequences, and current evidence

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Introduction: The first published literature on the topic of antidepressants and suicidality dates back to the mid-1950s. Today, 10 years after the black-box warning was issued, this controversial topic is still debated. This article will review the data behind the black-box warning and its revision; address the subsequent impact the warning had on depression diagnoses, prescribing patterns, follow-up visits, and suicide rates in the United States; and summarize meta-analyses on this topic published since the revised warning was issued in 2007.

Methods: A PubMed database search using the MeSH terms Antidepressive Agents and Suicide was conducted from January 2012 through October 2014 to identify articles published on the impact the Food and Drug Administration's black-box warning had on health care at a national level and from January 2007 through October 2014 using the same MeSH terms to identify meta-analyses on the current research regarding the link between antidepressants and suicidality. Search results for both topics were further limited to those articles published in English on human participants with the age criteria Child: Birth – 18 years, Adolescent: 13-18 years, or Young Adult: 19-24 years.

Results: Due to the black-box warning, depression diagnoses and antidepressant prescription issuance rates declined in young patients. It is still debated whether the black-box warning had an untoward effect on suicide rates. Most of the meta-analyses identified a small risk of suicidality in the populations studied. Because of the varying nature of the meta-analyses and the major limitation of the limited availability of prospectively collected suicidality data, an absolute risk is still yet to be determined.

Discussion/Conclusion: More studies on antidepressants conducted to prospectively identify suicidality in patients with Major Depressive Disorder and other varying diagnoses need to be completed to truly identify the incidence of suicidal behavior and ideation when initiating antidepressants. Albeit seemingly low, there is a risk of suicidality when initiating antidepressants; there is also risk in not treating depressed patients with antidepressants in whom they are indicated. Clinicians must be cognizant of this risk and monitor high-risk patients per the Food and Drug Administration–recommended guidelines.


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