Suicide and antidepressants.

Suicidal thoughts and suicide attempts are an integral part of various depressions. Suicide attempts are common in major depression but even more common in recurrent brief depression, and the rate is further increased when these depressions occur comorbidly. Combined depression, where recurrent brief depression and major depression coexist, is the strongest clinical predictor of suicide attempts in the literature. There have been very few controlled studies of treatments for depression in high-risk groups of suicide attempters. Psychotherapy has been found to significantly raise the suicide attempt rate compared with conventional treatment, whereas fluoxetine and mianserin were not different from placebo. The only treatment that has been found to lower the suicide attempt rate in those with a history of previous suicide attempts is low doses of flupenthixol, a neuroleptic licensed for depression in Europe. This drug had a significant advantage compared with placebo in a six-month study. There are indications from large studies that maprotiline and amitriptyline might raise the suicide attempt rate, compared with placebo or other antidepressants, independent of their inherent toxicity in overdose. Several analyses of coroners' data show that tricyclic antidepressants are associated with high and unacceptable death rates in overdose compared with SSRIs and other safer antidepressants. Toxic antidepressants should be avoided in those thought to be at particular risk.