From the Guidelines
Several psychotropic medications, particularly antidepressants like selective serotonin reuptake inhibitors (SSRIs), have been associated with an increased risk of suicidality, especially in children, adolescents, and young adults under 25. The medications that might induce suicidality include:
- Antidepressants, especially SSRIs like fluoxetine, sertraline, paroxetine, and escitalopram, which carry FDA black box warnings about increased suicidal thoughts 1
- Benzodiazepines, such as alprazolam and clonazepam
- Antipsychotics, including aripiprazole and quetiapine
- Mood stabilizers, like lamotrigine
- Certain anti-epileptic drugs, such as topiramate and levetiracetam The risk of suicidality appears to be highest during the first few weeks of treatment or following dose adjustments, and the mechanism may involve initial activation or agitation before therapeutic effects begin, neurochemical changes that temporarily worsen mood, or paradoxical reactions 1. Patients starting these medications should be monitored closely, especially during the first month, with more frequent follow-ups and clear instructions to report any new or worsening thoughts of suicide 1. Family members should also be educated about warning signs, and the benefits of these medications typically outweigh the risks when properly prescribed and monitored, as untreated psychiatric conditions themselves carry significant suicide risk.
From the FDA Drug Label
Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder (MDD) and other psychiatric disorders There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied
The psychotropics that might induce suicidality are:
- SSRIs (e.g., sertraline, fluoxetine)
- Other antidepressant drugs
These drugs may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder and other psychiatric disorders 2.
From the Research
Psychotropics that Might Induce Suicidality
- Selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased risk of suicidality in children and young adults aged 18-24, as indicated by a black box warning 3.
- The six major SSRIs marketed in the USA, including fluoxetine, citalopram, escitalopram, paroxetine, sertraline, and fluvoxamine, have unique pharmacokinetics, pharmacodynamics, and side effect profiles, which may contribute to the risk of suicidality 3.
- Some studies suggest that SSRIs may reduce the risk of suicidal behavior in adults, but the relationship between SSRIs and suicidality remains debated 4.
- A review of clinical studies, meta-analyses, and epidemiological studies found evidence of a possible link between SSRIs and suicidality, including a dose-dependent relationship between SSRIs and agitation and suicidality 5.
- Specific SSRIs, such as fluoxetine, have been associated with a higher incidence of agitation, weight loss, and dermatological reactions, which may contribute to the risk of suicidality 6.
- Other SSRIs, such as paroxetine, have been linked to a higher incidence of discontinuation reactions, sedation, tremor, sweating, sexual dysfunction, and gastrointestinal symptoms, which may also contribute to the risk of suicidality 6.
Key Findings
- The risk of suicidality associated with SSRIs is highest in children and young adults aged 18-24 3.
- The relationship between SSRIs and suicidality is complex and may depend on individual patient characteristics, such as history of suicide attempts or underlying psychiatric conditions 4, 5.
- Further research is needed to establish the magnitude of the risk and the characteristics of patients who may be most at risk of suicidality associated with SSRIs 5.