Does treatment with antidepressant medication increase suicidal behavior?

Suicidal ideation and behavior are commonly associated with psychiatric conditions, in particular the affective disorders. Patients diagnosed with Major Depression carry an estimated lifetime risk of suicide ranging from 15-30%. In recent years increasing attention has been paid to the psychobiology of suicide. Serotonin, an indolamine neurotransmitter, has been implicated as playing a role in suicidal behavior, especially in depressed patients. Treatment of depressive episodes with antidepressant medication has greatly improved the prognosis for survival through the suicidal period and recovery from the depressive episode. However, there has been considerable debate about the significance of reports that antidepressants may, on occasion, adversely affect depressed patients. Recently this has received much attention in the United States of America, particularly involving the antidepressant fluoxetine. In this paper we briefly outline previous studies on the role of serotonin in suicidal behavior in depression; and review the debate about antidepressants adversely affecting suicidal behavior. Possible mechanisms involving effects on the serotonergic system that could account for some of these adverse reactions are discussed, and a contextual framework is developed for interpreting clinical data on this important phenomenon.