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Risk of suicide attempt associated with isotretinoin: a nationwide cohort and nested case-time-control study
Catherine Droitcourt1,2,3,4, Emmanuel Nowak2,5,6, Caroline Rault1,2
1Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research].
Background:
Isotretinoin is the only effective treatment for severe acne. An isotretinoin-related suicide risk is still debated and under scrutiny by regulatory agencies. Our objectives were: to assess the risk of suicide attempt before, during and after isotretinoin treatment; to detect any potential triggering effect of isotretinoin initiation on suicide attempt.
Methods:
We implemented a cohort and nested case-time-control study of subjects treated with oral isotretinoin (course or initiation) aged 10-50 years, using the Nationwide French Health Insurance data (2009-2016). The main outcome was hospitalized suicide attempt. Standardized incidence ratios for hospitalized suicide attempts were calculated before, during and after isotretinoin treatment. The number of isotretinoin initiations was compared in risk and control periods of 2 months using a case-time-control analysis.
Results:
In all, 443 814 patients (median age 20.0 years; interquartile range 17.0-27.0 years) were exposed to isotretinoin, amounting to 244 154 person-years, with a marked seasonality for treatment initiation. Compared with the French general population, the occurrence of suicide attempts under isotretinoin treatment was markedly lower, with a standardized incidence ratio of 0.6 [95% confidence interval (CI) = 0.53-0.67]; the same applied, to a lesser extent, before and after isotretinoin treatment. In the case-time-control analysis, among cases of suicide attempt, 108 and 127 isotretinoin initiations were observed in the risk and control periods respectively (i.e. 0-2 months and 2-4 months before the date of suicide attempt). The comparison with the 1199 and 1253 initiations observed among matched controls in the same two periods yielded a case-time-control odds ratio of 0.89 (95% CI = 0.68-1.16). A sensitivity analysis using three-month periods and a complementary analysis adding completed suicides for case definition showed consistent results.
Conclusion:
Compared with the general population, a lower risk of suicide attempt was observed among patients exposed to isotretinoin and there was no evidence for a triggering effect of isotretinoin initiation on suicide attempt. A selection of patients at lower risk for suicidal behaviour and appropriate treatment management could explain these findings. Risk management plans should therefore be maintained.
Insights
This study found that isotretinoin treatment for severe acne was associated with a lower risk of suicide attempts compared to the general population. There was no evidence that starting isotretinoin triggered suicidal behavior.
Area of Science:
- Dermatology
- Psychiatry
- Public Health
Background:
- Isotretinoin is a highly effective treatment for severe acne.
- Concerns persist regarding a potential link between isotretinoin and suicide risk.
- Regulatory agencies are actively scrutinizing this debated association.
Purpose of the Study:
- To evaluate suicide attempt risk in patients before, during, and after isotretinoin treatment.
- To determine if initiating isotretinoin triggers suicide attempts.
- To provide evidence-based insights into isotretinoin's safety profile regarding suicidality.
Main Methods:
- A cohort and nested case-time-control study was conducted using French health insurance data (2009-2016).
- Included were patients aged 10-50 years treated with oral isotretinoin.
- Hospitalized suicide attempts served as the primary outcome measure.
Main Results:
- Patients treated with isotretinoin exhibited a significantly lower rate of suicide attempts compared to the general population (Standardized Incidence Ratio = 0.6).
- No increased risk of suicide attempts was observed before, during, or after isotretinoin treatment.
- Case-time-control analysis revealed no evidence that isotretinoin initiation triggered suicide attempts (Odds Ratio = 0.89).
Conclusions:
- Isotretinoin treatment is associated with a reduced risk of suicide attempts compared to the general population.
- No causal link or triggering effect of isotretinoin initiation on suicide attempts was identified.
- Patient selection for lower suicide risk and effective management strategies likely contribute to these findings, supporting continued risk management plans.
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