Ventricular Arrhythmia and Sudden Death Risk With Concomitant Antipsychotic and SSRI Use

Antipsychotics and selective serotonin reuptake inhibitors (SSRIs) are each associated with increased risk of ventricular arrhythmia or sudden death. Their concurrent use may further elevate this risk; however, clinical evidence remains limited.

To evaluate the risk of ventricular arrhythmia or sudden death in patients concurrently prescribed an antipsychotic and an SSRI.

This cohort study used a sequential target trial emulation method to analyze insurance claims data from health insurance databases in the US (2010-2023) and Taiwan (2010-2021). Eligible patients (adults initiating an antipsychotic with no SSRI use in the prior year) were included and assessed weekly for SSRI initiation from weeks 1 to 52 following antipsychotic initiation. Fifty-two weekly trials were emulated to assess the 1-year ventricular arrhythmia or sudden death risk following SSRI initiation in patients newly treated with antipsychotics. A per-protocol approach with inverse probability weighting and adjustment for time-varying covariates was applied.

SSRI initiation within 52 weeks after antipsychotic initiation, with patients classified weekly as SSRI initiators or noninitiators.

The outcome of interest was incident ventricular arrhythmia or sudden death. Hazard ratios (HRs) with 95% CIs were estimated using weighted pooled logistic regression models with robust variance estimators.

Overall, 307 818 unique patients in the US cohort (4 370 289 person-trials; mean [SD] age, 46.6 [18.8] years; 2 764 180 female [61.2%]) and 191 080 unique patients in the Taiwan cohort (2 150 639 person-trials; mean [SD] age, 51.0 [18.3] years; 1 184 464 female [55.1%]) met the eligibility criteria. In the adjusted cohorts, 52 825 US patients (17.2%) and 25 203 Taiwanese patients (14.7%) initiated SSRIs. The adjusted HRs for concurrent antipsychotic and SSRI use vs antipsychotic alone were 1.51 (95% CI, 1.04-2.19) in the US and 3.32 (95% CI, 2.26-4.88) in Taiwan. For high-risk SSRIs, citalopram and escitalopram, the adjusted HRs were 2.20 (95% CI, 1.39-3.46) and 2.84 (95% CI, 1.75-4.62), respectively. Sensitivity analyses supported robustness of primary findings, and positive and negative control analyses suggested limited residual confounding.

In this cohort study of adults initiating antipsychotics in the US and Taiwan, SSRI initiation in antipsychotic users was associated with an increased risk of ventricular arrhythmia or sudden death. Although rare, the potential severity of these events supported the need for cautious use of this combination.