The Emergence of Suicidal Ideation and Behavior During Antidepressant Pharmacotherapy

From making the cure of a disease more grievous than its endurance, Good Lord deliver us.— Sir Robert Hutchinson It has recently been suggested that a selective serotonin reuptake inhibitor, fluoxetine, may trigger suicidal ideation or acts in patients receiving this drug for the treatment of depression.1This hypothesized association is surprising because there is considerable evidence of serotonin deficiency in patients who attempt or complete suicide,2,3and fluoxetine selectively enhances serotonergic transmission. To resolve this apparent paradox, we reviewed the biologic aspects of suicidal behavior, with special reference to the role of serotonin (5-HT) and to the evidence for the emergence of paradoxical suicidality during antidepressant treatment. Special attention was also paid to the recent literature on selective serotonin reuptake inhibitors and fluoxetine and to the research and clinical implications of these findings. BIOLOGY OF SUICIDAL BEHAVIOR Suicide has traditionally been regarded as an extreme response