Absence of a Relationship Between Adverse Events and Suicidality During Pharmacotherapy for Depression

This study tested the hypothesis that some patients treated with an antidepressant who develop adverse events (e.g., activation, akathisia) experience emergent suicidality specifically associated with such events. Seventeen double-blind, controlled clinical trials conducted in the United States and Canada with 3,065 patients with major depression were evaluated for treatment-emergent adverse events (events that first occurred or worsened during therapy) and suicidality (a suicidal act or emergence of substantial suicidal ideation or both) with fluoxetine, placebo, and tricyclic antidepressants. Nine relevant adverse event clusters were evaluated: activation, sedation, activation and sedation, decreased libido, mania, psychosis, psychosis and mania, acute brain syndrome, and violence. Incidence rates were determined for suicidality that was and was not temporally associated with an adverse event cluster and were analyzed within and across treatments (incidence difference method). Most patients experienced neither a cluster event nor suicidality. Where suicidality was reported, it generally was not in temporal association with an adverse event cluster. In no cluster was the incidence of suicidality statistically significantly higher when reported in temporal association with an event than when not. Suicidality was associated infrequently with treatment-emergent activation and at comparable rates across treatments. No increased risk of suicidality associated with an adverse event cluster was observed between the treatment groups (fluoxetine versus tricyclic anti-depressants; fluoxetine versus placebo). These results from double-blind, placebo- and comparator-controlled fluoxetine clinical trials in patients with major depression do not suggest a relationship between a treatment-emergent adverse event pattern and suicidality in this population.