This week in the BMJ
Volume 330, Number 7488, Issue of 19 Feb 2005SSRIs and suicide: evidence supports the association
SSRIs and suicide: evidence supports the association
People taking selective serotonin reuptake inhibitors (SSRIs) are more likely to attempt suicide than people taking placebo or a non-SSRI drug. Fergusson and colleagues (p 396) systematically reviewed 702 randomised controlled trials including 87 650 participants. They found significantly higher odds of suicide attempts for SSRIs than for placebo (number needed to treat to harm 684) and for therapeutic interventions other than tricyclic antidepressants (239). The meta-analysis did not detect a difference between SSRIs and tricyclic antidepressants. A number of major methodological limitations of the published trials may have led to underestimates of the risk of suicide attempts, say the authors.
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SSRIs and suicide: drug companies' trials are inconclusive
Data submitted by drug companies for a safety review by the Medicines and Healthcare Products Regulatory Agency don't lead to firm conclusions about a possible association between selective serotonin reuptake inhibitors (SSRIs) and suicide in adults. Gunnell and colleagues (p 385) systematically reviewed 477 randomised controlled trials comparing SSRIs with placebo in over 40 000 participants. They found only weak evidence of an increased risk of self harm among patients taking SSRIs when compared with placebo (odds ratio 1.57, 95% credible interval 0.99 to 2.55).
SSRIs and suicide: risks seem to be similar to risks with tricyclics
The risk of suicide or non-fatal self harm does not seem to differ significantly in patients taking selective serotonin reuptake inhibitors (SSRIs) and those taking tricyclic antidepressants. In a nested case-control study, Martinez and colleagues (p 389) compared the risks in 146 095 people who were prescribed different antidepressants for the first time. They found some evidence of an association between SSRIs and self harm in people aged 18 or younger (adjusted odds ratio 1.59, 95% confidence interval 1.01 to 2.50), but could not rule out preferential prescribing affecting the results.
The practical implications of these three studies of SSRIs and suicide are discussed in an editorial by Cipriani et al (p 373).
Repetition of self harm is not predicted well
Neither emergency department staff nor psychiatrists can predict which patients will repeat self harm. Kapur and colleagues (p 394) analysed the records for 10 173 episodes of self harm in 7612 individuals over five years. Emergency department staff were more cautious than psychiatrists, rating more people at risk of repetition and identifying a greater proportion of those who did repeat. Psychiatrists were better at predicting which patients actually did repeat. Overall, though, most repetitions were among people assessed as at low or moderate risk.
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What is taught about cultural diversity?
Teaching about cultural diversity in medical schools in the United Kingdom and the Republic of Ireland has improved since 1995 but needs further improvement. In a cross sectional questionnaire survey by Dogra and colleagues (p 403), 72% of schools reported that they provide formal teaching about cultural diversity. The authors say that this teaching seems rather fragmented, and that uncertainty still remains as to what constitutes cultural diversity teaching.
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Subfecundity increases the risk of neonatal death
A long time to pregnancy (subfecundity) is associated with an increased risk of neonatal death. In Denmark, Basso and Olsen (p 393) examined the association through logistic regression (adjusting for mother's age, body mass index, smoking, and social class) of the data for 27 624 singleton babies and their mothers who were part of the Danish national birth cohort. The babies of women who tried for longer than one year to conceive their first child had a higher risk of neonatal death than those conceived sooner (adjusted odds ratio 2.82, 95% confidence interval 1.35 to 5.90). The finding needs to be corroborated elsewhere, the authors say.
Locked-in syndrome
In the locked-in syndrome, which is caused by damage to the ventral pons and leaves the patient with quadriplegia, anarthria, and preserved consciousness, the 10 year survival rate is as high as 80%. This week's clinical review by Smith and Delargy (p 406) summarises what is known about the clinical features, classification, diagnosis, management, and prognosis of patients with locked-in syndrome. The authors emphasise the need for early rehabilitation management, which can significantly improve the quality of life of these patients and their carers.
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