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Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose

  • Keith Hawton (a1), Helen Bergen (a1), Sue Simkin (a1), Jayne Cooper (a2), Keith Waters (a3), David Gunnell (a4) and Navneet Kapur (a5)...
Abstract
Background

Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important.

Aims

To assess the relative toxicity of specific tricyclic antidepressants (TCAs), a serotonin and noradrenaline reuptake inhibitor (SNRI), a noradrenergic and specific serotonergic antidepressant (NaSSA), and selective serotonin reuptake inhibitors (SSRIs).

Method

Observational study of prescriptions (UK), poisoning deaths involving single antidepressants receiving coroners' verdicts of suicide or undetermined intent (England and Wales) and non-fatal self-poisoning episodes presenting to six general hospitals (in Oxford, Manchester and Derby) between 2000 and 2006. Calculation of fatal toxicity index based on ratio of rates of deaths to prescriptions, and case fatality based on ratio of rates of deaths to non-fatal self-poisonings.

Results

Fatal toxicity and case fatality indices provided very similar results (rho for relative ranking of indices 0.99). Case fatality rate ratios showed greater toxicity for TCAs (13.8, 95% CI 13.0–14.7) than the SNRI venlafaxine (2.5, 95% CI 2.0–3.1) and the NaSSA mirtazapine (1.9, 95% CI 1.1–2.9), both of which had greater toxicity than the SSRIs (0.5, 95% CI 0.4–0.7). Within the TCAs, compared with amitriptyline both dosulepin (relative toxicity index 2.7) and doxepin (2.6) were more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs (1.1, 95% CI 0.8–1.4 v. 0.3, 95% CI 0.2–0.4).

Conclusions

There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, and to regulatory policy.

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Copyright
Corresponding author
Correspondence: Keith Hawton, Centre for Suicide Research, University of Oxford, Department of Psychiatry, Warneford Hospital, Headington, Oxford OX3 7JX, UK. Email: keith.hawton@psych.ox.ac.uk
Footnotes
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Declaration of interest

D.G. is a member of the Medicines and Healthcare products Regulatory Agency's Pharmacovigilance Expert Advisory Group.

Footnotes
References
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Supplementary Table S1

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Supplementary materials

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Supplementary Table S1

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Supplementary materials

Hawton et al. supplementary material
Supplementary Table S1

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Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose

  • Keith Hawton (a1), Helen Bergen (a1), Sue Simkin (a1), Jayne Cooper (a2), Keith Waters (a3), David Gunnell (a4) and Navneet Kapur (a5)...
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