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Precursors to suicidality and violence on antidepressants: systematic review of trials in adult healthy volunteers


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Objective: To quantify the risk of suicidality and violence when selective serotonin and serotonin-norepinephrine reuptake inhibitors are given to adult healthy volunteers with no signs of a mental disorder. Design: Systematic review and meta-analysis. Main outcome measure: Harms related to suicidality, hostility, activation events, psychotic events and mood disturbances. Setting: Published trials identified by searching PubMed and Embase and clinical study reports obtained from the European and UK drug regulators. Participants: Double-blind, placebo-controlled trials in adult healthy volunteers that reported on suicidality or violence or precursor events to suicidality or violence. Results: A total of 5787 publications were screened and 130 trials fulfilled our inclusion criteria. The trials were generally uninformative; 97 trials did not report the randomisation method, 75 trials did not report any discontinuations and 63 trials did not report any adverse events or lack thereof. Eleven of the 130 published trials and two of 29 clinical study reports we received from the regulatory agencies presented data for our meta-analysis. Treatment of adult healthy volunteers with antidepressants doubled their risk of harms related to suicidality and violence, odds ratio 1.85 (95% confidence interval 1.11 to 3.08, p = 0.02, I(2 )= 18%). The number needed to treat to harm one healthy person was 16 (95% confidence interval 8 to 100; Mantel-Haenszel risk difference 0.06). There can be little doubt that we underestimated the harms of antidepressants, as we only had access to the published articles for 11 of our 13 trials. Conclusions: Antidepressants double the occurrence of events in adult healthy volunteers that can lead to suicide and violence.
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Precursors to suicidality and violence on antidepressants:
systematic review of trials in adult healthy volunteers
Andreas Ø Bielefeldt
, Pia B Danborg
and Peter C Gøtzsche
Nordic Cochrane Centre, Rigshospitalet, 2100 Copenhagen Ø, Denmark
Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark
Corresponding author: Peter C Gøtzsche. Email:
Objective: To quantify the risk of suicidality and violence
when selective serotonin and serotonin-norepinephrine
reuptake inhibitors are given to adult healthy volunteers
with no signs of a mental disorder.
Design: Systematic review and meta-analysis.
Main outcome measure: Harms related to suicidality, hostil-
ity, activation events, psychotic events and mood disturbances.
Setting: Published trials identified by searching PubMed and
Embase and clinical study reports obtained from the
European and UK drug regulators.
Participants: Double-blind, placebo-controlled trials in
adult healthy volunteers that reported on suicidality or vio-
lence or precursor events to suicidality or violence.
Results: A total of 5787 publications were screened and 130
trials fulfilled our inclusion criteria. The trials were generally
uninformative; 97 trials did not report the randomisation
method, 75 trials did not report any discontinuations and
63 trials did not report any adverse events or lack thereof.
Eleven of the 130 published trials and two of 29 clinical study
reports we received from the regulator y agencies presented
data for our meta-analysis. Treatment of adult healthy vol-
unteers with antidepressants doubled their risk of harms
related to suicidality and violence, odds ratio 1.85 (95%
confidence interval 1.11 to 3.08, p¼0.02, I
¼18%). The
number needed to treat to harm one healthy person was
16 (95% confidence interval 8 to 100; Mantel-Haenszel risk
difference 0.06). There can be little doubt that we under-
estimated the harms of antidepressants, as we only had
access to the published articles for 11 of our 13 trials.
Conclusions: Antidepressants double the occurrence of
events in adult healthy volunteers that can lead to suicide
and violence.
Psychiatry, antidepressants, depression, healthy volunteers
The reporting of harms in drug trials is generally
poor, with inadequate explanation of how they were
collected, and often harms are missing altogether.
From 2011 to 2012, the Nordic Cochrane Centre
received unredacted clinical study reports on
antidepressants filed for regulatory approval at the
European Medicines Agency and the UK Medicines
and Healthcare products Regulatory Agency. We
demonstrated selective reporting of major harms in
the published articles of duloxetine and inconsisten-
cies between the protocols and the clinical study
Furthermore, we noticed that the adverse
events tables in clinical study reports had hidden sui-
cidal events due to the medical dictionaries and
coding conventions used.
Based on the 70 clinical
study reports we received, we found that antidepres-
sants more than doubled the risk of suicidal and
aggressive behaviour in children and adolescents.
A 2012 systematic review of 33 trials in healthy
volunteers documented various effects of selective
serotonin reuptake inhibitors but only mentioned
the adverse events in a few words.
The review was
based on published articles and none of these lived
fully up to the CONSORT guideline for good
Since their introduction in the late 1980s, the
benefits and harms of selective serotonin reuptake
inhibitors and serotonin-norepinephrine reuptake
inhibitors have been the subject of huge debate.
Because their harms – in particular suicidality –
have often been explained away as if they were dis-
ease symptoms or only a problem in children,
wished to quantify the risk of suicidality and violence
when these drugs are given to adult healthy
According to our prespecified protocol (available
from the authors), we included double-blind,
randomised placebo-controlled trials of selective
serotonin reuptake inhibitors or serotonin-norepi-
nephrine reuptake inhibitors (called antidepressants
throughout this paper) in adult healthy volunteers
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with no signs of a mental disorder. There were no
language restrictions. We excluded trials in abusers
of tobacco, drugs or alcohol and also imaging studies,
as these have another objective and furthermore are
of poor methodological quality.
We searched PubMed (1966 to December 2015)
and Embase (1974 to December 2015) using the
search strings specified in Table 1. The searches
were conducted in collaboration with an information
specialist to ensure the inclusion of drugs that were
not indexed in PubMed’s MeSH thesaurus. One
researcher (AØB) screened all search results by read-
ing titles and abstracts, and all excluded studies were
rescreened by the same researcher who also read the
included studies and extracted relevant trial data, e.g.
design, population size, harms, discontinuations and
funding, to a spreadsheet. A second researcher (PBD)
extracted data on a randomly selected sample of 30
articles; as there were no discrepancies, we did not
perform data extraction in duplicate.
We also included relevant clinical study reports on
antidepressant drugs we received from regulatory
agencies for our projects in this area.
We checked
whether the clinical study reports had been published
by searching for investigator names and drugs on
PubMed and Embase.
We defined harms as adverse events that were
either suicidality or violence or were considered pre-
cursor events to suicidality or violence in the litera-
ture, with a particular focus on the list of criteria used
by the Food and Drug Administration for its 2006
meta-analysis of suicidality in 100,000 patients
(Table 2).
We categorised the harms as suicidal-
ity, violence, activation events, psychotic events and
mood disturbances.
Uncertainties during data extraction were resolved
by discussion between the authors. If the reporting of
harms was unclear, we contacted the authors of the
trials for clarification. We assessed the risk of bias in
the trials focusing on randomisation and blinding.
We performed a meta-analysis calculating Peto’s
odds ratio for dichotomous outcomes with Review
Manager. Because of the considerable risk of carry-
over effects in crossover trials, we only used trials that
reported on periods separately.
We identified 5787 publications in PubMed and
Embase, removed 569 duplicate entries, and screened
the titles and abstracts of the remaining 5218 records,
which left 316 articles for full-text reading (Figure 1).
We excluded 174 of these articles because the studies
were crossover trials using antidepressant inhibitor, a
placebo and a third drug, or because the studies were
parallel trials that used a drug other than an antidepres-
sant as an interaction drug. This left 142 articles on a
total of 130 trials that fulfilled our inclusion criteria, 52
of which were two-period crossover trials. Ten different
antidepressants were tested in the trials; citalopram
(n¼33) and paroxetine (n¼27) were most commonly
The trials did not report much about their
methodology. All 130 trials were allegedly randomised,
but 97 (75%) did not describe the method and 75 (58%)
did not report any discontinuations or lack thereof.
Reporting of adverse events was generally inad-
equate; 63 trials (48%) did not report any adverse
events or stated that there were none; 43 trials
(33%) reported at least one adverse event; while 24
trials (18%) reported only the most frequently occur-
ring adverse events or those leading to discontinu-
ation. The source of funding was industry in 29
trials (22%), non-industrial sources in 47 trials
(36%), mixed in 17 trials (13%) and not reported in
37 trials (28%).
Thirteen of the 130 trials reported on at least one
of our predefined harms, 10 of which were parallel
group trials and three crossover trials. We could not
include two of the crossover trials, as there were no
Table 1. Search strings for PubMed and Embase.
Database Search string entered
PubMed (‘‘Healthy Volunteers’’[Mesh] OR Healthy OR Normal) AND (‘‘atomoxetine’’[Supplementary Concept] OR
‘‘reboxetine’’[Supplementary Concept] OR ‘‘O-desmethylvenlafaxine’’[Supplementary Concept] OR
‘‘clovoxamine’’[Supplementary Concept] OR ‘‘Serotonin Uptake Inhibitors’’[Pharmacological Action])
Embase 1 exp serotonin uptake inhibitor/
2 exp serotonin noradrenalin reuptake inhibitor/
3 1 or 2
4 normal human
5 3 and 4
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data for each period separately. We included the first
period of the third crossover trial, which ended pre-
maturely due to carryover effects despite a four-week
washout period.
We received 29 clinical study reports from the
regulatory agencies, two of which fulfilled our inclu-
sion criteria for the meta-analysis. None of them had
been published. Most of the remaining clinical study
reports described non-blinded bioavailability studies
or drug interaction studies.
Thus, we included 11 trials from our literature
and two from the regulatory
in our meta-analysis. The drugs were
citalopram, escitalopram, fluoxetine, paroxetine, ser-
traline or venlafaxine, in all cases given orally. Four
trials were not industry sponsored and did not have
industry employees among the authors.
A2,A3,A5,A 7
Trial characteristics, length of treatment and our pre-
defined harms with reported severity are shown in
Table 3. The harms we found all occurred within the
randomised phase of the trials, not during the with-
drawal phase after the trials were finished. The median
age was 30 years; 40% of the volunteers were women,
and the median publication year was 2008.
Risk of bias in the included trials
Adequate methods for sequence generation and con-
cealment of treatment allocation were described for
six trials
and for concealment of alloca-
tion for two trials.
The methods were not spe-
cified in five trials.
Adequate blinding
methods were mentioned for seven trials
and not specified in six trials.
We did not
Table 2. Types of harms looked for when reading the reports.
Suicidality Core event Accident, asphyxia, attempt, burn, cut, drown, firearm, gas, gun, hanged, immol-
ation, injury, jump, monoxide, mutilate, overdose, poison, self-damage, self-
harm, self-inflicted, self-injury, shoot, suicide, suffocate
Potential event
Violence Core event Antisocial behaviour, assaultive behaviour, criminal behaviour, homicidal idea-
tion, homicide, physical abuse, physical assault, physically threatening
behaviour, violence-related symptom
Potential event
Activation events Core event Aggression, agitation, akathisia, amphetamine speed-like response, anxiety,
anxiety attack, argumentative, caffeine feeling, CNS stimulation, euphoria,
excessive energy, feeling euphoric, fidgetiness, frustration, hostility, hyper-
activity, hyperkinesia, hypomania (also listed as psychotic event), increased
agitation, increased anxiety, increased energy, increased irritability, inner
shakiness, irritability, jitteriness, jittery, mania (also listed as psychotic event),
motor restlessness, nervousness, overanxious, overstimulation, racing
thoughts, restless, restlessness, shakiness, skin crawling, unusual energy
Potential event Easily startled, panic, panic attack, panic symptoms, tenseness, tension, tension
increased, trembling, tremor, unable to relax
Psychotic events Core event Abnormal feelings, abnormal thinking, behavioural dyscontrol, confusion, delir-
ium, delusions, disorientation, feelings of doom, hallucinations, hypomania
(also listed as activation event), hysteria, incoherent thoughts, intrusive
thoughts, mania (also listed as activation event), paranoia, psychosis, unusual
Potential event Abnormal dreams, bad dreams, increased dreams, intense dreams, nightmares,
strange dreams, vivid dreams
Core event Anhedonic, apathy, depersonalisation, derealisation, disinhibition, emotionally
detached, emotional lability, feeling blank, flat effect, flattened, impulsivity,
indifference, lack of empathy, reduced ability to feel positive emotions,
Potential event
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look at attrition because the subject of our research
was side effects, not beneficial effects.
Treatment of adult healthy volunteers with anti-
depressants doubled their risk of harms related to
suicidality and violence, odds ratio 1.85 (95% confi-
dence interval 1.11 to 3.08, p¼0.02, I
(Figure 2). The number needed to treat to harm one
healthy person was 16 (95% confidence interval 8 to
100; Mantel-Haenszel risk difference 0.06). Two clin-
ical study reports and one published trial reported the
severity of the harms.
The century-old belief that patients with depression
are at heightened risk of suicide as they begin to
recover and their energy and motivation return
Figure 1. PRISMA flow diagram of included studies based on the literature searches.
5218 records screened
4902 obviously ineligible
records excluded
142 arcles (130 trials) included in
qualitave synthesis
5787 records idenfied in databases
13 published trials
117 trials did not report on any of
our predefined harms
569 duplicates excluded
316 full-text arcles
174 arcles excluded
because the trials used
drugs other than
andepressants and placebo
2 crossover trials did not
show results for first
period separately
11 published trials plus
2 unpublished clinical study reports
included in meta-analysis
29 clinical study reports from
drug agencies
27 clinical study reports
were either about open
label studies or used an
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is being propagated everywhere, e.g. in the 2003 prac-
tice guideline from the American Psychiatric
Association, which states that ‘clinical observations
suggest that there may be an early increase in suicide
risk as depressive symptoms begin to lift but before
they are fully resolved’.
Because of this deeply ingrained idea, many
psychiatrists believe that when patients become sui-
cidal on an antidepressant drug, it is not an adverse
effect of the drug but a positive sign that the drug
starts working.
However, a systematic review
from 2009 showed that the research that has been
carried out contradicts this belief,
and our review
also suggests that it is wrong. We found that anti-
depressants double the risk of suicidality and vio-
lence, and it is particularly interesting that the
volunteers in the studies we reviewed were healthy
adults with no signs of a mental disorder. Our
results agree closely with a review of paroxetine
trials in both adults and children with mental dis-
orders using regulatory data released after a court
case. It included events both during treatment and
in the subsequent withdrawal phase and found a
doubling in hostility events (odds ratio 2.10, 95%
confidence interval 1.27 to 3.48).
While it is now generally accepted that antidepres-
sants increase the risk of suicide and violence in chil-
dren and adolescents
(although many psychiatrists
still deny this
), most people believe that these drugs
are not dangerous for adults. This is a potentially
lethal misconception.
As far as we know, our review is the first of the risk
of suicide and violence in healthy volunteers. It was
inspired by David Healy’s work.
In 2000, Healy pub-
lished a study he had carried out with 20 healthy
volunteers – all with no history of depression or
other mental illness – and to his big surprise, two of
them became suicidal when they received sertraline.
One was on her way out the door to kill herself in
front of a train or a car when a phone call saved her.
Both volunteers remained disturbed several months
later and seriously questioned the stability of their
In one of the two crossover trials we excluded
because we did not have data on the first period sepa-
rately, a healthy volunteer committed suicide, which
was mentioned in both published articles.
had received duloxetine in increasing doses for 16
days, tapered off the maximum dose of 400 mg daily
very quickly (in just four days according to the design
of the study) and killed herself four days later while
on placebo. The authors, several of whom were
employees of Eli Lilly or owned stock in the com-
pany, judged her suicide ‘to be unrelated to study
drug treatment’,
although it is well known that
the suicide risk is high when an antidepressant is
stopped abruptly.
There was no more informa-
tion about the suicide in the articles, and it was not
included in the listing of adverse events we acquired
from Eli Lilly, which only mentioned a woman who
reported suicidal ideation twice while on placebo. As
we do not know if this was the same patient, we asked
Eli Lilly for access to anonymised data for the volun-
teer who committed suicide and the detailed person
narrative, as we also wanted to know how it could be
possible to state that the suicide was not related to
Figure 2. Meta-analysis of suicidal or violent events or precursors to such events.
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Table 3. Harms in the meta-analysed trials. Some trials included arms with drugs that were not antidepressants; these data are not shown.
Study Study design Sex and age
Drug, dosage,
length of treatment
Number of
Harms of interest
in antidepressant
Harms of interest
in placebo group
Almeida (2010)
Parallel study Based on 18 completers:
Male: 18
Mean age, citalopram: 27.8
years (no range). Mean
age, placebo: 26.7 years
(no range).
20 mg citalopram,
28 days
Citalopram: 10
Placebo: 10
1 (agitation)
Briscoe (2008)
Parallel study Male: 10. Female 10.
Mean age: 29 years (20–44).
20–80 mg fluoxe-
tine, 56 days
Fluoxetine: 14
Placebo: 6
1 (vivid dreams)
Carpenter (2011)
Parallel study Male: 8.
Female: 13.
Mean age, sertraline: 30.2
years (20–46).
Mean age, placebo: 28.7 years
50–100 mg sertra-
line, 42 days
Sertraline: 11
Placebo: 11
1 (severe
Chial (2003)
Parallel study Based on 39 completers:
Male: 23. Female: 16.
Mean age, venlafaxine: 28.8
years (no range).
Mean age, placebo: 31.1 years
(no range).
150 mg venlafaxine,
Venlafaxine: 20
Placebo: 20
1 (jittery)
Furlan (2001)
Parallel study Based on 49 completers:
Male: 27. Female: 22.
Mean age, paroxetine: 75.1
years (no range).
Mean age, sertraline: 70.7
years (no range).
Mean age, placebo: 70.3 years
(no range).
10–40 mg paroxe-
tine, 21 days;
50–150 mg sertra-
line, 21 days
Paroxetine: 18
Sertraline: 16
Placebo: 20
1 (nervousness)
Garcia-Leal (2010)
Parallel study Male: 43.
Mean age: 23.6 years (19–31).
10 mg or 20 mg
Escitalopram: 31
Placebo: 12
1 (anxious, on
10 mg)
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Table 3. Continued.
Study Study design Sex and age
Drug, dosage,
length of treatment
Number of
Harms of interest
in antidepressant
Harms of interest
in placebo group
Knorr (2011)
Parallel study Male: 50.
Female: 28.
Mean age: 32 years (no
10 mg escitalopram,
28 days
Escitalopram: 39
Placebo: 39
6 (restlessness)
1 (tremor)
9 (restlessness)
1 (tremor)
Levine (1987)
Parallel study Male: 14.
Female: 106.
Mean age, fluoxetine: 43
years (no range).
Mean age, placebo: 46 years
(no range).
20–80 mg fluoxe-
tine, 56 days
Fluoxetine: 60
Placebo: 60
4 (anxiety)
4 (depression)
7 (nervousness)
3 (tremor)
5 (anxiety)
1 (depression)
2 (nervousness)
Madeo (2008)
Parallel study Male: 48.
Mean age, citalopram: 31.1
years (no range).
Mean age, fluoxetine: 29.2
years (no range).
Mean age, placebo: 29.2 years
(no range).
20–40 mg citalo-
pram, 31 days;
20 mg fluoxetine,
31 days
Citalopram: 16
Fluoxetine: 16
Placebo: 16
1 (anxiety, on
Montejo (2015)
Parallel study No gender data.
Mean age, escitalopram: 24.1
years (no range).
Mean age, placebo: 23.0 years
(no range).
20 mg escitalopram,
63 days
Escitalopram: 36
Placebo: 32
4 (abnormal
1 (agitation and
1 (anxiety)
2 (abnormal
Pijl (1991)
Crossover study,
converted to
parallel study by
trialists due to
carryover effects
Female: 23.
Mean age, fluoxetine: 38.1
years (25–53).
Mean age, placebo: 37.3 years
60 mg fluoxetine,
60 days
Fluoxetine: 11
Placebo: 12
3 (tremor) 1 (tremor)
CSR 050-001
Parallel study Male: 52.
Mean age, sertraline: 32.1
years (19–60).
Mean age, placebo: 35.8 years
10 mg, 25 mg,
50 mg, 75 mg,
100 mg, 125 mg,
150 mg, 175 mg,
200 mg, 250 mg,
300 mg, 350 mg or
400 mg sertraline,
Sertraline: 40 (39
were random-
Placebo: 12 (13
1 (mild nervous-
1 (mild tremor)
1 (mild euphoria)
1 (mild tremor)
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Table 3. Continued.
Study Study design Sex and age
Drug, dosage,
length of treatment
Number of
Harms of interest
in antidepressant
Harms of interest
in placebo group
CSR 050-201
Parallel study Male: 24.
Mean age, 200 mg sertraline:
25.8 (20–32).
Mean age, 400 mg sertraline:
27.1 (22–34).
Mean age, placebo: 25.9
200 mg or 400 mg
sertraline, 14
Sertraline 200 mg: 8
Sertraline 400 mg: 8
Placebo: 8
200 mg:
2 (nervousness,
one moderate,
one severe)
2 (tremor, one
moderate, one
2 (thinking
abnormal, one
mild, one
400 mg:
2 (nervousness,
one mild, one
3 (tremor, two
moderate, one
1 (thinking
1 (moderate
2 (thinking
abnormal, one
mild, one
CSR: clinical study report.
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duloxetine, but the company refused to give us the
In another of Eli Lilly’s studies, a healthy 19-year-
old student who had taken duloxetine in order to help
pay her college tuition hanged herself in a laboratory
run by Lilly.
It turned out that missing in the
FDA’s files was any record of the college student
and at least four other volunteers known to have
committed suicide, and Lilly admitted that it had
never made public at least two of those deaths.
In the other crossover trial we had to exclude, an
unknown number of volunteers discontinued parox-
etine due to restlessness, tremor and other adverse
We contacted the corresponding author
of the study who referred us to the first author, but
despite several attempts of making contact via two
different email addresses and phone (to the doctor’s
assistant), this author never responded.
Exploratory analyses of the clinical study reports
Although only two of the 29 clinical study reports
were eligible for our meta-analysis, e.g. as the studies
needed to be double-blind, two researchers (AØB and
PBD) read them all (2224 pages) and extracted data
independently, as we wanted to explore possible
selective reporting of harms in the published articles.
Nineteen clinical study reports reported on the harms
we investigated and nine of these were published, but
less than half of the harms were reported in the art-
icles (21 of 50 events on antidepressants and two of
four events on placebo).
One of these studies
was mentioned by David
who had spoken with the study investigator,
Ian Hindmarch. It was a crossover trial of the
interaction between sertraline and diazepam that
was terminated due to unexpected adverse events
after only four days, before the first phase had been
completed and before any of the volunteers had
received diazepam. All five volunteers in the sertraline
group became agitated and four of them anxious,
while one of seven volunteers in the placebo group
became aggressive, agitated and anxious. The study
was never published.
There can be little doubt that we underestimated the
harms of antidepressants. For 11 of our 13 trials, we
only had access to the published article, and it well
documented that the drug companies underreport
seriously the harms of antidepressants related to sui-
cide and violence, either by simply omitting them
from the reports, by calling them something else or
by committing scientific misconduct.
In trials
of duloxetine and sertraline, for example, only 33 of
45 cases of suicidal ideation, attempt or injury listed
in a trial register were also mentioned in the pub-
lished reports.
Psychiatrists believe that the suicide risk with anti-
depressants is only increased till age 24, but this mis-
conception builds on seriously flawed trial data that
the FDA has published.
Several meta-analysts have
pointed out just how unreliable the trials are.
A 2005 meta-analysis conducted by independent
researchers of the published trials included 87,650
patients of all ages and found twice as many suicide
attempts on drug than on placebo (odds ratio 2.28,
95% CI 1.14 to 4.55).
They also found out that
many suicide attempts must have been missing;
some of the investigators responded that there were
suicide attempts they had not reported in their trials,
while others replied that they did not even look for
them. Further, events occurring shortly after active
treatment was stopped were not counted. Another
2005 meta-analysis conducted by independent
researchers used UK drug regulator data and included
40,826 patients; they found a non-significant doubling
in suicides or self-harm events when events occurring
later than 24 hours after the randomised phase was
over were included (relative risk 2.14, 95% confidence
interval 0.96 to 4.75, our calculation).
researchers also noted that the companies had under-
reported the suicide risk in their trials, and they found
that non-fatal self-harm and suicidality were seriously
underreported compared to the reported suicides.
Even the FDA’s 2006 meta-analysis of 100,000
patients in 372 placebo-controlled trials
is ser-
iously flawed. Based on trials that were included in
FDA’s analysis, one of us has estimated that there are
likely to have been 15 times more suicides on anti-
depressant drugs than reported by the FDA.
important reasons for the underreporting of suicides
are that the FDA trusted the data the companies sent
to them and that they only included events up to 24
hours after the randomised phase was over.
We did not plan for any sensitivity analyses related
to whether the randomisation and blinding methods
were adequately described, as we were very well aware
before we started our review that in the sort of trials
we would find, there would likely be very little or no
information about this. We reviewed trials in healthy
volunteers, which have a completely different purpose
than standard treatment trials, and the drug compa-
nies do not have any particular incentive to provide
details about how they blinded the drug and the pla-
cebo and how they randomised the volunteers in such
trials. Furthermore, we studied harms, not clinical
beneficial effects, as we included healthy people. It
would therefore be inappropriate to assume that
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trials that did not describe blinding and randomisa-
tion methods are less reliable than other trials.
Antidepressants double the occurrence of events in
adult healthy volunteers that can lead to suicide
and violence. We consider it likely that antidepres-
sants increase suicides at all ages.
Competing Interests: All authors have completed the ICMJE
uniform disclosure form at
pdf (available on request from the corresponding author) and
declare no financial relationships with any organisation that
might have an interest in the submitted work in the previous
three years; no other relationships or activities that could appear
to have influenced the submitted work.
Funding: This study was funded by the Nordic Cochrane Centre,
Rigshospitalet. PBD is funded by a scholarship from the
University of Copenhagen, Faculty of Health and Medical
Sciences. The funding sources had no influence on any part of
the study.
Ethical Approval: No patient consent has been obtained for this
study, as it is a systematic review.
Guarantor: PCG
Contributorship: All authors had full access to all the data in the
study and take responsibility for the integrity of the data and the
accuracy of the analysis; AØB and PCG contributed to the study
concept and design and to the acquisition of data; AØB and PBD
contributed to searching, screening and extraction of data. All
authors contributed to the analysis and interpretation of data.
AØB and PCG contributed to the drafts of the manuscript, and
all authors critically reviewed the manuscript for publication. PCG
provided administrative and material support and was the study
supervisor and guarantor.
Acknowledgements: The authors thank information specialist
Henrik Hornemann from the Copenhagen University Library for
assistance in creating search strings in medical databases; Cochrane
collaborators from Japan, Maiko Suto, Erika Ota, and Sadequa
Shahrook, and China, Zhang Xin, for helping accessing, assessing,
translatingand interpretingforeign language articles; Justin Northrup
and Malcolm Mitchell from Eli Lilly, Joan Korth-Bradley and Chris
Gutteridge from Pfizer, and Steven Troy, formerly from Wyeth, for
supplying supplemental data. The authors thank our colleagues
Tarang Sharma, Emma Maund and Asbjørn Hro
´bjartsson for valu-
able comments and input throughout the project.
Provenance: Not commissioned; previously peer-reviewed at
another journal and peer-reviewed for JRSM by Julie Morris.
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... The relationship between the selective serotonin reuptake inhibitor antidepressants found in this study (fluoxetine, escitalopram, paroxetine, sertraline) and violence has been extensively explained by Breggin, according to whom these drugs cause a wide range of mental disturbances, such as suicidality, manic psychosis and agitated depression, which can lead to violence towards others and suicide [19]. An association between these antidepressants and violence has been found in several studies [16,17,20,27,31] In addition, some of them also found an association with paroxetine [16,17]. ...
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Self-inflicted violence is a major and growing public health problem and its prediction and prevention is challenging for healthcare systems worldwide. Our aim was to identify prescribed drugs associated with self-directed violent behaviors in Spain. A descriptive, longitudinal and retrospective study of spontaneous reports of adverse drug reactions corresponding to self-directed violence was recorded in the Spanish Pharmacovigilance Database (FEDRA®) from 1984 to 31 March 2021. A total of 710 cases were reported in the study period. The mean age was 45.52 years (range 1–94). There were no gender differences except in children, where most reports were of male children. The main therapeutic groups that were involved included drugs for the nervous system (64.5%) and anti-infectives for systemic use (13.2%). The most commonly reported drugs were varenicline, fluoxetine, lorazepam, escitalopram, venlafaxine, veralipride, pregabalin, roflumilast and bupropion. There were reports of montelukast, hydroxychloroquine, isotretinoin, methylphenidate, infliximab, natalizumab, ribavirin and efavirenz, which were less known to be involved in self-directed violence. This study shows that self-directed violence is a rare adverse drug reaction, and can be related to the use of some medicines. It is important for healthcare professionals to consider this risk in their clinical praxis, implementing person-centred approaches. Further studies are needed, considering comorbidities and potential interactions.
... Particularly, side effects related to mental health and suicidality would be the most concerning for the treating physicians, due to the relatively controversial reports on the association between suicidal behavior and antidepressant medications (12). This issue pertains mainly to a specific group of patients with mental disorders and more to children and adolescents with mental health problems, however it has also been suggested that some anti-depressant medications can double the risk of events that may lead to suicide and violence in healthy individuals (13). In the context of urinary incontinence, a recent meta-analysis of clinical study reports (data submitted to regulatory bodies) did not find any reported cases of suicidality, violence, or akathisia with duloxetine use (14). ...
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Duloxetine is the only available agent for the medical treatment of stress urinary incontinence (SUI). In this systematic review, we analyzed the efficacy and safety of duloxetine treatment in women with SUI and stress-predominant mixed urinary incontinence (SPMUI). We searched the literature using OVID MEDLINE, Embase and ULAKBIM (Turkish database) databases for placebo-controlled studies on the use of duloxetine in women with SUI or SPMUI. Data on change in incontinence episode frequency (IEF), decrease in the number of continence pads used, increase in voiding interval (minute) and discontinuation rates due to adverse effects and lack of efficacy (%) were extracted. A total of 12 randomized controlled trials were included. Duloxetine treatment results in an 18% decrease in IEF and 16% decrease in the number of incontinence pads used compared to pre-treatment status. It also increases the time interval between the voids by 18 min. Duloxetine treatment was associated with higher treatment discontinuation rates compared with placebo. The reason for discontinuation was related to the side effects of the treatment rather than lack of efficacy. Duloxetine can be an effective treatment option in women with UI based on high-level evidence supporting its efficacy. Further studies with larger patient populations and longer durations of follow-up are required to assess its safety profile.
... Most relevant studies have shown no reduction in alcohol consumption or craving with SSRIs [27][28][29], and citalopram treatment was associated with worse outcomes for some measures of alcohol dependence in one study [30]. Given that SSRIs may be associated with increased aggression and suicidality in certain populations [31,32], it is reasonable to question the risk/benefit profile of SSRIs in Alcohol Use Disorder. ...
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Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for patients who misuse alcohol, especially in the context of comorbid depressive symptoms. Deficits in impulse control and decision-making are linked to routine alcohol consumption and alcohol dependence. The goal of this study was to determine the effects of a single dose of citalopram on measures of impulsivity, decision-making, and/or brain dopamine receptor availability in alcohol-dependent individuals. A double-blind, placebo-controlled, within-subject, outpatient study was conducted with active alcohol-dependent (DSM-IV-TR criteria) participants ( n = 12 ) and matched healthy controls ( n = 13 ). Serial doses of both citalopram (40 mg) and saline were administered intravenously before laboratory tests of decision-making (Balloon Analogue Risk Task, delay discounting task, and Loss Aversion Gambling Task) and positron emission tomography with [18F]-fallypride to measure dopamine D2/3 receptor availability, separated by at least one week. Alcohol-dependent participants demonstrated greater loss aversion than healthy controls, but there were no group differences in risk taking on the Balloon Analogue Risk Task. Citalopram increased delay discounting across groups, with no group difference in the effect. There were no effects of citalopram on risk taking on the Balloon Analogue Risk Task. PET showed a negative correlation between thalamic dopamine D2/3 receptor availability and loss aversion across groups. The effect of citalopram to decrease the valuation of monetary reward as a function of delay raises the possibility that SSRIs can influence risky decision-making in clinical populations. In addition, these results suggest that altered thalamic dopamine signaling may play an important role in disproportionately valuing losses in patients with Alcohol Use Disorder. This trial is registered under registration NCT01657760.
... [11][12][13][14] Yet, most trials assessing the efficacy of antidepressants are poorly suited to examining adverse outcomes: they are often short term, are underpowered to look at most adverse outcomes, have methodological shortcomings 15,16 and do not always report adverse effects, particularly serious ones. 15,[17][18][19][20][21] Depression is strongly associated with adverse risk profiles such as excess adiposity, smoking, poor diet and physical inactivity. 22,23 These phenotypes and behaviours are established risk factors for a number of chronic conditions, including cardiovascular disease. ...
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Background: Antidepressants are one of the most widely prescribed drugs in the global north. However, little is known about the health consequences of long-term treatment. Aims: This study aimed to investigate the association between antidepressant use and adverse events. Method: The study cohort consisted of UK Biobank participants whose data was linked to primary care records (N = 222 121). We assessed the association between antidepressant use by drug class (selective serotonin reuptake inhibitors (SSRIs) and 'other') and four morbidity (diabetes, hypertension, coronary heart disease (CHD), cerebrovascular disease (CV)) and two mortality (cardiovascular disease (CVD) and all-cause) outcomes, using Cox's proportional hazards model at 5- and 10-year follow-up. Results: SSRI treatment was associated with decreased risk of diabetes at 5 years (hazard ratio 0.64, 95% CI 0.49-0.83) and 10 years (hazard ratio 0.68, 95% CI 0.53-0.87), and hypertension at 10 years (hazard ratio 0.77, 95% CI 0.66-0.89). At 10-year follow-up, SSRI treatment was associated with increased risks of CV (hazard ratio 1.34, 95% CI 1.02-1.77), CVD mortality (hazard ratio 1.87, 95% CI 1.38-2.53) and all-cause mortality (hazard ratio 1.73, 95% CI 1.48-2.03), and 'other' class treatment was associated with increased risk of CHD (hazard ratio 1.99, 95% CI 1.31-3.01), CVD (hazard ratio 1.86, 95% CI 1.10-3.15) and all-cause mortality (hazard ratio 2.20, 95% CI 1.71-2.84). Conclusions: Our findings indicate an association between long-term antidepressant usage and elevated risks of CHD, CVD mortality and all-cause mortality. Further research is needed to assess whether the observed associations are causal, and elucidate the underlying mechanisms.
Suicide is the last stage of depression, and antidepressants (ATDs) are drugs created with the aim of preventing the disease from advancing to more critical stages. However, in 2004, a study conducted by the Food and Drug Administration (FDA) found an association between the use of ATDs and increased risks of suicidal behavior/ideation in users. Thus, several studies were carried out to find out whether this statement is still plausible, as new antidepressants were created during this period and, in addition, ATDs are still the gold standard treatment in the most severe forms of depression, in this sense, the analysis of its risk-benefit is of fundamental importance. This study is an integrative literature review, described from 2012 to 2022, using the following databases: PubMed and VHL. The objective of the research was to describe whether the use of antidepressants is associated with a higher risk of suicide in patients. Among the results found in the analysis of 23 articles, 5 drugs were found that were related to a greater probability of developing suicidal behavior/ideation. However, venlafaxine showed a connection with self-cide much better than the others, and in a qualitative sense, it was the drug with the most evidence. Therefore, the study was not so conclusive due to difficulties in analyzing secondary data. Most of the data collected require greater methodological rigor, moreover, none of the surveys covered a difference between population groups, other than age, showing low variety in the studies.
Background Antidepressant (AD) medications increase suicidality for some, or all, age groups. Some, or all, types of ADs, are frequently used in suicides involving overdoses. Methods The article examines a previously unanalyzed data set summarizing 7,829 media reports of Coroners’ inquests in England and Wales that mention ADs, between 2003 and 2020. Results The most frequently cited ADs were SSRIs (48.9%) and tricyclics (24.6%). The specific drugs cited most often were the SSRI drug citalopram (19.8%) and the tricyclic drug amitriptyline (17.5%). Of 2,329 cases of death by overdose, 933 (40.1%) were overdoses of ADs, 512 of which (54.9%) did not involve other substances. The ADs most frequently named were amitriptyline (186), and citalopram (86). A further 929 were overdoses of unnamed medicines, a proportion of which may have been ADs. Limitations The data set, which relies primarily on archives of local newspapers, is incomplete and therefore underestimates the total numbers involved. The accuracy of coroners’ verdicts is not perfect. Conclusions If preventing suicide is a primary reason for prescribing ADs, this data set includes several thousand people for whom the drugs clearly did not work. Furthermore, about 1,000 people used the drugs that were supposed to alleviate their depression to kill themselves. Systematic analyses of all inquests would be more informative. Meanwhile, reducing the overprescribing of these relatively ineffective and, for some, lethally dangerous substances is suggested, to reduce suicides.
Purpose The purpose of this paper is to analyse how novel homicide defences predicated on contemporary neuroscience align with legal insanity. Design/methodology/approach Doctrinal analysis, systematic investigation of relevant statutes and cases, was used to elucidate how the law of insanity is evolving. Cases represent the first recorded instance of a particular neuroscientific defence. US appellate cases were categorised according to the mechanism of action of neurotransmitter relied upon in court. A case study approach was also used to provide a contextualised understanding of the case outcome in depth. Findings Findings broadly depict how the employment of expert testimony runs parallel with our contemporary understanding of key neurotransmitters and their function in human behaviour. Generally, medico-legal evidence concerning neuromodulating agents and violent behaviour was inconclusive. However, the outcome of defence strategy may depend on the underlying neurotransmitter involved. Practical implications This study shows that as more discoveries are made about the neurobiological underpinnings of human behaviour; this new knowledge will continue to seep into the US court system as innovative defence strategies with varying success. Medical and legal practitioners may gauge the success of a defence depending on the neuromodulating agent. Originality/value Many scholars have focused on the role of neuroimaging as neuroscientific evidence and how it is used is shaping US criminal jurisprudence. To the best of the author’s knowledge, no study has incorporated the true origin of neuroscientific evidence as being underpinned by the understanding of neurotransmitters.
Background: Fluoxetine was approved for depression in children and adolescents based on two placebo-controlled trials, X065 and HCJE, with 96 and 219 participants, respectively. Objective: To review these trials, which appear to have been misreported. Methods: Systematic review of the clinical study reports and publications. The primary outcomes were the efficacy variables in the trial protocols, suicidal events, and precursors to suicidality or violence. Results: Essential information was missing and there were unexplained numerical inconsistencies. (1) The efficacy outcomes were biased in favour of fluoxetine by differential dropouts and missing data. The efficacy on the Children's Depression Rating Scale-Revised was 4% of the baseline score, which is not clinically relevant. Patient ratings did not find fluoxetine effective. (2) Suicidal events were missing in the publications and the study reports. Precursors to suicidality or violence occurred more often on fluoxetine than on placebo. For trial HCJE, the number needed to harm was 6 for nervous system events, 7 for moderate or severe harm, and 10 for severe harm. Fluoxetine reduced height and weight over 19 weeks by 1.0 cm and 1.1 kg, respectively, and prolonged the QT interval. Conclusions: Our reanalysis of the two pivotal trials showed that fluoxetine is unsafe and ineffective.
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Objective To study serious harms associated with selective serotonin and serotonin-norepinephrine reuptake inhibitors. Design Systematic review and meta-analysis. Main outcome measures Mortality and suicidality. Secondary outcomes were aggressive behaviour and akathisia. Data sources Clinical study reports for duloxetine, fluoxetine, paroxetine, sertraline, and venlafaxine obtained from the European and UK drug regulators, and summary trial reports for duloxetine and fluoxetine from Eli Lilly’s website. Eligibility criteria for study selection Double blind placebo controlled trials that contained any patient narratives or individual patient listings of harms. Data extraction and analysis Two researchers extracted data independently; the outcomes were meta-analysed by Peto’s exact method (fixed effect model). Results We included 70 trials (64 381 pages of clinical study reports) with 18 526 patients. These trials had limitations in the study design and discrepancies in reporting, which may have led to serious under-reporting of harms. For example, some outcomes appeared only in individual patient listings in appendices, which we had for only 32 trials, and we did not have case report forms for any of the trials. Differences in mortality (all deaths were in adults, odds ratio 1.28, 95% confidence interval 0.40 to 4.06), suicidality (1.21, 0.84 to 1.74), and akathisia (2.04, 0.93 to 4.48) were not significant, whereas patients taking antidepressants displayed more aggressive behaviour (1.93, 1.26 to 2.95). For adults, the odds ratios were 0.81 (0.51 to 1.28) for suicidality, 1.09 (0.55 to 2.14) for aggression, and 2.00 (0.79 to 5.04) for akathisia. The corresponding values for children and adolescents were 2.39 (1.31 to 4.33), 2.79 (1.62 to 4.81), and 2.15 (0.48 to 9.65). In the summary trial reports on Eli Lilly’s website, almost all deaths were noted, but all suicidal ideation events were missing, and the information on the remaining outcomes was incomplete. Conclusions Because of the shortcomings identified and having only partial access to appendices with no access to case report forms, the harms could not be estimated accurately. In adults there was no significant increase in all four outcomes, but in children and adolescents the risk of suicidality and aggression doubled. To elucidate the harms reliably, access to anonymised individual patient data is needed.
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The present double-blind, placebo-controlled study evaluates the effects of agomelatine and the selective serotonin reuptake inhibitor escitalopram on sexual dysfunction in healthy men and women. A total of 133 healthy volunteers (67 men, 66 women) were randomly assigned to agomelatine (25 or 50 mg) or escitalopram (20 mg) or placebo for nine weeks. Sexual acceptability was evaluated by using the psychotropic-related sexual dysfunction questionnaire 5-items total score and sexual dysfunction relative to each sub-score (in 110 volunteers with sexual activity). Sexual dysfunction was evaluated at baseline and after two, five and eight weeks of treatment and one week after drug discontinuation. The psychotropic-related sexual dysfunction questionnaire 5-items total score was significantly lower in both agomelatine groups versus escitalopram at all visits (p < 0.01 to p < 0.0001) with no difference between agomelatine and placebo nor between both agomelatine doses. Similar results were observed after drug discontinuation. The total score was significantly higher in the escitalopram group than in the placebo group at each post-baseline visit (p < 0.01 to p < 0.001). Similar results were observed regardless of volunteers' gender. Compared to placebo, only escitalopram significantly impaired dysfunction relative to "delayed orgasm or ejaculation" (p < 0.01) and "absence of orgasm or ejaculation" (p < 0.05 to p < 0.01). The percentage of participants with a sexual dysfunction was higher in the escitalopram group than in agomelatine groups (p < 0.01 to p < 0.05) and placebo (p < 0.01). The study confirms the better sexual acceptability profile of agomelatine (25 or 50 mg) in healthy men and women, compared to escitalopram. Evaluation of the effect of agomelatine and escitalopram on emotions and motivation in healthy male and female volunteers. ISRCTN75872983. © The Author(s) 2015.
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Objective To examine the degree of concordance in reporting serious adverse events (SAEs) from antidepressant and antipsychotic drug trials among journal articles and clinical trial summaries, and to categorise types of discrepancies. Design Cross-sectional study of summaries of all antidepressant and antipsychotic trials included in an online trial registry and their first associated stand-alone journal articles. Setting, sponsored by Pharmaceutical Research and Manufacturers of America;, administered by the US National Institutes of Health. Main outcome measure 3 coders extracted data on the numbers and types of SAEs. Results 244 trial summaries for six antidepressant and antipsychotic drugs were retrieved, 142 (58.2%) listing an associated article. Of 1608 SAEs in drug-treated participants according to trial summaries, 694 (43.2%) did not appear in associated articles. Nearly 60% of SAEs counted in articles and 41% in trial summaries had no description. Most cases of death (62.3%) and suicide (53.3%) were not reported in articles. Half or more of the 142 pairs were discordant in reporting the number (49.3%) or description (67.6%) of SAEs. These discrepancies resulted from journal articles’ (1) omission of complete SAE data, (2) reporting acute phase study results only and (3) more restrictive reporting criteria. Trial summaries with zero SAE were 2.35 (95% CI, 1.58 to 3.49; p<0.001) times more likely to be published with no discrepancy in their associated journal article. Since was removed from the Internet in 2011, only 7.8% of retrieved trial summaries appear with results on Conclusions Substantial discrepancies exist in SAE data found in journal articles and registered summaries of antidepressant and antipsychotic drug trials. Two main scientific sources accessible to clinicians and researchers are limited by incomplete, ambiguous and inconsistent reporting. Access to complete and accurate data from clinical trials of drugs currently in use remains a pressing concern.
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Objective To assess the effects of coding and coding conventions on summaries and tabulations of adverse events data on suicidality within clinical study reports. Design Systematic electronic search for adverse events of suicidality in tables, narratives, and listings of adverse events in individual patients within clinical study reports. Where possible, for each event we extracted the original term reported by the investigator, the term as coded by the medical coding dictionary, medical coding dictionary used, and the patient’s trial identification number. Using the patient’s trial identification number, we attempted to reconcile data on the same event between the different formats for presenting data on adverse events within the clinical study report. Setting 9 randomised placebo controlled trials of duloxetine for major depressive disorder submitted to the European Medicines Agency for marketing approval. Data sources Clinical study reports obtained from the EMA in 2011. Results Six trials used the medical coding dictionary COSTART (Coding Symbols for a Thesaurus of Adverse Reaction Terms) and three used MedDRA (Medical Dictionary for Regulatory Activities). Suicides were clearly identifiable in all formats of adverse event data in clinical study reports. Suicide attempts presented in tables included both definitive and provisional diagnoses. Suicidal ideation and preparatory behaviour were obscured in some tables owing to the lack of specificity of the medical coding dictionary, especially COSTART. Furthermore, we found one event of suicidal ideation described in narrative text that was absent from tables and adverse event listings of individual patients. The reason for this is unclear, but may be due to the coding conventions used. Conclusion Data on adverse events in tables in clinical study reports may not accurately represent the underlying patient data because of the medical dictionaries and coding conventions used. In clinical study reports, the listings of adverse events for individual patients and narratives of adverse events can provide additional information, including original investigator reported adverse event terms, which can enable a more accurate estimate of harms.
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Objective To determine, using research on duloxetine for major depressive disorder as an example, if there are inconsistencies between protocols, clinical study reports, and main publicly available sources (journal articles and trial registries), and within clinical study reports themselves, with respect to benefits and major harms. Design Data on primary efficacy analysis and major harms extracted from each data source and compared. Setting Nine randomised placebo controlled trials of duloxetine (total 2878 patients) submitted to the European Medicines Agency (EMA) for marketing approval for major depressive disorder. Data sources Clinical study reports, including protocols as appendices (total 13 729 pages), were obtained from the EMA in May 2011. Journal articles were identified through relevant literature databases and contacting the manufacturer, Eli Lilly. and the manufacturer’s online clinical trial registry were searched for trial results. Results Clinical study reports fully described the primary efficacy analysis and major harms (deaths (including suicides), suicide attempts, serious adverse events, and discontinuations because of adverse events). There were minor inconsistencies in the population in the primary efficacy analysis between the protocol and clinical study report and within the clinical study report for one trial. Furthermore, we found contradictory information within the reports for seven serious adverse events and eight adverse events that led to discontinuation but with no apparent bias. In each trial, a median of 406 (range 177-645) and 166 (100-241) treatment emergent adverse events (adverse events that emerged or worsened after study drug was started) in the randomised phase were not reported in journal articles and Lilly trial registry reports, respectively. We also found publication bias in relation to beneficial effects. Conclusion Clinical study reports contained extensive data on major harms that were unavailable in journal articles and in trial registry reports. There were inconsistencies between protocols and clinical study reports and within clinical study reports. Clinical study reports should be used as the data source for systematic reviews of drugs, but they should first be checked against protocols and within themselves for accuracy and consistency.
Evidence from many sources confirms that selective serotonin reuptake inhibitors (SSRIs) commonly cause or exacerbate a wide range of abnormal mental and behavioral conditions. These adverse drug reactions include the following overlapping clinical phenomena: a stimulant profile that ranges from mild agitation to manic psychoses, agitated depression, obsessive preoccupations that are alien or uncharacteristic of the individual, and akathisia. Each of these reactions can worsen the individual's mental condition and can result in suicidality, violence, and other forms of extreme abnormal behavior. Evidence for these reactions is found in clinical reports, controlled clinical trials, and epidemiological studies in children and adults. Recognition of these adverse drug reactions and withdrawal from the offending drugs can prevent misdiagnosis and the worsening of potentially severe iatrogenic disorders. These findings also have forensic application in criminal, malpractice, and product liability cases.