I have never heard of this before and it seems entirely different from the reports I have heard from many people that took antidepressants as teens or young adults.  Is there some source you can site that provides evidence supporting the idea that the completed suicides of younger people on or withdrawing from antidepressants is the result of "drug-induced psychosis"? 

Hi Maria,

Sorry for late response. I do some casual research on depression and SSRIs. I have read about it but I have not read any medical journal article on it. Below are extract from: https://www.drugs.com/sfx/prozac-side-effects.html#refs on Prozac (one of the SSRIs).

"Psychiatric

Antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. An increased risk of suicidal thinking and behavior in children, adolescents, and young adults (aged 18 to 24 years) with major depressive disorder (MDD) and other psychiatric disorders has been reported with short-term use of antidepressant drugs. Adult and pediatric patients receiving antidepressants for MDD, as well as for psychiatric and nonpsychiatric indications, have reported symptoms that may be precursors to emerging suicidality, including anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania. Causality has not been established".  

Here is the latest study from Prof Peter Gotzsche founder of the Nordic Cochrane Collection who found that antidepressants double the risk of suicide and violence in young people. http://www.bmj.com/content/352/bmj.i65

It's a recent publication. Glad you have such a related and reputable journal article. I searched the word "suicide" under Eli Lilly's website and it says no such word was found. Regards, [email protected]

Mylan Pharmaceuticals who manufacture a generic form of Fluoxetine (Prozac) have admitted their drug was the probable cause of my son's suicide in a written causality assessment. 

Happy to see my article being used for discussions! The FDA and EMA both have warnings for the same due to drug induced reactions for children, adolescents and youth (18-24 years). 

Not as happy as we are that you researched and published it Tarang! The FDA and EMA may have warnings (as I believe does the Canadian Regulator) but there is no black box warning required in most countries in the world and my experience is that doctors either don't tell patients about the suicide and violence risk or play it down saying its extremely rare and an over reaction by the FDA.

Thanks! :-) That is true Maria, hence our effort to highlight the issue again through our research. NICE guidance has very strict restrictions to the use of these drugs for this age group but this doesn't hold true for other countries (including Denmark where I am now based) and even in UK prescribing patterns show that the NICE guidance is not always adhered to.

Dear Maria,

The reason I questioned your claim of "drug-induced psychosis", is because I have never seen true psychosis in such individuals.  I do agree that something is happening in relation to the medication and the suicidality, but it is not a form of psychosis. 

I was unable to publicly speak about it at the time of my first post, but last year I coauthored a book on suicidality.  The primary focus of the book is to get the world to focus on suicidality as a separate set of psychiatric disorders, instead of always assuming it is due to depression or due to a triggering life event.

In this book we describe several phenotypes of suicidality disorder.  One of these phenotypes is Impulse Attack Suicidality Disorder (IASD).  The primary feature of this IASD is the experience of Unexpected Suicidal Impulse Attacks (USIAs).  A USIA is an unexpected, unprovoked, urgent need to make a suicide attempt.  It often occurs with physical symptoms and most times some of these physical symptoms are pre-cognitive.  That is, as the USIA is happening, the physical symptoms regularly occur in advance of any suicidal ideation.  We liken these attacks to a sneeze.  People experience sneezes without planning when they will occur and without experiencing sneezing ideations prior to the sneeze.  The sneeze just happens.  Similarly, the USIA's just happen and the person experiencing them cannot control them or prevent them from occurring.  These patients report their brain being on autopilot, detecting ways to kill themself from the common objects around them and consistently bullying them into making a suicide attempt.   They also report that the symptoms lessen if they decide to make a suicide attempt.

One subject with IASD was followed in a great deal of detail over the course of several years.  She was one of the children in the 1990's that reported an increase in her suicidality in response to her first treatment of antidepressants.  However, being 'only a child' her psychiatrists dismissed her concerns.  More recently, she was on another trial of an antidepressant, citalopram.  We were able to document that the citalopram caused a 39% increase in upswitches of this impulsive suicidality.  In other words, the citalopram, even at a very low dosage, caused theses impulse attacks to happen more frequently.  The subject reported this left less time to recover between the USIA's.  She said it began to wear her down to the point that she seriously considered giving into this urge just so that she wouldn't have to keep resisting what seemed increasingly inevitable; her death by suicide.

I suspect this may have been what your son experienced.  The main way to prevent such deaths in the future is to get mental health professionals to understand that suicidality is not just a symptom of depression.  Once they understand that they can likely get their head around the different phenotypes of suicidality disorders and can begin treating patients based upon the specific suicidality disorder phenotype they experience. This would result in patients like you son being recognized as having IASD and being properly treated without the use of antidepressants. 

Best wishes,

Jennifer M. Giddens

Taranga, my experience, in working with families bereaved by antidepressant induced suicide and those at risk of suicide is that the NICE guidelines are rarely followed. Medication is first line treatment due to both the unavailability of talking therapies and doctors erroneously believing SSRIs protect against suicide. In my country, policy is that medication is first line treatment.

Hi Jennifer

I guess where we differ is that I don't consider suicidal ideation or completed suicide to be a mental disorder and more than I consider nausea or the development of akathisia as a result of SSRI use to be mental disorders. It is also my experience, supported by literature that those who avoid psychiatry have better outcomes and are less likely to become suicidal or die from suicide than those who engage with mental health services. Suicide is a behaviour not an illness and is triggered by social environmental factors and SSRI use. Suicide prevention therefore requires social interventions aimed at altering environments rather than 'fixing' people and the avoidance of 'treatments' which have been proven to double the risk of suicide.

Suicidal thinking is prevalent in the population and my concern is that conceptualizing it as a mental disorder will increase completed suicide rates by increasing the involvement of those suffering emotional distress in mental health services where such engagement is a key risk factor for suicide.

In relation to my son. DNA testing post mortem showed he was an intermediate metaboliser (having one inactive allelle at CYP4503D6) and suffered a range of serious adverse reactions to Fluoxetine as this genotype would predict. In addition to severe akathisia in the days leading to his suicide, in the half hour before his death the evidence is that he experienced hallucinations, paranoia and rapid cycling of moods. What else he felt or experienced will never be known. I have the same genotype as my child and my experience of taking SSRIs is a complete loss of contact with external reality and irresistible suicidal impulses. I'm not a fan of psychiatric labeling but this is what I meant when I used the term psychosis.

While I respect your decisions for yourself, I cannot condone the mindset that all suicidality is the result of "social environmental factors and SSRI use".  There are people that do not have "social environmental factors" and have never taken an SSRI which experience suicidality.  For example, it is very common for people disgnosed with Huntington's disease to experience suicidality at the early stages of the disease.  It is not uncommon for those diagnosed with ALS to experience suicidality out of the concern of slowly suffocating to death.  Medical illness is one of the phenotypes we described.  Another is suicidality induced by substances.  A third is live event induced, which would likely capture the group you refer to as having "social environmental factors".  Overall, we have 12 distinct phenotypes.  Of which, only one of them is mood disorder induced.  Some in this group would have major depressive disorder and they would likely positively to antidepressants.  However, another subgroup of this group are those with bipolar disorder and they should not be put on antidepressants because it would likely induce mania.  

There are thousands of people experiencing suicidality which is perfectly treatable if they are given the proper treatment.  Some of the phenotypes do not currently have approved treatments, but that will quickly change over the next several years. 

I suspect the "irresistible suicidal impulses" you describe in response to taking an SSRI is the Unexpected Suicidal Impulse Attack that is characteristic of Impulse Attack Suicidality Disorder.  The subject I mentioned in my first response has been adequately treated with a high magnesium oxide and low calcium dietary intake regimen.  She went from experiencing as many as 800+ minutes of suicidality daily down to no suicidality for the past 1.5+ years as long as she adheres to this regimen.  If something as simple as increasing magnesium intake and reducing calcium intake can save the lives of people struggling with suicidality, then I think it is reasonable for them to seek treatment and at least try to see if it helps them.

Please note, the above high magnesium oxide and low calcium dietary intake regimen has only been clearly documented as being effective in one subject.  Other case reports are expected in the coming months.  Also, no regulatory agency has approved this high magnesium oxide and low calcium dietary intake regimen for the treatment of suicidality.

Best wishes,

Jennifer M. Giddens

I agree that physical illnesses can cause suicidal thinking and behaviour. The solution therefore would be to treat those illnesses. Similarly, where suicidality is induced by SSRIs, the solution is not to use SSRIs, particularly as the evidence is that that they have little or no benefit above placebo.