Abstract
Introduction
The safety of antidepressants following overdose is critical because of the high risk of suicide attempts in depressed patients. This study was conducted to decrease the fatality rate of antidepressant overdoses by providing data to shift prescribing toward safer antidepressants.
Methods
US poison control data for 2000–2004 were analyzed by 25 antidepressant types. Medical outcome differences were quantified using a hazard index (number of major or fatal outcomes per 1000 reported antidepressant ingestions).
Results
Of 82,802 suicidal single-agent ingestions of identifiable antidepressants approved for use in the US, cases occurred predominantly in females and peaked in teens. Fatal cases peaked at 40 to 49 years of age. Suicidal ingestions of the SSRIs, SNRIs, and other antidepressants peaked in teens, lithium in the twenties, tricyclics and tetracyclics in the thirties, and MAO inhibitors in the forties. There were 40 major or fatal outcomes per 1000 cases. Weighted by antidepressant type, the mean hazard index for the 25 antidepressants was 79 (range: 0 to 292). Amoxapine (292), maprotiline (211), and desipramine (187) had the highest hazard indices. The tricyclic antidepressants, MAO inhibitors, maprotiline, and bupropion were in the more severe half of antidepressants, ranked by hazard index. All SSRIs had low hazard indices. Hazard index and exposure frequency were inversely correlated (R = −0.423, p = 0.035), while hazard index and use of critical care were positively correlated for the 25 antidepressant types (R = 0.797, p < 0.001). Clinical effect profiles for each antidepressant type are presented.
Conclusion
Suicidal overdose severity varied considerably by antidepressant type. Prescribing decisions should be informed by regularly updated comparative overdose severity data.
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References
Dumais A, Lesage AD, Alda M, Rouleau G, Dumont M, Chawky N, et al. Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men.Am J Psychiatry 2005; 162 (11): 2116–2124.
Friedman RA, Leon AC. Expanding the black box: depression, antidepressants, and the risk of suicide.N Engl J Med 2007; 356 (23): 2343–2346.
Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: a review of the past 10 years.J Am Acad Child Adolesc Psychiatry 2003; 42(4): 386–405.
Amos R, Appleby L, Kiernan K. Changes in rates of suicide by car exhaust asphyxiation in England and Wales.Psychol Med 2001; 31(5): 935–939.
Gunnell D, Middleton N, Frankel S. Method availability and the prevention of suicide: a re-analysis of secular trends in England and Wales 1950–1975.Soc Psychiatry Psychiatr Epidemiol 2000; 35(10): 437–443.
Lester D. Effects of detoxification of domestic gas on suicide in the Netherlands.Psychol Rep 1991; 68(1): 202.
Ohberg A, Lonnqvist J, Sarna S, Vuori E, Penttila A. Trends and availability of suicide methods in Finland: proposals for restrictive measures.Br J Psychiatry 1995; 166 (1): 35–43.
Wiedenmann A, Weyerer S. The impact of availability, attraction and lethality of suicide methods on suicide rates in Germany.Acta Psychiatr Scand 1993; 88(5): 364–368.
Carrington PJ, Moyer S. Gun control and suicide in Ontario.Am J Psychiatry 1994; 151(4): 606–608.
Kendell RE. Catalytic converters and prevention of suicides.Lancet 1998; 352(9139): 1525.
Farmer RD, Pinder RM. Why do fatal overdose rates vary between antidepressants?Acta Psychiatr Scand Suppl 1989; 354: 25–35.
Watson WA, Litovitz TL, Rodgers GC, Klein-Schwartz W, Reid N, Youniss J, et al. 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med 2005; 23(5): 589–666.
Litovitz T. The TESS database: Use in product safety assessment.Drug Saf 1998; 18(1): 9–19.
Uitenbroek DG [webpage on the Internet]. SISA Binomial [published 1997; cited 2006 Feb 25]. Available from: http://home.clara.net/sisa/binomial.htm
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control [webpage on the Internet]. Web-based Injury Statistics Query and Reporting System (WISQARS) [published 2005; cited 2006 Feb 27]. Available from:www.cdc.gov/ncipc/wisqars
Litovitz T, White NC, Watson WA. Epidemiology of pediatric poison exposures: an analysis of 2003 poison control center data.Clin Ped Emerg Med 2005; 6(2): 68–75.
Woolf AD, Watson WA, Smolinske S, Litovitz T. The severity of toxic reactions to ephedra: comparisons to other botanical products and national trends from 1993–2002.Clin Toxicol 2005; 43(5): 347–355.
Litovitz T, Manoguerra A. Comparison of pediatric poisoning hazards: an analysis of 3.8 million exposure incidents.Pediatrics 1992; 89(6): 999–1006.
Cobaugh DJ, Krenzelok EP. Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.Am J Health Syst Pharm 2006; 63(22): 222–2234.
Crouch BI, Caravati EM, Mitchell A, Martin AC. Poisoning in older adults: a 5-year experience of US poison control centers.Ann Pharmacother 2004; 38(12): 2005–2011.
Tenenbein M. Unit-dose packaging of iron supplements and reduction of iron poisoning in young children.Arch Pediatr Adolesc Med 2005; 159(6): 557–560.
U.S. Department of Health and Human Services [webpage on the Internet]. News release: FDA announces plans to prohibit sales of dietary supplements containing ephedra (2003, December) [published 2003 Dec; cited 2005 Nov 4]. Available from: http://www.cfsan.fda.gov/~lrd/hhsephe2.htmlREF
Henry JA, Alexander CA, Sener EK. Relative mortality from overdose of antidepressants.BMJ 1995; 310(6974): 221–224.
Rose JC, Unis AS. A mortality index for postmarketing surveillance of new medications.Am J Emerg Med 2000; 18(2): 176–179.
Kapur S, Mieczkowski T, Mann JJ. Antidepressant medications and the relative risk of suicide attempt and suicide.JAMA 1992; 268(24): 3441–3445.
Montgomery SA, Baldwin D, Green M. Why do amitriptyline and dothiepin appear to be so dangerous in overdose?Acta Psychiatr Scand Suppl 1989; 354: 47–53.
Isacsson G, Bergman U. Risks with citalopram in perspective.Lancet 1996; 348(9033): 1033.
Ramchandani P, Murray B, Hawton K, House A. Deliberate self poisoning with antidepressant drugs: a comparison of the relative hospital costs of cases of overdose of tricyclics with those of selective-serotonin reuptake inhibitors.J Affect Disord 2000; 60(2): 97–100.
Linakis JG, Frederick KA. Poisoning deaths not reported to the regional poison control center.Ann Emerg Med 1993; 22(12): 1822–1828.
Soslow AR, Woolf AD. Reliability of data sources for poisoning deaths in Massachusetts.Am J Emerg Med 1992; 10(2): 124–127.
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White, N.C., Litovitz, T. & Clancy, C. Suicidal antidepressant overdoses: A comparative analysis by antidepressant type. J. Med. Toxicol. 4, 238–250 (2008). https://doi.org/10.1007/BF03161207
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DOI: https://doi.org/10.1007/BF03161207