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Fluoxetine and sertraline may be associated with lower risk of suicide death than paroxetine in adults with depression

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Question: What is the risk of suicide death for people with depression on antidepressants?

People: 502 179 adults in the Veterans Affairs (VA) Health System with depression (identified using implantable cardioverter defibrillator (ICD) coding), who started taking any of the most commonly used antidepressants between April 1999 and September 2004. A new antidepressant start (index date) was defined as filling of a prescription for any of the antidepressants after at least 6 months with no observed antidepressant prescription fills. Exclusion criteria: diagnosis of bipolar I, schizophrenia or schizoaffective disorder.

Setting: Department of VA Health System, USA; 1999–2004.

Risk factors: New start on one of the antidepressants (27.0% started sertraline, 26.1% citalopram, 14.0% fluoxetine, 13.3% paroxetine, 10.9% bupropion, 4.4% venlafaxine and 4.2% mirtazapine). Days of exposure to the antidepressant were defined as a start date of the first new fill continuing until completion of the last days’ fill supply. To examine the relationships between suicide and antidepressant use, conventional Cox regression models, Cox models with inverse probability of treatment weighting (IPTW), propensity-stratified Cox models (PSCM), marginal structural models (MSM analysis of 12 month follow-up data reported here) and instrumental variable …

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  • Sources of funding: The Department of Veteran Affairs, Health Services Research and Development Service and the National Institute of Mental Health.


  • Competing interests None.