Antidepressant Agents and Suicide Death Among US Department of Veterans Affairs Patients in Depression Treatment
Antidepressant Agents and Suicide Death Among US Department of Veterans Affairs Patients in Depression Treatment
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DOI：
10.1097/jcp.0b013e3182539f11
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发表时间：
2012-06-01
影响因子：
2.9
通讯作者：
McCarthy, John F.
中科院分区：
文献类型：
--
作者：
Valenstein, Marcia;Kim, Hyungjin Myra;McCarthy, John F.
背景：关于抗抑郁药和自杀风险的研究报告结果不一，很少有人研究自杀死亡。使用观察数据的研究可以积累大量的样本量，这是研究自杀死亡所需的，但必须解决选择偏差。我们评估了自杀死亡与7种最常用的抗抑郁药治疗之间的关系，这些药物来自退伍军人事务部抑郁症患者的全国样本。多重分析策略被用来解决潜在的选择bias.Methods：我们确定了退伍军人事务部的抑郁症诊断和新的抗抑郁药开始之间的1999年4月1日，2004年9月30日（N = 502,179）。传统的考克斯回归模型、治疗加权逆概率的考克斯模型、倾向分层的考克斯模型、边际结构模型（MSM）和工具变量分析被用于研究自杀与安非他酮、西酞普兰、氟西汀、米氮平、帕罗西汀、舍曲林和文拉法辛暴露之间的关系。抗抑郁药的粗自杀率从每10万人年88人到247人不等。在多个考克斯模型和MSM中，舍曲林和氟西汀的自杀死亡风险低于帕罗西汀。在考克斯模型中，安非他酮的风险低于几种抗抑郁药，但在MSM中则不然。工具变量分析没有发现抗抑郁药之间的显着差异。讨论：大多数抗抑郁药在自杀死亡的风险方面没有差异。然而，在几种分析方法中，虽然不是工具变量分析，但氟西汀和舍曲林的自杀死亡风险低于帕罗西汀。这些发现与美国食品和药物管理局对随机对照试验的荟萃分析一致，该分析报告舍曲林的“自杀倾向”风险较低，氟西汀的风险有低于其他抗抑郁药的趋势。然而，分析方法的结果差异表明，在解释结果时要谨慎。
Background: Studies report mixed findings regarding antidepressant agents and suicide risks, and few examine suicide deaths. Studies using observational data can accrue the large sample sizes, needed to examine suicide death, but selection biases must be addressed. We assessed associations between suicide death and treatment with the 7 most commonly used antidepressants in a national sample of Department of Veterans Affairs patients in depression treatment. Multiple analytic strategies were used to address potential selection biases.Methods: We identified Department of Veterans Affairs patients with depression diagnoses and new antidepressant starts between April 1, 1999, and September 30, 2004 (N = 502,179). Conventional Cox regression models, Cox models with inverse probability of treatment weighting, propensity-stratified Cox models, marginal structural models (MSM), and instrumental variable analyses were used to examine relationships between suicide and exposure to bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine.Results: Crude suicide rates varied from 88 to 247 per 100,000 person-years across antidepressant agents. In multiple Cox models and MSMs, sertraline and fluoxetine had lower risks for suicide death than paroxetine. Bupropion had lower risks than several antidepressants in Cox models but not MSMs. Instrumental variable analyses did not find significant differences across antidepressants.Discussion: Most antidepressants did not differ in their risk for suicide death. However, across several analytic approaches, although not instrumental variable analyses, fluoxetine and sertraline had lower risks of suicide death than paroxetine. These findings are congruent with the Food and Drug Administration meta-analysis of randomized controlled trials reporting lower risks for "suicidality" for sertraline and a trend toward lower risks with fluoxetine than for other antidepressants. Nevertheless, divergence in findings by analytic approach suggests caution when interpreting results.