SSRIs and suicidality is the induction of anxiety and agitation by SSRIs. Again, controlled studies do not support this suggestion; in fact, they suggest the converse. Controlled studies such as those reported by Sheehan et al. (1992) demonstrate that SSRIs result in an earlier onset of therapeutic effect on somatic anxiety compared with other antidepressants or placebo. Paroxetine is superior to placebo in the treatment of agitation after 4 and 6 weeks of treatment, and superior to the active control after 4 weeks of treatment. Both paroxetine and the active control are more protective against newly emergent agitation compared with placebo. So, there appears to be little evidence of an aggravating effect on anxiety. Controlled studies indicate that drugs like paroxetine seem to have a therapeutic effect and not an aggravating effect on agitation.

Postmarketing surveillance studies have been carried out that bear on this question of emergent suicidality (Inman et al., 1993; Zaninelli and Meister, 1999). Such postmarketing surveys of thousands of patients who received paroxetine found the incidence of reported suicidal behavior attributed to the medication to be so infrequent as to be negligible. Thus, both controlled clinical trials, including large meta-analyses of large groups of patients as well as these postmarketing surveys, provide no support for the concerns of emergent suicidality.

Anxiolytic Medications

Anxiety is a common symptom in many mental illnesses, including depression, bipolar disorder, and schizophrenia, and acute anxiety and agitation are associated with an increased risk of both suicide and suicide attempts. Additionally, anxiety is a prominent feature in suicidality that is related to psychosocial stressors. Benzodiazepines are the most commonly used medications to relieve anxiety in such cases. The data relating benzodiazepines to suicide are limited. There are, in fact, some reports (Melander et al., 1991; Neutel and Patten, 1997; Taiminen, 1993) that suggest that the use of benzodiazpines is associated with an increased risk of suicide. Causality is unknown and difficult to assess. The interpretation of this observation is confounded by the fact that benzodiazepines are often used as a means to complete suicide.

ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) is a safe and effective medical treatment for affective disorders (Avery and Winokur, 1977), particularly in severe refractory depression. It is most often used in the treatment of depression with or without psychotic features, acute mania, and schizophrenia (APA, 1990; Fink and Sackeim, 1996; Mukherjee et al., 1994),



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