The risks of SSRIs and suicidal thoughts

And why researchers are also making the case for olanzapine to be removed as a first-line treatment for early psychosis.

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Increasing a patient’s SSRI dose too fast can occasionally improve motivation without changing mood, making them more susceptible to suicide, delegates at the 2023 WONCA conference heard.  

Other conference presentations on mental health looked at weight gain in early psychosis, short interventions to improve medical student wellbeing and what almost 20 years of the DIAMOND depression study has found.  

Here are two of those talks, in brief.  

Case study: sertraline and suicidal ideation  

Victorian GP Dr Naomi Harris gave a detailed case presentation on the Friday looking at a 51-year-old female patient who presented with strong suicidal ideation and planning.  

The patient, who was previously unknown to Dr Harris, had been stable for many years on 50mg of sertraline daily, but had self-ceased the medicine nine months earlier. 

Around a fortnight before she presented to Dr Harris the patient had a breakdown and was put back on sertraline at a dose of 150mg per day. She had never been on a dose this high.  

“When she presented to me, her main complaints were that her mind was racing, she wasn’t able to sleep – she was describing total insomnia – absolutely no appetite, poor concentration, had the shakes, was sweating, teary, anxious and experiencing a real sense of impending doom,” Dr Harris said.  

“She was spending the entire nighttime lying there thinking about suicide … and then feeling increasingly distressed about the fact that she was spending so much time thinking about suicide and planning what she was going to do.”  

Serotonin syndrome was initially considered as a differential diagnosis but didn’t capture the psychological component of what the patient was experiencing. 

After doing a literature review, Dr Harris identified evidence to suggest an increased risk of suicide attempt and suicide in older people with major depression who take sertraline.  

“Another theory that [I read] was that when someone is feeling in the grips of a severe depression … and they go on to a serotonergic agent, they improve to the point that they’re still sad, but no longer amotivated,” she said.  

“[They] no longer feel hopeless or helpless and are therefore able to plan [suicide].”  

Dr Harris told delegates that she had seen another patient with very similar features very recently, making it two cases within 12 months, which had prompted her to present at WONCA. 

Weight gain in early psychosis 

Speaking at one of the final sessions at WONCA, medical student Hayden Su presented findings from a study on weight gain in early psychosis which had been conducted in southwest Sydney.  

Mr Su, under the supervision of prominent GP Dr Michael Tam, used routinely collected data from 110 patients admitted to the Liverpool Hospital early psychosis intervention program between 2017 and 2020 to map out typical weight gain patterns.  

Ultimately, he found that patients experienced a 5% increase in body weight at one month, followed by smaller bursts amounting to an overall average gain of 18% at one year.  

“The proportion of patients who experienced significant weight gain, defined as more than 7% [of baseline body weight], rapidly increased from 22% in the first month to 61% at five months,” Mr Su told delegates.  

“Overall, 70% of patients experienced significant weight gain within a year.” 

The proportion of patients with BMI greater than 25 increased from a 36% to 71%, while the proportion of people with BMI greater than 30 increased from 16% to 38%.  

The effect was strong no matter what antipsychotic medicine patients were on, but people on olanzapine and clozapine fared the worst.  

“The results are likely due to medication naivety, [but] could also be a manifestation of the higher rates of poor lifestyle behaviours and socio-economic disadvantage of southwest Sydney,” Mr Su said.  

“Olanzapine and clozapine did cause more weight gain in this local context, thus their usage should be very carefully considered.  

“While clozapine is already limited to treatment resistant schizophrenia, olanzapine is still sometimes administered as a first-line therapy for early psychosis, which evidently needs to change.”  

WONCA was held in Sydney from 26-29 October.