Every time there’s a school shooting or any sort of mass violence, the subject of SSRIs comes up from one commenter or another.
Sometimes people also bring up the subject of fatherlessness and mass shooters, which I wrote about at length in this post, the gist of which is that there is no connection although it’s popularly thought that there is.
Now, on to SSRIs. It is notoriously difficult to do research on whether SSRIs trigger more violence, have no effect, or help prevent violence, and if so in what populations. It’s a popular internet meme that they trigger violence, but the evidence is not at all clear that that is so, and as I said it’s very difficult to design a good study. One obvious reason is that such people are often at higher risk for violence in the first place, and drugs are not given randomly. There is almost certainly something already different about the people who get them and those who don’t.
This is one of the better-designed studies, and as you can see if you read it it’s very hard to tell what it all means, if anything. For example:
As is often the case, the authors of the study themselves are rather cautious. While obviously concerned that it is possible that SSRIs may actually cause violent behavior in a small minority of people, they fully recognize that other explanations are possible. These include the possibility that what is driving the violent behavior is medication undertreatment, based on the finding that the risk with violence was only found among individuals who were likely taking subtherapeutic doses. As reported by MedScape, one of the study authors, Seena Fazel, states: “Our own view is that some evidence suggests that it’s a bit more complicated than that, because we found a link with subtherapeutic doses of SSRIs, and that would suggest to us that it may be that it’s actually a lack of treatment [and] it could be residual symptoms that are driving this link.” At the same time, if antidepressants really worked wonders for young people, we should see that therapeutic SSRI usage was associated with a reduced risk of violent behavior, which it wasn’t.
A couple other factors also deserve mention. The idea of comparing periods on and off medication within the same individual is a clever design, because many individual factors that might be related to risk of violence, like one’s socioeconomic status or DNA, are held constant. However, because the period of medication use was not randomized (and couldn’t be), it introduces the very likely complicating issue that individuals were taking medications during times when they were feeling more depressed, anxious, and angry to start with, and thus at higher risk of acting violently. Finally, it is important to note that a statistically significant association certainly does not mean that most people taking antidepressants are out there hurting others. When taking SSRI medications, the conviction rate of violent crimes was at a 1.0% rate compared to 0.6% without medications.
There’s also this:
Our study encompassed nationwide data over a 15-year period. In this period, the homicide rate per 100,000 remained fairly constant, with a moderate decline in recent years, leading to an average of 160 homicide victims per year. The suicide rate decreased steadily from 10.26 (approximately 1,500 victims) in 1994 to 8.77 (approximately 1,400 victims) per 100,000 in 2008. The homicide–suicide rate remained relatively stable, averaging at 0.05 per 100,000 (varying from 4 to 14 victims per year, see Fig. 1). In the same period, the rate of total antidepressant use increased considerably, from 3,038.81 in 1994 to 5,650.58 per 100,000 in 2008. A similar increase was observed for the rate of SSRI use alone, which more than doubled from 1,482.25 in 1994 to 3,161.15 per 100,000 in 2008 as well as the rate of SSRI use including venlafaxine, with an increase of 1,486.81 in 1994 to 3,904.20 per 100,000 in 2008. Over the same period, the number of defined daily doses used rose from 59.6 million in 1994 to 245.3 million in 2008: a fourfold increase. This indicates that not only more people used antidepressants, but also that the mean duration or intensity of the treatment grew…
Rates of the use of SSRIs including venlafaxine were also found to be negatively associated with both homicide rates and suicide rates. No significant independent association was found between rates of SSRIs including venlafaxine and homicide–suicide.
Here’s an article about suicide and SSRIs for young people:
The 2004 study examined the clinical trial data that had been collected on two types of medications, selective serotonin reuptake inhibitors (SSRI) and selective norepinephrine reuptake inhibitors (SNRI). The results of the study prompted the Food and Drug Administration (FDA) to issue a black box warning, the most serious level of warning in prescription drug labeling, for the risk of suicides in children and adolescents being treated with antidepressants in 2004. The warning was extended to young adults ages 18 to 25 years in 2006.
The researchers in the current study performed a meta-analysis of 41 studies, reviewing the data on a total of 9,185 youths, adults, and geriatric patients who were treated with fluoxetine (Prozac is one common brand) and venlafaxine (Effexor) immediate (IR) and extended release (ER) preparations…
In all three age groups, treatment with fluoxetine and with venlafaxine IR and ER resulted in a statistically significant improvement in depressive symptoms when compared to treatment with placebo. The decline in depressive symptoms was also faster for patients treated with medication than control group patients. In the adult and geriatric patients who were treated with fluoxetine or venlafaxine, suicidal thoughts and behaviors decreased over time.
As the patients became less depressed, they had fewer suicidal thoughts and attempts. Although the youths who were treated with medication showed the same statistically significant decrease in depressive symptoms as the older populations, they did not show a decrease in suicidal ideation and actions.
“In kids, we don’t see a harmful effect, but we do see a disassociation between the beneficial effects on depression and the potential beneficial effect on suicide,” said the study’s lead author…
The newest analysis did not support the idea that there was an increased risk of suicide in children and adolescents taking fluoxetine, an SSRI. In explaining the difference in their findings, the researchers note that these original meta-analyses included fewer studies and the studies were of shorter term than the longitudinal data they analyzed.
There probably will be a number of readers here who say something like this: “It’s all lies promulgated to cover up the damage drug companies do and to preserve their profits.” You’re welcome to that point of view, and certainly during the COVID years the CDC and many other official entities have earned our distrust. But if you throw out all research, including older studies such as these, you are left with internet memes and paranoia. That’s not science, either. I believe that most of these studies are attempts at valid research on a subject that is inherently difficult to study, and that the bulk of the evidence indicates that SSRIs do not increase violent behavior.
