SSRIs for Depression: Initial Dosing Important For Suicide Risk Interview with:
Dr. Philippe Courtet MD PhD
Centre Hospitalier Régional Universitaire de Montpellier, Institut National de la Santé et de la Récherche Médicale ,
Université Montpellier, Montpellier, France
Fondation Fondamental, Créteil, France

Medical Research: What are the main findings of the study?

Dr. Courtet: Depressed outpatients who are beginning the treatment with a SSRI at higher dose than recommended present an increased risk (x2) of worsening of suicidal ideation during the first 6 weeks of treatment.

This is consistent with the study by Miller et al published in the same journal few weeks ago, reporting a double risk of suicide attempt in young subjects (<24 yrs) who are begun an SSRI at higher dose than recommended.

Our results showed that the increased suicide risk with the high dose of SSRI is not restricted to youngsters and is independent of the severity of the depression.

Medical Research: What was most surprising about the results?

Dr. Courtet: The observation of this effect of the dose of the SSRI on increased suicidal ideation independently of potential confounders (baseline severity of the current depression or the depressive illness and suicide risk factors).

Medical Research: What should clinicians and patients take away from your report?

Dr. Courtet: SSRsI are associated with a lower risk of worsening of suicidal ideation during the first weeks after introduction than non SSRI and when a SSRI is chosen by the clinician: “start low go slow“ (as proposed by an editorial by Brent & Gibbons accompanying the Miller’ paper) in all patients and not only in young ones.

This concerns about one fourth of the patients, who begin antidepressants at higher dose than recommended.

Also: a careful monitoring of suicidal ideation is necessary before and after the introduction of the antidepressant, as a worsening of suicidal ideation occurs in a minority of patients who exist.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Courtet: Studies on the impact of dose initiation and dose escalation in the face of response on depression, on suicidal ideation and suicidal behaviour should be done.

These studies should take into account risk factors of suicidal behaviour and factors of non response to antidepressants as potential confounders (history of suicide attempt, comorbidities, number of past depressive episodes…).


Courtet P, Lopez-Castroman J, Jaussent I, Gorwood PM. Antidepressant Dosage and Suicidal Ideation. JAMA Intern Med. Published online September 22, 2014. doi:10.1001/jamainternmed.2014.4509.


Last Updated on December 21, 2014 by Marie Benz MD FAAD