There has been a question as to if antidepressants come with a cost. Of cardiovascular events. Such balances are common in medicine: the most common example is the oral contraceptive, which does increase the risk of myocardial infarction and strokes among women who take them, to the point that one should counsel a smoking woman over 35 about this. From a comment on the paper… the main table from which is below.

The study cohort was selected a primary care database with longitudinal health records of more than 12 million patients from more than 600 general practices across the United Kingdom. As quality rarely fits with quantity, the use of the motto “garbage in, garbage out” could be part of the answer.

Prescrire, the international independent drug bulletin just re-warned: Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, carries an increased risk of adverse cardiovascular effects and of overdose deaths, compared with most other serotonin reuptake inhibitors (SRIs), whereas the efficacy of all SRIs is similar and limited. Venlafaxine shares the adverse effects of SRIs, but is associated with additional adverse effects, especially cardiovascular – tachycardia, hypertension, severe cardiac arrhythmia – which are foreseeable, given its pharmacological profile. These adverse effects are generally fatal in the case of overdose or risk factors (eg. hypokalaemia), with no compensation in terms of efficacy. Citalopram and its derivative escitalopram too, ought also to be ruled out as well because they too expose patients to an increase in adverse cardiovascular effects, whereas they offer no benefit in terms of efficacy.

The bibliography must be questioned too as it ignored the cases of citalopram and venlafaxine overdoses published, even from “core clinical journals”.

Depression, of course, can kill. By suicide. So there is a matter of balance. But what is the risk of cardiovascular events?

The main findings of this large population based cohort study were that selective serotonin reuptake inhibitors were not associated with an increased risk of arrhythmia, myocardial infarction, or stroke or transient ischaemic attack in a general population cohort of people with depression aged 20 to 64 and that risk of arrhythmia was not significantly increased in patients treated with citalopram even at high doses (40 mg/day and over), although numbers in this category were relatively small. We found some evidence that selective serotonin reuptake inhibitors were associated with a reduced risk of arrhythmia and myocardial infarction. Fluoxetine was associated with the lowest risks of these two outcomes, but overall no significant differences were seen between the selective serotonin reuptake inhibitors. The risk of arrhythmia was significantly increased in the first four weeks of starting tricyclic and related antidepressants, and the tricyclic drug lofepramine was associated with a significantly increased risk of myocardial infarction in the first year of follow-up.

A recent paper (requested as a consequence of regulatory authorities clarifying use of antidepressants with suicidal thoughts) clearly highlights the reduction in suicide attempts following introduction of an antidepressants and the rates are statistically lower, than in untreated depression. It included a large analytic cohort of a total of 128 111 participants (52 355 from the incident depression cohort and 75 756 from the general population sample).

This paper concludes that selective serotonin reuptake inhibitors were not associated with an increased risk of arrhythmia, myocardial infarction, or stroke or transient ischemic attack in a general population cohort of people with depression aged 20 to 64. The authors even suggested some evidence that selective serotonin reuptake inhibitors were associated with a reduced risk of arrhythmia and myocardial infarction.

It is important to note that within the bio-psycho-social model, one cannot overlook the most recent findings of the national survey looking at the patient’s experiences of negative effects of psychological treatment. Of 14 587 respondents, 763 (5.2%) reported experiencing lasting bad effects. Reporting the negative effects varied across the spectrum of therapies with likes of cognitive behavior therapy and solution focused therapy accounting for 4%, whereas psychodynamic psychotherapy peaked at 9%.

Hence to summarize, we believe this paper along with the references quoted, changes the balance towards antidepressant prescribing in appropriate patients.

We need to consider what the adverse effects of any intervention are. And then do some balancing of risk. We need the data from large cohorts to estimate such risks correctly: the early studies are simply too small — even if they have a thousand participants — to have enough power for rare events. This dataset is barely big enough.

But in routine use, these medications are safer than the oral contraceptive. The idea that the elite approve of the more risky one (as a ‘human right’) while saying the use of antidepressants is a consipiracy of big pharma, although attractive, is not confirmed by the current evidence.