Severe Acne Linked to Suicide Risk
before, during and after tx
risk incr during tx and up to 6mo later
retrospective Swedish cohort study reported online in BMJ
BMJ. 2010;341:c5812, c5866.
Isotretinoin = 13-cis-retinoic acid
used since the 1980s to treat severe recalcitrant nodular acne
study to eval risk of attempted suicide before, during, and after treatment with isotretinoin for severe acne
Sweden from 1980 to 2001
patient register of isotretinoin users 1980-89 linked to hospital discharge/cause-of-death registers 1980-2001
n=5756 pts age 15-49
5756 patients; 3613 (63%) male
Average age of men when they were first prescribed isotretinoin was 22 years, women was 27
during study period 128 pts admitted to the hospital for attempted suicide
SIR for attempted suicide was increased during the year before treatment: 1.57 (95% confidence interval [CI], 0.86 - 2.63) for all, including repeated attempts, and 1.36 (95% CI, 0.65 - 2.50) for only first attempts.
risk for suicide attempts further incr during and up to 6 months after treatment, with a SIR of 1.78 (95% CI, 1.04 - 2.85) for all attempts and 1.93 (95% CI, 1.08 - 3.18) for first attempts
At 3 years after treatment was stopped, the observed number of suicide attempts was close to the expected number, and this remained stable during 15-year follow-up, with a SIR of 1.04 (95% CI, 0.74 - 1.43) for all attempts and 0.97 (95% CI, 0.64 - 1.40) for first attempts.
Of 32 patients who had attempted suicide before, 12 (38%) made a new attempt/committed suicide thereafter
Of pts who made first attemt within 6mo after tx, 10 (71%) of the 14 tried/did during followup
For 1 additional first suicide attempt to occur, the number needed to harm was 2300 new 6-month treatments per year. For 1 additional repeated attempt, the number needed to harm was 5000 per year.
"An increased risk of attempted suicide was apparent up to six months after the end of treatment with isotretinoin, which motivates a close monitoring of patients for suicidal behaviour for up to a year after treatment has ended," the study authors write. "However, the risk of attempted suicide was already rising before treatment, so an additional risk due to the isotretinoin treatment cannot be established. As patients with a history of suicide attempts before treatment made new attempts to a lesser extent than did patients who started such behaviour in connection with treatment, patients with severe acne should not automatically have isotretinoin treatment withheld because of a history of attempted suicide."