Although a relationship is alleged, there are no empirical data establishing a causal link between selective serotonin reuptake inhibitors (SSRIs) and homicide-suicide. Many factors contribute to the occurrence of homicide-suicides, including characteristics of the perpetrator, victim(s), as well as the context of the event. Several of our studies show the lack of involvement of SSRIs in homicide-suicides as well as the complexity of clinical patterns.
As part of a case-control study, we reviewed medical examiner files of all 20 spousal homicide-suicides perpetrated by persons age 55 and older throughout Florida in 1998 and 1999. None of the perpetrators tested positive for antidepressants on postmortem toxicology. Of 40 suicide controls matched for age, gender, marital status, method of death, and medical examiner district, only one tested positive for an antidepressant, nortriptyline.
In our 1998 AJP paper, 1.8% (3) of the perpetrators of 171 homicide-suicides in four Florida Medical Examiner Districts from 1988 through 1994, tested positive for antidepressants. Two were positive for amitriptyline and its active metabolite, nortriptyline: a 70 yr. old man killed his 55 yr. old wife with an ax before committing suicide with a knife, and a 46 yr. old male stabbed his 52 yr. old girlfriend and himself multiple times. The third offender, a 44 yr. old woman who shot her female roommate, tested positive for nortriptyline.
The presence of psychopathology, especially depression, in young and old perpetrators, is well documented, but, unfortunately, these psychiatric problems are usually undetected and untreated. When perpetrators had been taking antidepressants, they either had not responded to the antidepressant, it was too early in treatment for them to have responded, or the severity of their depression was not recognized and progressed to a psychotic depression or switched them into a manic episode.
Homicide-suicides are violent events, but they are not caused by SSRIs or other antidepressants. They are the consequence of untreated psychopathology coupled with relationship dynamics as well as other stressors and diatheses. Perpetrators are usually men with dominant personalities who have an intense, long-term involvement with the victim(s). They plan the homicide-suicide carefully, usually over a long time, when they perceive separation and a threat to their ability to control the relationship(s), such as divorce or a challenge to their ability to provide caregiving.
The clinical challenge of homicide-suicide is to identify risk factors and improve diagnosis and treatment for psychopathology and relatioinship violence.
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