To the Editor: Since the introduction of fluoxetine a decade and a half ago, there has been controversy in the lay media and scientific literature as to whether fluoxetine and other selective serotonin reuptake inhibitor (SSRI) antidepressants cause violence and suicide. Proponents of that position have based their opinions on case reports or large clinical groups in comparing patients taking SSRIs to those taking other types of antidepressants (1, 2). Those finding no association between the use of SSRIs and violence and suicide have compared patients taking SSRIs to those receiving placebo in terms of the incidence of violent and suicidal behaviors (3, 4).

We chose a different strategy to examine this controversial topic. We reviewed all murder-suicides that took place in New York City from 1990 through 1998 using data collected from the files of New York City’s chief medical examiner. Blood from murderers who committed suicide is routinely tested for drugs, including antidepressants. There were 127 murder-suicides over the 9-year period. Three of the murderers (2.4%) were taking antidepressants according to results of toxicological testing. A 46-year-old woman who killed her son and then herself with injections of heroin was taking amitriptyline. A 48-year-old man who set fire to rags and paper in a closet and lay on his two young sons and his young daughter was taking amitriptyline. A 77-year-old man who killed his spouse and then himself with a gun was taking sertraline.

The findings in our study lend no support to the position that the use of SSRIs is associated with violence or suicide. The fact that only 2.4% of these persons were taking antidepressants at the time they killed family members and then themselves is less than one would expect in the general population, given that SSRIs were widely prescribed in the 1990s (5). These data do not support an association between the use of SSRIs and violence or suicide. There is no evidence suggesting that clinicians should hesitate in prescribing SSRIs, which have been shown to be safe and effective, for fear of violent and/or suicidal consequences.