Plöderl and Hengartner raise questions [1] regarding our study [2], which we address below in the context of previous research. Our study, employing a self-controlled design, found that incidence rates of suicidal behavior were highest in the month before treatment start, and then declined over treatment time. However, rates remained elevated throughout treatment compared with the month 1 year before treatment initiation.

Plöderl and Hengartner state that our findings are different to those of a previous Swedish study using a self-controlled design [3]. This is not entirely accurate. First, this 2013 study considered only death by suicide, whereas our work examines suicide attempts and death by suicide in more recent data. Second, both studies found that the risk of suicide outcomes was elevated after SSRI treatment initiation when compared to a reference period a year before the index date (date of death or date of SSRI initiation, respectively). Third, our study additionally showed that, when considering suicide attempts, the risk was highest in the month prior to treatment initiation. This is consistent with the well-replicated observation that individuals are prescribed SSRIs when most mentally unwell, and a recent review has highlighted that existing observational studies of antidepressant safety insufficiently account for confounding by indication [4].

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