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In Reply: Drs Tondo and Baldessarini comment on our point that suicidal behavior in conditions such as bipolar disorder and schizophrenia may respond specifically to lithium and clozapine, respectively, by raising the interesting question as to why randomized controlled trials have not shown that antidepressants reduce rates of suicidal behavior in major depressive disorder. Part of the reason may be that clinical trials in major depression have almost uniformly not been designed to detect effects on suicidal behavior, and that most trials excluded acutely suicidal patients. Studies specifically designed to address this question are needed because use of antidepressants in major depression has emerged as the centerpiece of most suicide prevention efforts.

Drs Knox and Caine fly to the defense of the US Air Force Suicide Prevention Program as being much more than a gatekeeper program. We do not disagree but point out that reports from this admirable program have . . . [Full Text of this Article]

J. John Mann, MD
jjm@columbia.edu
Columbia University
Division of Neuroscience
New York, NY

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