Background: Several systematic reviews have been published about the relationship of the use of selective serotonin reuptake inhibitors (SSRIs) and risk of suicidal ideation or behavior but there has been no formal assessment of the quality of these reports.
Aim: Assess the methodological quality of systematic reviews about the relationship of SSRI use and suicidal ideation and behavior; and provide overall conclusions based on this assessment.
Methods: Systematic reviews of RCTs that compared SSRIs to placebo and used suicidal ideation or behavior as a key outcome variable were identified by searching Pubmed, Embase, The Cochrane Library, EBSCO, PsycINFO, Chinese National Knowledge Infrastructure, Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, and the Chinese Biological Medical Literature Database. The methodological quality of included reviews was independently assessed by two expert raters using the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) scale.
Results: Twelve systematic reviews and meta-analyses were identified. The inter-rater reliability of the overall AMSTAR quality score was excellent (ICC=0.86) but the inter-rater reliability of 5 of the 11 AMSTAR items was poor (Kappa <0.60). Based on the AMSTAR total score, there was one high-quality review, eight moderate-quality reviews, and three low-quality reviews. The high-quality review and three of the moderate-quality reviews reported a significantly increased risk of suicidal ideation or behavior in the SSRI group compared to the placebo group. Three of the four reviews limited to children and adolescents found a significantly increased risk of suicidal ideation or behavior with SSRI use which was most evident in teenagers taking paroxetine and in teenagers with depressive disorders.
Conclusions: The available evidence suggests that adolescents may experience an increase in suicidal ideation and behavior with SSRI use, particularly those who have a depressive disorder and those treated with paroxetine. However, there are few high-quality reviews on this issue, so some doubt about the evidence remains. The AMSTAR scale may be useful in the ongoing efforts to improve the quality of systematic reviews, but further work is needed on tightening the operational criteria for some of the items in the scale.
背景: 关于使用选择性5- 羟色胺再摄取抑制剂（SSRIs） 与自杀意念或行为的关系，一些系统综述已发表，但 是对这些报告的质量并没有做过正式的评估。
目的: 评估有关使用SSRI 与自杀意念和行为之间关系 的系统综述的方法学质量; 并提供在此评估的基础上 得出的总体结论。
方法: 通过检索Pubmed, Embase，Cochrane 图书馆， EBSCO，PsycINFO，中国国家知网，中国科技期刊重庆 维普数据库，万方数据库，和中国生物医学文献数据 库来确定相关的系统综述，这些系统综述纳入了比较 SSRI 类药物与安慰剂、以自杀意念或行为作为关键变 量的随机对照试验。两个专家评估者独自采用多系统 综述11 项评估量表（AMSTAR）对纳入评估的文献进 行方法学质量的评估。
结果: 共检出12 篇系统综述和meta 分析。AMSTAR 总体质量评分的评分者信度非常好（ICC=0.86），但 11 个AMSTAR 项目中有5 项的评分者信度较差（Kappa 值<0.60）。根据AMSTAR 总分，仅1 篇为高质量等级， 8 篇为中等质量等级，3 篇为低质量等级。这篇高质 量综述和3 篇中等质量的综述均报告SSRI 组中自杀意 念或行为的风险显著高于安慰剂组。4 篇仅限于儿童 和青少年的综述中有3 篇报道服用帕罗西汀和患有抑 郁症的青少年有显著增加自杀意念或行为的风险。
结论: 现有证据表明，青少年使用SSRI 类药物可能会 增加自杀意念和行为的风险，尤其是抑郁症患者和服 用帕罗西汀的患者。但是，相关高质量的综述很少， 所以对这一结论还存有疑问。AMSTAR 量表对于提高 系统综述质量也许是有用的，但对量表中的某些项目 需要严格操作标准。
Keywords: AMSTAR; methodological quality; selective serotonin reuptake inhibitors; suicidal behavior; suicidal ideation; systematic reviews.