The Royal Pharmaceutical Society has been asked to review the monograph for Sertraline in the BNF following an inquest into the suicide of a young man in 2021.

On May 5, East Sussex assistant coroner Michael Spencer issued a Report to Prevent Future Deaths to the RPS and NICE concerning the suicide of Joshua Asprey on June 14 2021. These reports are a statutory requirement following an inquest where a coroner believes there may be a risk of deaths occurring in similar circumstances in the future.

The 19-year-old man, who had a history of anxiety, died from multiple injuries after jumping from a cliff. This took place three days after a telephone consultation with his GP led to him being put on a higher dose of Sertraline, a medicine he was commenced on in late May 2021. 

According to the assistant coroner’s report, the young man “began to have thoughts contemplating suicide” after his dose was increased. His GP relied on information in the British National Formulary, “which does not identify suicidal ideation as a risk of prescribing Sertraline”.

A suicide note left on Joshua Asprey’s computer stated: “The reason for my current state of thoughts and plans is probably due to suicidal thoughts caused by a side effect of changing from [redacted] dosage of sertraline.

“However, while this is the trigger in the short term, these thoughts have existed and persisted within me for many years now and to blame solely the medication would be unjust.”

The assistant coroner wrote: “There was insufficient evidence on which to conclude that there was a causative link between the increased prescription of sertraline and Joshua’s death.”

Inconsistencies highlighted

Evidence heard during the inquest “highlighted an inconsistency” between the patient information leaflet (PIL) provided by the manufacturer and the March 2023 edition of the BNF.

In a list of uncommon side effects, the PIL stated in bold writing: “Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation.”

There is no specific mention of suicidal ideation in the Sertraline monograph in the BNF. However, it does list “thinking abnormal” as an uncommon side effect, and the section on Depression and the use of Antidepressant Drugs states: “The use of antidepressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour and particularly suicidal behaviour are particularly at risk.”

In his report, Mr Spencer said he was “concerned that there is a risk” that a medical practitioner using the BNF “with a view to determining dosage and treatment with Sertraline” will be unaware of the potential risks.

He added: “It may be that the evidence of risk of suicidal ideation associated with Sertraline specifically (as opposed to SSRIs) is so low that it need not be referred to in the BNF, notwithstanding its inclusion in the PIL. 

“Nevertheless, this is a matter of concern that would in my view benefit from further consideration.”

A spokesperson for the BNF told Pharmacy Network News: “We have carefully considered the coroner’s report including his observations and comments related to the BNF monograph for Sertraline, a selective serotonin re-uptake inhibitor. Suicidal behaviours are known side-effects of all SSRIs, and antidepressant medicines in general. 

“This information is covered in the BNF class monograph for SSRIs, to which Sertraline refers, and the treatment summary for Depression includes information about monitoring for suicidal ideation. In response to the coroner’s report, we are planning communications to raise awareness of the ways that information relating to class effects and conditions are presented within BNF Publications.”