We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Comment & Response |

Antidepressant Dose and Risk of Deliberate Self-harm—Reply

Matthew Miller, MD, MPH, ScD1,2; Sonja Swanson, ScD2; Til Stürmer, MD, PhD3
[+] Author Affiliations
1Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Burlington, Massachusetts
2Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
3Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
JAMA Intern Med. 2015;175(3):464. doi:10.1001/jamainternmed.2014.7180.
Text Size: A A A
Published online


In Reply We welcome the opportunity Petersen and Nazareth provide with their letter to emphasize the importance of assessing the likely direction and quantifying the likely magnitude of biases in our study,1 including confounding by indication.

As we stated originally, although it is possible that unmeasured confounding accounts for the dose-response relationship we observed, it is not obvious what unmeasured factors might have led to meaningful confounding of our results. For example, our sensitivity analyses indicate that suicidal ideation prior to antidepressant therapy was not associated with the dose prescribed after adjusting for our propensity score, indicating that prior suicidality may be reasonably approximated by accounting for the patient characteristics at our disposal. Furthermore, our bias analyses demonstrate that an unmeasured confounder that could explain away the heightened risk of deliberate self-harm among youth initiating high-dose therapy would need to be more than 10-times as imbalanced across dose levels than were our measures of psychiatric comorbidity and more strongly associated with deliberate self-harm than our strongest predictor of deliberate self-harm (ie, a history of deliberate self-harm), even after accounting for the other risk factors included in our propensity score. Our bias analysis allows readers to speculate about the extent to which any purported unmeasured confounder satisfies these requirements.


Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





March 1, 2015
Irene Petersen, PhD; Irwin Nazareth, PhD
1Department of Primary Care and Population Health, University College London, London, England
JAMA Intern Med. 2015;175(3):463-464. doi:10.1001/jamainternmed.2014.7171.
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...