A commonly prescribed class of blood pressure medications may be associated with a higher risk of suicide among older adults, according to a large Canadian study that is prompting renewed scrutiny of the mental health effects of cardiovascular drugs.
Researchers from St Michael’s Hospital in Ontario examined health records spanning 18 years and found that older patients prescribed angiotensin receptor blockers (ARBs) were significantly more likely to die by suicide than those treated with angiotensin converting enzyme inhibitors (ACEIs), another widely used class of antihypertensive drugs.
A closer look at the data
The study analyzed 964 suicide cases involving people aged 66 years and older who had been prescribed either an ACEI or an ARB within the previous 100 days. These cases were compared with 3,856 matched controls who had received the same medications but died of other causes.
The findings revealed a notable difference between the two drug classes. Among those who died by suicide, 26% had been exposed to ARBs, compared with 18.4% who had received ACEIs. After adjusting for other factors, the researchers calculated an odds ratio of 1.63, suggesting a substantially higher risk of suicide associated with ARB use compared with ACEIs.
The median age of participants was 76, and nearly 80% were male, reflecting the demographic most commonly affected by both cardiovascular disease and suicide in later life.
Mental health and heart disease: a complex link
Lead author Dr Muhammad Mamdani and colleagues emphasized that the findings should be viewed in the broader context of the well-established, two-way relationship between depression and cardiovascular disease.
“The effect of these drugs on mental health outcomes, particularly suicide, is of increasing interest because of the bidirectional association between depression and cardiovascular disease,” the authors wrote.
While the study does not prove that ARBs directly cause suicidal behavior, it raises important questions about how medications that act on the renin angiotensin system may influence mood, cognition, or other neurochemical pathways in vulnerable patients.
Common drugs, serious implications
ACEIs and ARBs are mainstays of treatment for hypertension, heart failure, and kidney disease, and are often considered similarly effective. In the study, the most commonly prescribed ACEIs were ramipril (38.8%) and enalapril (15%). Among ARBs, valsartan, telmisartan, and candesartan were each prescribed to about 16.7% of patients.
Given how frequently these drugs are used, even a modest increase in suicide risk could have significant public health implications.
“Given their high prevalence of use, the severity of the outcome, and the similar efficacy of these drug classes in treating the same conditions, clinicians may opt for preferential use of ACEIs over ARBs where possible,” the authors noted.
What this means for patients and doctors
Experts caution that patients should not stop or change their medication without consulting their doctor. For many people, ARBs are prescribed because ACEIs cause side effects such as persistent cough or angioedema, and they remain highly effective and generally well tolerated.
However, the study underscores the importance of considering mental health when prescribing cardiovascular medications particularly in older adults, who may already be at increased risk of depression, social isolation, and suicide.
Further research is needed to confirm the findings, explore potential biological mechanisms, and determine whether certain ARBs carry higher risks than others. In the meantime, the authors suggest that clinicians remain alert to changes in mood or behavior following the initiation of antihypertensive therapy and factor mental health history into prescribing decisions.
As the population ages and the burden of both cardiovascular disease and mental illness continues to rise, studies like this highlight the need for more integrated care—where the heart and the mind are treated as inseparable parts of the same patient.
