DO ANTIDEPRESSANTS CAUSE SUICIDE? -- A POST TO ANGER ALL SIDES.
In my chapter on the marketing of antidepressants in Japan I make the case that drug companies endeavored to sell both the American conception of depression along with the drugs purporting to cure that illness. Near the end of the chapter I take on what has to be one of the most polarizing issues in psychopharmacology today, namely: Whether SSRIs can sometime spark violent and/or suicidal behavior.
Unfortunately for me, I came to a conclusion that will no doubt anger both sides of a highly contentious debate.
Experts who have looked closely at the human trial data for SSRIs estimates that these antidepressants show a positive effect for about one in ten test subjects but that they can spark extreme agitation in about one in twenty patients. For some, that agitation, called akathisia, will be so disquieting that it will spark suicidal thoughts or behavior. The likelihood is that these drugs are ineffective in most patients, work well for a small percentage of patients, and spark suicidal thoughts or behaviors in another
small segment.
Two well-designed studies conducted fifteen years apart both point to this conclusion. In 1993 three researchers from the department of Psychiatry at Harvard concluded that antidepressants, including Prozac, likely lessened the chances of suicide in some patients while raising it in others. “These observations suggest that antidepressants may redistribute the risk, attenuating risk in some patients who respond well, while possibly enhancing risk in others who respond more poorly.”
Fully fifteen years later another set of researchers, these from the college of Physicians and Surgeons of Columbia University, came to a similar but more refined conclusion. This study looked closely at two years’ worth of patient data and found that in adults
there was no significant difference between the group that got the drug and the group that didn’t. In teenagers and children, however, those who took the drug were significantly more likely than those who didn’t to attempt suicide within four months after being started on the drug. Looking at the data further, researchers found one group in which the drug had a protective effect against suicidal behavior: adult men. The redistribution of the risk, in this case, appeared to be away from adult males and toward teenagers and
children.
In the end it is possible that both the critics of SSRIs and their promoters might have legitimate points on the suicide question. This is because these two groups tend to use two different data sets to bolster their main point. The critics point to the human trials which chart patients’ first few weeks on the drugs. While the SSRI advocates tend to use larger population data sets which often show an overall decrease in suicides in populations that have access to these drugs.
Here’s why they could both come to legitimate – but opposite conclusions:
The agitation and aggression sometimes noted as a reaction to these drugs are most pronounced early in the treatment, the very period often focused on in clinical trials. In real-world use such negative reactions to the drug may lessen or disappear after this
early period. More likely, attentive doctors may quickly take a patient off a drug if they note a severely negative response. (Which is to say that patients who respond well are more likely to stay on the drug for the long-term.)
Thus it is possible that these drugs can increase suicidality in test subjects in short-term clinical trials, as critics have contended, and yet when judged over years, reduce suicide in the overall population.
Even if it proves to be true that SSRIs reduce suicidality in large populations, the drug companies and the researchers who helped them distort or underreport negative data in clinical trials might still be culpable. (More on this aspect of the debate in the book.) Had those early treatment risks been accurately reported in the published research on these drugs, doctors would have had a chance to change the way they monitored their patients and been better prepared to spot a patient having a bad reaction. Doctors almost certainly would have second-guessed prescribing this medication to those with only minor symptoms of depression.
Unfortunately for me, I came to a conclusion that will no doubt anger both sides of a highly contentious debate.
Experts who have looked closely at the human trial data for SSRIs estimates that these antidepressants show a positive effect for about one in ten test subjects but that they can spark extreme agitation in about one in twenty patients. For some, that agitation, called akathisia, will be so disquieting that it will spark suicidal thoughts or behavior. The likelihood is that these drugs are ineffective in most patients, work well for a small percentage of patients, and spark suicidal thoughts or behaviors in another
small segment.
Two well-designed studies conducted fifteen years apart both point to this conclusion. In 1993 three researchers from the department of Psychiatry at Harvard concluded that antidepressants, including Prozac, likely lessened the chances of suicide in some patients while raising it in others. “These observations suggest that antidepressants may redistribute the risk, attenuating risk in some patients who respond well, while possibly enhancing risk in others who respond more poorly.”
Fully fifteen years later another set of researchers, these from the college of Physicians and Surgeons of Columbia University, came to a similar but more refined conclusion. This study looked closely at two years’ worth of patient data and found that in adults
there was no significant difference between the group that got the drug and the group that didn’t. In teenagers and children, however, those who took the drug were significantly more likely than those who didn’t to attempt suicide within four months after being started on the drug. Looking at the data further, researchers found one group in which the drug had a protective effect against suicidal behavior: adult men. The redistribution of the risk, in this case, appeared to be away from adult males and toward teenagers and
children.
In the end it is possible that both the critics of SSRIs and their promoters might have legitimate points on the suicide question. This is because these two groups tend to use two different data sets to bolster their main point. The critics point to the human trials which chart patients’ first few weeks on the drugs. While the SSRI advocates tend to use larger population data sets which often show an overall decrease in suicides in populations that have access to these drugs.
Here’s why they could both come to legitimate – but opposite conclusions:
The agitation and aggression sometimes noted as a reaction to these drugs are most pronounced early in the treatment, the very period often focused on in clinical trials. In real-world use such negative reactions to the drug may lessen or disappear after this
early period. More likely, attentive doctors may quickly take a patient off a drug if they note a severely negative response. (Which is to say that patients who respond well are more likely to stay on the drug for the long-term.)
Thus it is possible that these drugs can increase suicidality in test subjects in short-term clinical trials, as critics have contended, and yet when judged over years, reduce suicide in the overall population.
Even if it proves to be true that SSRIs reduce suicidality in large populations, the drug companies and the researchers who helped them distort or underreport negative data in clinical trials might still be culpable. (More on this aspect of the debate in the book.) Had those early treatment risks been accurately reported in the published research on these drugs, doctors would have had a chance to change the way they monitored their patients and been better prepared to spot a patient having a bad reaction. Doctors almost certainly would have second-guessed prescribing this medication to those with only minor symptoms of depression.
Posted by Ethan Watters at 10/28/2009 10:21 AM 
Categories: depression
Tags: suicide antidepressants ssri paxil GlaxoSmithKline
Categories: depression
Tags: suicide antidepressants ssri paxil GlaxoSmithKline
As I read this entry, my heart pounded with anger, disbelief...I am one of those people who have used anti-depressants and have has severe suicidal thoughts. Clearly I am alive today. Yet the journey through the depression and the affects of the medication have reshaped my life.
As the studies go, I am assuming there the subjects are monitored and the medication is dosed as according to the manufactures instructions. All well and good for a study. Not reality.
As someone who has battled with depression and have sought support from many sources, I can tell you that very few patients who begin anti-depressants are able to take the medication according to the instructions. The real danger lays in the irregularity of dosage. The danger zone is while you are coming up to full dosage within your body. With irregularity of dosage, the risk of suicide are increased. The zone of getting into the groove with the dosage is ambiguous.
Remember, state of patient. In a state of ennui, lonely, fearful, barely awake..not a state conducive to paying attention to dosage. Herein lies the flaw of the studies. Herein lies the flaw of prescribing.
I battled pernicious anemia for several years, because it was misdiagnosed as depression. While depression is the primary symptom, it is the one that keeps diagnosis at bay. It also kept me from being able to keep track of dosage for over a year.
I floated in and out of suicidal thoughts, nearly finding the desperation to do it. I lived alone, no one to help remind me...I had no focus, no ability to pay attention. Yet, I was dancing with the side effects of the anti-depressants...
I am lucky to be alive. Only by the grace of God and the love of my friends, do I sit here today, able to think through this at all.
I send pleas out to the researchers to come to a sense of reality and begin to do research that is based on the real lives of those who live with depression.
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I appreciate the careful, fair-minded discussion of this complicated question, and the willingness to come to a non-polemical conclusion. One of the remarkable things about your book is that it puts the suicide issue in context, revealing it to be a small part of a much larger and profound scandal.
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