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
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
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.