Monday, December 11, 2006

The Lastest On Antidepressants and Suicide

[posted by dinah, not roy]

Don't forget to listen to the MY THREE SHRINKS Podcast! See link below.

Do SSRI's cause people to become suicidal? The question feels old-- I remember when these medications first came out and there were questions about whether the medications made people violent, seems that years later we still have the same questions.

It seems like this is something we should know-- it's been a while now, two decades in fact. It's easy if everyone who takes a medication gets an unusual symptom, harder if only a few people who take a medication have an adverse reaction, and harder still if the symptom caused by the medication is the same as the symptom caused by the disease the medicine treats!

In 2004, the FDA mandated that all the newer anti-depressants carry a black box warning stating that they may cause suicidal ideation in children and adolescents. The research is convincing that a small percentage of children (1 to 2 percent) who were not having ideas about suicide before they started medications, had them after they started, generally in the first weeks of treatment. No child in any study died of suicide, though this is such a rare event that it gets difficult to look at prospectively. Sorry, no links here, I've just heard a bunch of talks. Most recently (meaning last week) I heard Mark Riddle, the Chairman of Child Psychiatry at Johns Hopkins Hospital talk about treating adolescent suicide attempters: he noted that in any given year, 2.9 percent of adolescents have a suicide attempt requiring medical treatment. Think about this, it's a general population number: in a high school of 1000 kids, 29 will have a suicide attempt requiring medical intervention, many more will have suicide gestures and not get help. Completed suicides? 6 to 8 per 100,000 .... a rare event, but given that kiddy death is pretty rare, a significant cause of childhood mortality.

This coming week, the FDA will hear testimony about whether the Black Box warning should also include adults. See: and press the link for the brief if you'd like to read all 140 pages in a pdf file. What will a Black Box warning mean? In my psychiatric practice, I don't think it will mean anything. Many of my patients feel helped by these medications. It may make some patients with depression less willing to try medicines, and more importantly, it may make some primary care docs afraid to prescribe them. I have to wonder why some symptoms get the dreaded Black Box warning and other's don't and why the designation has become so heated. Another post for another day.

So last week, the Archive of General Psychiatry published this
amazing study on a followup of over 15,000 patients in Finland. It included all patients admitted to Finnish hospitals for suicide attempts over a 7 year period (excluding those with psychosis) and followed their future behaviors noting whether or not they took medications and which medications they took. I tried to follow the charts and the data, but it was too confusing and too overwhelming. Please, if anyone out there could follow these statistics, please help me. I was left to just read the results and the conclusions and some of the thinking about it all. This study, however, is terrific in that in includes everyone in the country who attempted suicide, and they tracked whether the patients filled their prescriptions, so they had a fairly good idea of whether the patients were actually taking them.

And the findings? People taking SSRI's/SNRI's (eg effexor) had a markedly higher rate of serious suicide attempts. Now this could be because the people given/ or taking the medications were sicker-- there's not necessarily a cause and effect here. Furthermore people taking SSRI's/SNRI's had a markedly lower rate of both completed suicide and death from cardiovascular disease (Hey, didn't Roy talk about this on our podcast???). Some of the numbers surprised me: in their avg 3.4 year follow up of 15,390 , there were 1583 deaths-- could it be that nearly 10% of their suicidal patients died? 602 were suicides. The average age of their population was just under 39. The protective factor for cardiovascular mortality was huge: 30-40% reduction in deaths.

Other interesting facts: Paroxetine (paxil) was associated with a high mortality among the 10-19 age group with 4 deaths: 1 suicide, 1 drowning, 2 unintentional injuries. Venlafaxine was the only medicine associated with increased risk of suicide and Fluoxetine (prozac) was the only one associated with decreased risk of suicide. And I didn't see bupropion (wellbutrin) mentioned anywhere at all in the article. The strongest predictor of completed suicide was number of past attempts.


Anonymous said...

Most of the data being presented as of late is pointing to the fact that anti-depresants actually CAUSE suicides. Isn't psyciatry and psychiatric meds in somewhat of a state of disrepute?

Sarebear said...

have any of the studies dealt with a factor of, being on meds allows patients to bring up deeper issues than before, and bringing up alot of that sort of thing might be leading to some of this?

Cause I've had that feeling at times, that DANG I'm talking about stuff I wouldn't have even been able to get near before, but can seriously make me want to go outside in the subzero weather, without a coat, and a bunch of xanax to helpme sleep, so's I can die peacefully.

Anyway. Not that I'm in that mood.

But dagnabbit sometimes therapy temporarily makes things harder, and part of that is because the meds allow me to approach t hings that I wouldn't have without.

Dinah said...

To Very Concerned:
There is no data that show that anti-depressants cause suicide. There is some data that show that 1-2 percent of children develop suicidal ideas on the medications. No child in these studies has died of suicide. There is a recent epidemeological study (November, 2006 I think but could be wrong) that in counties with higher SSRI Prescribing, the rates of child suicide are lower (simply looking at pharmacy data versus causes of death).

To Sarebear: None of the studies look at this on that level, and in fact the data point to suicidal ideation in kids (where most of the work has been done) as being a very early occurance-- in the first days to weeks of starting medication-- so probably not about the psychotherapy. Then again, really, no one seems to know what's going on here.

The shrinky concern is that we see patients take these medicines and get better and think gee, if people stop using them, will the rates of suicide due to depression (which we know is a cause of suicide) go UP? Would be interesting if the Finnish study'd included out-patients.

Gerbil said...

My two theories:
1) Antidepressants seem to be particularly effective for people with predominantly vegetative symptoms. So perhaps the relationship between antidepressants and suicide risk is actually mediated by energy levels, i.e., people have fully formed suicide plans even without medication, but lack the wherewithal to follow through until their energy levels increase.

2) Relatedly, I seem to recall a study about 5IAA (sp?) levels in people who've committed suicide by "violent" means vs. non-violent means, plus a comparisons with aggressive and non-aggressive monkeys. However it's abbreviated, it's a precursor to serotonin, and it's associated with aggressive behavior. So perhaps SSRIs not only prevent serotonin reuptake, but also act to increase 5IAA levels to a point where people become more self-aggressive than they would otherwise be.

Happiness is a double-edged sword, I guess.

Anonymous said...

I'm an individual with Bipolar and a long treatment history. I felt suicidal for the first time in 10 years following antidepressant treatment. From my perspective, this side effect was in no way related to my increased energy levels. These thoughts grew from a developing agitated, and extremely hostile psychosis - all symptoms which I had never experienced and were terrifying. These side effects are similar to the positive symptoms of schizophrenia. They are experienced as additional symptoms brought out by the drug, not as existing symptoms exasperated by the drug, or the additional energy derived from the experience. It is likely that many cases of Bipolar Disorder are only triggered by anti-depressant use, causing the high number of suicides/attempts.