Can Black Box Warnings Kill?

I'm going to write about a story I saw on-line about a depressed mother who poisoned her small child. It's a terribly tragic story, and please keep in mind that I only know what I read in the article Here, and I've never examined anyone involved. The question being asked at the trial is that of whether the mother, who was depressed, was legally sane and knew it was wrong to kill her child, and that's not what I'm going to write about. I didn't pick a graphic to go with this blog post, because I couldn't think of any photo that would be appropriate to such an angst-ridden topic.

I'm pulling a few sentences from the newspaper article to use as a springboard for discussion:

They said Sparrow told a nurse practitioner she was considering using sedatives to kill herself, her daughter and her dog, but that medical professional did not contact the authorities or otherwise try to get Sparrow committed to a psychiatric hospital.

After hearing Sparrow had just stopped taking the antidepressant Prozac for fear it was causing the suicidal thoughts, the nurse practitioner let her go home with the instruction to come back if she didn't feel better...

I was struck by two things in the recounting of the story as I read it: that both the patient and the nurse practitioner thought her suicidal thoughts came from the Prozac (and both, perhaps, trusted they would stop with the cessation of the medicine--- obviously I don't know that's what they thought, but it's implied in this particular recounting of the story), and that a homicidal mother was apparently allowed to leave a clinic without being evaluated by a psychiatrist, I think. So my comments are general, because I don't trust a press account to be all-inclusive, and perhaps things transpired that didn't make it in to print.

When Prozac first came on the market, there were some concerns that it made people suicidal, and these concerns were dismissed. With years (oh, more than a decade) researchers revisited this idea and concluded that people under the age of 26 have a low incidence (1-2%) of violent thoughts caused by anti-depressants, and so we have the Black Box Warning about such thoughts. Does all the publicity about how the possibility of suicidal thoughts can arise from the medications narrow peoples' thinking? If we think a medication has caused a suicidal idea, does this prevent people from exploring other options? Perhaps the medication isn't working, or perhaps the depression has gotten worse and has broken through. Perhaps something else has transpired that increases risk. And if the medication is the culprit, what do we know about how long one has to be off it before such violent thoughts stop and the risk is gone? I think the answer is that we don't know.

I don't know if the woman described above saw a doctor the day she was in the clinic, or what exactly she said to the nurse practitioner. I don't know if the outcome would have been any different if she'd been committed to a psychiatric facility. What I do know is that when any story has a tragic ending, it's hard to wonder if more couldn't have been done.

We pass so-called scope-of-practice laws--- should psychologists prescribe? Should nurse-practitioners practice essentially independently? The fuss goes into the legislative battles before-the-fact, one fought primarily by legislators and lobbyists, not clinicians. We don't generally look backwards and ask if poor outcomes are more more likely to occur in settings where we've dropped our standards and we don't seem to ever ask if we should revoke those decisions. I'm not saying we should--- but perhaps we should ask more questions.

Suicide Rates Shoot Up in Youths

Dennis O'Brien reports in today's Baltimore Sun that the suicide rates in children and adolescents have increased since 2004, after over a decade of decreases. It was in 2004 that the US FDA decided to add black box warnings to antidepressants stating that they may increase the risk of suicide or suicidal thoughts. Many speculate that the sudden and dramatic increase is related to the 22% decrease in antidepressant prescriptions in this same population.

As noted in our review of a June 2007 AJP article in Podcast #26 (Black Box Reloaded), there was a 58% drop in the expected number of antidepressant prescriptions for kids after the black box was added, while the proportion of depressed children who remained untreated with antidepressants increased some three-fold, going from 20% to 60% (see dramatic graph). At least at last year's FDA hearing, they decided to make a more measured warning, noting that antidepressant medication treatment can be protective and reduce suicidality, as well.

O'Brien wrote:

Among people ages 10 to 24, the number of suicides jumped from 4,258 to 4,599 in 2004, the most significant rise in teen suicides in 14 years, according to a report by the Centers for Disease Control and Prevention. That reverses a 28 percent slide in suicide rates for the age group that began in 1990.
. . .
"There's been concern that the black box would lead to a reduction in prescribing and therefore an increase in suicides, and my guess is that's what's happening," said Dr. Mark Riddle, director of child and adolescent psychiatry at the Johns Hopkins Children's Center.

Some doctors are reluctant to prescribe an antidepressant to a child if it comes with the FDA's most stringent warning label, Riddle said: "People see it as a potential feeding frenzy for the malpractice lawyers and it's just scared the clinicians off."
. . .
But other outside experts were reluctant to link the black box warnings with a one-year rise in suicides. . . "There are so many social issues that go into suicide rates and how they're reported."

We also reviewed two other articles (Simon & Savarino and Gibbons et al) about the timing of suicide and treatment in Podcast #30 (Parity Feels Like a Bird). These articles point to increased rates of suicide attempts prior to the initiation of either antidepressant or psychotherapeutic treatments.

The September 2007 AJP article by Gibbons et al (a different article than the Gibbons article above) that is mentioned in the Baltimore Sun story provides data on reductions in antidepressant prescriptions by age category since 2004, clearly showing that the reductions are most pronounced in the youngest age groups and become less so with older groups. The only group with an increase in prescription rates is 60 years and older. This is the age group which the FDA has found to be most clearly protected by antidepressant treatment.

The article, entitled "Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," concludes with the following warning:

In December 2006, the FDA’s Psychopharmacologic Drugs Advisory Committee recommended that the black box warning be extended to cover young adults, and in May 2007, the FDA asked drug manufacturers to revise their labels accordingly. If the intent of the pediatric black box warning was to save lives, the warning failed, and in fact it may have had the opposite effect; more children and adolescents have committed suicide since it was introduced. If as a result of extending the black box warning to adults there is a 20% decrease in SSRI prescriptions in the general population, we predict that it will result in 3,040 more suicides (a 10% increase) in 1 year (17). If the FDA’s goal is to ensure that children and adults treated with antidepressants receive adequate follow-up care to better detect and treat emergent suicidal thoughts, the current black box warning is not a useful approach; what should be considered instead is better education and training of physicians.

My Three Shrinks Podcast 26: Black Box Reloaded

[25] . . . [26] . . . [27] . . . [All]

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We again record this podcast in Dinah's backyard, with a guest cardinal who comments throughout the whole thing.

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June 24, 2007: #26 Black Box Reloaded

Topics include:

• Side Effects of Psychotherapy. Sharon Begley from Newsweek wrote an article entitled, "Get Shrunk at Your Own Risk." We discuss this particularly in reference to grief and bereavement, PTSD, and CISD.
  
  
• Discussion at Cheryl Fuller's Jung at Heart about therapy as a treatment for an illness vs. as a tool to improve one's life. And here's an afterthought.
  
  
• The Impact of the FDA's SSRI Black Box on the Decline in Depression Treatment in Kids. We discuss the June 2007 AJP article by Libby et al. showing that there was a 58% drop in expected number of antidepressant prescriptions for this population after the black boxes went up, and that the proportion of depressed children who remained untreated with antidepressants increased some three-fold. Other data has showed an increase in the suicide rate if this population afterwards. In the graph below, the black line represents the percentage of kids with major depression who were prescribed no antidepressant.
  
• Q&A: "In my neck of the woods there is pretty much NO 'talk' therapy in short term inpatient settings. I know of many depressed individuals who have decompensated in these settings, and have had their depression actually increase on their departure. Any thoughts?"
  

The tune at the end is "Advice for the Young at Heart" from Tears for Fears, which you can get for less than a buck at iTunes.

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Things I Wish I Knew

We come to day with day with a list of Shoulds we take at face value (--where would you like me to begin? Don't smoke, don't drink excessively, don't be overweight, exercise, take your meds, ingest enough calcium, don't shoot heroin, stay out of jail, don't quit too many jobs, get your screening colonoscopy at 50, yearly mammograms after 40, wear a condom, sunlight is good, sunlight is bad, sunscreen is good, sunscreen is bad, coffee is good, coffee is bad....) only to have them rethought time and again. Roy is now finally off his HRT or so I'm told, he still doesn't look post-menopausal to me.

A few things I find myself wishing I knew the answers to:

Will my children be damaged by all the video-game playing I allow?
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.

If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?

Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.

Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?

If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?

Why do some people seemed to be unscathed by decades of smoking marijuana?

When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?

If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?

When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?

And what about the patient whose last depressive episode (of many) lasted nearly a year and who has never been able to tolerate lowering her zyprexa, should I stop it given that her risk factors for diabetes and heart disease are screaming in my face (they preceded the zyprexa, but it can't be helping)? How do we know the worst of two evils?

Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?

Sometimes I wish I had a crystal ball that worked, one where I could fine tune it to ask the subtle what-ifs. When it comes to the long-term prognosis for diet Coke and hair chemical abusers, well, there are some things I just don't want to know.

What's Inside the Black Box? FDA Antidepressants Hearing, pt. 2

[posted by Roy]

A couple days ago, I reported on the results of the FDA Psychopharmacologic Drugs Advisory Committee's hearing on December 13, 2006, on the FDA's plan to add a black box warning about the increased risk of suicidality in young adults. (I tried to get this done earlier, but just didn't have the time.)

Here are some notes I made at the hearing...

Sheila Matthews, from AbleChild.org, suggested requiring MedWatch info on all pharmaceutical advertising. I think this is a great idea. MedWatch is the voluntary, side-effect reporting mechanism for the FDA. Few prescribers and fewer consumers use it to report side effects. They should go one further and make it very easy to report side effects... almost as easy as googling the side effects.

There were two out of state attorneys who brought a number of their clients to testify. There were also at least two people there testifying for the Church of Scient ology's C C H R (and making excellent points, I might add, about Lilly's reported lack of following through with their promise 15 years ago to provide additional data. There were quite a few who lost family members tragically after taking only several doses of medication. It is indeed hard to understand how a chemical can cause one to conduct such complex, planned behaviors. Yet, listening to their testimony, it was hard to wonder how their response to these antidepressants could not have contributed to their deaths.

Heidi Bryan, from the Feeling Blue Suicide Prevention Council, pointed out that a big part of the not-enough-follow-up problem was due to the lack of parity for mental health treatment. Even Medicare charges 2-1/2 times as much for co-payments for outpatient mental health diagnoses than they do for the same symptoms caused by non-psychiatric diagnoses (e.g., major depression vs hypothyroidism).

I think that managed care and pharma has so convinced folks that taking a pill is just as effective as talk therapy, that there is now a backlash that will soon require these companies to drop their discriminatory policies.

All of the voting committee members, including Wayne Goodman, Gail Griffith, George Armenteros, Andrew C. Leon, Marcia J. Slattery, Susan K. Schultz, Jean Bronstein, and the chair, Daniel S. Pine, repeatedly pointed out the importance of balancing any labeling changes with language which emphasizes the need to weigh the relative risks of nontreatment with those of treatment, even comparing the risk of treatment with that of non-treatment. In fact, when the vote came up about extending the language in the black box to include the young adults, two members voted against (Griffith and Pines), while the other six voted for it under the condition that balancing language be included as well. They told the FDA that they wanted to review the draft language prior to making a final decision.

Joe Glenmullen, who authored "Prozac Backlash", testified, as well. He and others state the the FDA has been tricked by the drug companies, by not being given complete information about all clinical trial results.

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So, then the committee deliberated for a few hours. I must say, the committee members rather awkwardly, but repeatedly, made several important points...

• The FDA needs to make the drug companies collect and provide better data.
  
• There is inadequate data on this "activation syndrome", referring to akathisia, agitation, and anxiety apparently induced by antidepressants in some individuals.
• Collecting pharmacogenetic data might help in determining which individuals might be at higher risk of developing this and other side effects.
• The FDA is not collecting adequate data to differentiate between suicidal thoughts and suicidal behaviors and attempts. The pharmaceutical companies need to be directed to supply this type of fine-grained data. The fact that the currently reviewed data on "suicidality" makes it impossible to differentiate these two important characteristics suggests that any change in warning language needs to be carefully worded.
• The committee insisted on the FDA adding balancing language to reflect not only the increased risk of "suicidality" in young adults, but also the other side of the coin -- the increased risk associated with untreated depression. Additionally, they'd like language which refers to the apparent protective effect of these drugs in older adults, especially in seniors. It was noted that this would be the first time that the FDA has included in a black box information of a positive nature.
• They are concerned about the unintended consequences of decreased access to depression treatment as a result of the black box warning. Recent CDC information was noted, indicating that since the 2004 pediatric black box was added, prescriptions in kids are down, while suicides are up. This trend has already been noted in adults, and the fear is that it will only get worse with language that extends to young adults.
• The "25 to 30 year old" group mentioned in Part 1 was not chosen scientifically. It just fit the data. Thus, there is nothing special that happens when you turn 25 or when you turn 31to alter your risk. Because of this, they considered instead using language like "young adults", but this idea didn't seem to be too popular.
• Some of the possible explanations discussed for the biphasic nature of the data (higher risk when younger, lower risk when older) included induction of mania, late maturation of frontal lobes so impulsivity and experience improve as you get older, and greater tolerance for uncomfortable affect with age. They agreed that more data would be helpful.
• The committee also felt it was very important to emphasize the need for close follow-up when treating people of any age with depression. There was concern that it could sound like older people don't need to be followed as closely due to this "protective effect".
  
• Finally, the FDA acknowledged concern about telling doctors how to practice, and crossing the line into federal regulation of the practice of medicine. However, it was pointed out that, when the stakes are high enough, as with clozapine, the FDA has had no trouble advising things like frequency of monitoring lab tests. Telling prescribers that people with depression starting antidepressants should be followed at least weekly at first should be no different. Hopefully, they won't wimp out.

I'll leave you with two good quotes.

"Maybe we don't need a black box on antidepressants. Maybe we need a black box on Depression."

"How many will die with the black box? How many will die without it?"

technorati tags:FDA, depression, hearing, PDAC, antidepressants, suicide, suicidality, SSRIs, psychiatry, psychiatric, medication

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FDA Hearing on Antidepressants, Depression, and Suicide

[Posted by Roy]

I attended yesterday's hearing, missing the FDA's presentation in the morning, but arriving for the public comments part and the afternoon deliberations. (Check out the FDA's 150-page .pdf testimony.) I was also among the 75 people who provided testimony to the committee. The meeting lasted a total of 9.5 hours!

This is the first time I've been to an FDA Advisory Committee meeting. These are public meetings (required to be public, by law) in which the committee members discuss the issues and make decisions. The FDA presents data to them; in this case, it was data from numerous clinical trials solicited from big pharma to especially get at the question of induction of suicidal thoughts or behaviors by antidepressant medications. After the committee hears these data, they listen to public testimony. After that, they discuss what they heard, and respond to the FDA's recommendations in the form of support, opposition, or other recommendations.

The committee is advisory in nature, meaning that the FDA takes what they say into consideration, but is not bound by their recommendations. The FDA does typically follow their recommendations. Three of the committee members could not vote due to conflicts of interest (receiving industry funds for clinical research and such).

In this post, I will first cut to the chase and tell you what the committee's recommendations were. In a second post, I'll give you more details to flesh out some of the discussion points and concerns that the committee raised, and also discuss the public testimony, some of it being very gut-wrenching and impassioned.

If I had to choose one image that best describes the entire hearing, it is the one above.

What this demonstrates is that as age goes up, the relative risk of suicidal thoughts or behavior goes down. The numbers plotted are the Odds Ratios... meaning that, compared to the folks taking placebo, what are the odds that those taking antidepressants are likely to have either thoughts of suicide or actual suicidal behavior. So, an O.R.=1 means that the chances are the same, which means no difference. An O.R.=2 means your chance is doubled. An O.R.=0.5 means your chance is halved. The black square is the estimated O.R., and the gray bar represents the 95% Confidence Interval... meaning that the statistical probability of the true O.R. being within the gray bar is 95%. Thus, if the gray bar touches 1 (the vertical dashed line), then the two groups (placebo and medication) are NOT statistically significant. If they do not touch 1, then they ARE statistically significant. Got it? To put it most simply, left of the dashed line is good, right of the line is bad.

So, the pediatric Odds Ratio does not include 1; this result supports the decision made in 2004 to add a black box warning that says these medications are associated with an increase in suicidal thoughts or behavior. (As it turns out, it is just thoughts, not behavior, but I'll address that in the second post.)

The 18-24 year-old Odds Ratio does include 1 (0.91-2.70), thus we cannot say that there is an increased risk.

The 31-64 year-old Odds Ratio just includes 1, but the estimated O.R. is less than 1, meaning that we cannot say there is a decreased risk, but there almost is.

For the over 65 group, there is clearly a significantly decreased risk of suicidal thoughts or behaviors. Note that these appear to be rare events... 12 people out of 3227 taking medication, and 24 out of 2397 taking placebo reported suicidal thoughts or behaviors. Hard to believe that only 1% of people with major depression had suicidal thoughts, huh?

Okay, so here is what the committee decided:

1. There is a clear relationship between age and suicidal thoughts or behaviors in people taking antidepressants.


2. Keep the black box warning that currently exists, but be very cautious about discouraging depression treatment and attempt to include balancing language that states that the risk of suicidal thoughts or behaviors when not taking medications should be considered. (They do not have data that tells them what that number is.)


3. Encourage careful monitoring of all people being treated for depression.


4. Extend language in the black box to indicate that the increased risk of suicidal thoughts or behaviors extends to around age 25, where it starts to drop off and become a decreased risk in the 30's and up.


5. Encourage collection of data on the "activation syndrome" that some people get when taking antidepressant medications, especially SSRI's.


6. Encourage collection of data which differentiates between suicidal thoughts and suicidal behaviors.

More later this evening.

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: http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-index.htm 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.

My Three Shrinks Podcast 2: Roots

[1] . . . [2] . . . [3] . . . [All]

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We'd like to thank our readers and listeners for your kind comments and suggestions about our first podcast. This one's a bit longer, at about 33 minutes. I think we'll get better about the time. About 20 minutes seems to be a good balance.

This is actually the second half of the original podcast, which went long so we sliced it into two podcasts. Don't expect to get a podcast every other day... if we do one every other week, I'll be pleasantly surprised (though I'm striving for every Sunday). Maybe we can be like Digg's Kevin Rose and Alex Albrecht and drink alcohol at the beginning of each podcast... that would be interesting.
Here are the show notes for the podcast:

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December 10, 2006: Roots

Topics include:

• Dr Anonymous is again not mentioned in this podcast (but we do thank him for the idea about the musical bumpers between topics)
• Thorazine Immunity: Clink reviews a 1992 case in which a prisoner sued the on-call psychiatrist for involuntarily medicating him with chlorpromazine due to violent, self-injurious behavior... but without going through any hearing panels for forced meds [Federal Code: Civil action for deprivation of rights]
  
• Dinah brings a duck to the "Shrink Rap Studio" (my kitchen table)
• FDA hearing on December 13 about adding a black boxed warning on antidepressant labels about the possibility of increased suicidality in adults: Will this reduce access to these drugs, causing undertreatment of depression and actually INCREASE suicide rates? (Check here for background materials)
• Recent PubMed articles and Corpus Callosum post about this whole antidepressants and suicide issue. Also, Dinah mentioned this, hot-off-the-press, Finnish article, showing an increase risk of attempts and a decreased risk of deaths.
  
• Treatment of social phobia [PubMed]
• Social phobia and alcohol [PubMed]
• Paxil- and other SSRI-related withdrawal symptoms [PubMed]
• Sexual dysfunction and SSRIs [PubMed]
• Putting roots on someone
• Psilocybin mushrooms for Monk's OCD
• Maryland psychologists discuss adoptions in gay marriages
• NYT: Gender dysphoric children
  

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This podcast is available on iTunes. You can also download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

technorati tags:thorazine, podcast, shrinkrap, civil, rights, duck, SSRI, antidepressants, suicide, depression, black, box, FDA, hearing, Paxil, Prozac, gay, marriage, adoption, gender, psychologist, psychiatrist, psychiatry, blog

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