Can antidepressants CAUSE suicidal tendencies?

[Wyvern]

On Monday, the FDA issued an advisory urging doctors to watch for worsening depression or suicidal thoughts in patients who take any of 10 antidepressants. The FDA advises that patients be monitored especially at the beginning of treatment
or whenever the antidepressant dose is changed.

There does not appear to be sufficient evidence to support such an advisory. The FDA itself admits that they don't know that these drugs are responsible for the behavioral changes indicated in the advisory. I'm wondering if the FDA assumed a cause and effect relationship that doesn't actually exist, or that they have the cause and effect reversed. For example, a change in the behaviors indicated will often prompt the use, or change in dosage, of one or more of these drugs. There is also quite a lag time for these drugs to take effect. It is, therefore, no surprise that these tendencies occur in some patients upon beginning a course of these medications. In addition, many people begin participating in in-depth psychotherapy concurrently with a change in medication, thus making them more vulnerable to their emotions around the same time.

I suspect that liability concerns alone prompted this advisory. My fear is that people will discontinue their medications (although the FDA recommends against doing so) and that others will not get the help they need because of a fear caused by this advisory.


http://content.health.msn.com/content/article/84/98068.htm

March 22, 2004 -- The FDA is issuing a warning about the possibility of worsening depression or suicidal thoughts in people, particularly children, who take any of 10 popular antidepressants, especially at the beginning of treatment or when the doses are increased or decreased.

The FDA has sent a letter to drug manufacturers requesting labeling changes on these antidepressants -- warning of possible suicide, worsening depression, anxiety, and panic attacks in adults and children.

Antidepressants involved in this warning label request are:

Prozac (also sold generically as fluoxetine)
Zoloft
Paxil
Luvox
Celexa
Lexapro
Wellbutrin
Effexor
Serzone
Remeron

"We don't know that the drugs are responsible for these behavioral changes, but nonetheless we're telling physicians and families to be aware of this and that if the behaviors do emerge, to get treatment right away," said Russell Katz, a director with the FDA's Center for Drug Evaluation and Research, in a news teleconference today.

. . . and this:

The FDA has been closely reviewing studies of antidepressants in children for the past year after an initial report on studies of Paxil and other drugs suggested an increased risk of suicidal thoughts in children given antidepressants. No suicides occurred in any of the trials, the FDA reports.

The analysis has involved 25 controlled trials with 4,000 children taking antidepressants, said Katz. "Those reviews are ongoing."

Today's action "arose from an unexpected observation in some studies of an apparent excess of emotionability, a catch-all term ... that includes suicidal [thoughts]," said Robert Temple, MD, the FDA's director of medical policy.

However, closer examination has shown that the accounts are unclear -- whether certain behaviors reported were actual suicide attempts or other self-injurious behavior that was not suicide-related.

"As we've gone into the studies in detail, it's become evident that the terms used were highly varied and [the studies] not very well done," Temple said.

Another article for your information:

http://content.health.msn.com/content/article/84/98069.htm

 

[Khonshu]

Generally, someone in the deepest throes of manic depression won't be suicidal. They simply don't have the energy. Now, when they start their recovery & begin to feel a little more "normal", then the suicidal tendencies may appear.

So, the suicidal tendency may be indirectly related to the recovery that the medicines help produce.

 

[Wrath of the Swarm]

No, we're already familiar with the "activation" problems of antidepressants. It has been claimed that seemingly non-suicidal people have suddenly killed themselves after beginning treatment with these drugs - thus supposedly causing them to become that way.

 

[Khonshu]

Reading back, I wasn't clear - the suicidal tendencies don't just "appear" from nowhere, they just tend to surface as recovery begins. Suicidal feelings don't generally just appear, there's usually a buildup before suicide is actually attempted. As the depressed individual begins to feel better, their desire/motivation for action returns - for better and/or for worse.

There is no evidence that antidepressants cause suicidal tendencies, but suicide tends to occur during the early recovery phases - which is usually shortly after medication begins. So it certainly LOOKS kinda causational, but there's no evidence of causation, just that the timing tends to coincide. People recovering from depression and suddenly committing suicide is nothing new.

If you are feeling suicidal and suffering from depression, please let your doctor know what you are feeling - if they don't know, they certainly can't help...

 

[Wrath of the Swarm]

You were perfectly clear. The anecdotes that induced the FDA to put out this warning involved depressed but not previously suicidal people who unexpectedly killed themselves after beginning antidepressant treatment. Your objections are not relevant.

 

[Suezoled]

You were perfectly clear. The anecdotes that induced the FDA to put out this warning involved depressed but not previously suicidal people who unexpectedly killed themselves after beginning antidepressant treatment. Your objections are not relevant.

Not suicidal? Or did not voice suicidal ideology? Were not known to be suicidal? While some anti-depressants have been, anecdotally, known to make a patient feel worse, it has also been conjectured that an anti-depressant lessens the depression to the point where the patient can function enough to commit suicide.

 

[Wrath of the Swarm]

Yes, so people in severe depressions are watched carefully when prescibed antidepressants in case the activating effects of the drugs make it easier for them to attempt suicide.

The anecdotal cases did not involve people that seriously depressed. C'mon, think, people!

 

[Suezoled]

Yes, so people in severe depressions are watched carefully when prescibed antidepressants in case the activating effects of the drugs make it easier for them to attempt suicide.

The anecdotal cases did not involve people that seriously depressed. C'mon, think, people!

No, they are not always. And yes, anecdotal did involved cases that were seriously depressed. I am citing my own anecdotal cases when I volunteered.

 

[Khonshu]

I wasn't aware I was objecting to anything - my intent was to clarify an earlier statement.

I would have to agree with Suezoled - the seriously depressed are not always monitored that closely, if that's even possible. There is still a stigma about talking about mental health issues, even to a professional.

Is an FDA advisory to physicians such a bad thing? It seems to amount to a "heads up" notice telling physicians to be aware of possible - although admittedly unproven - effects related to either the medication or the conditions it is prescribed for.

A larger issue, I think, is whether GP's should be able to prescribe such medications with little training in the field of psychology. It seems to make about as much sense to go to a general practioner for a severe bout of depression as it does to go to a psychologist for a knee injury.

 

[Wrath of the Swarm]

The anecdotal reports that have caused the FDA so much concern are the ones that suggest mildly-depressed non-suicidal people suddenly became suicidal with little warning. It would be difficult to show that more seriously depressed people became suicidal after they began taking a particular antidepressant.

It makes as much sense to go to a psychologist for a broken knee as it does to go to a psychologist for a mental disorder.

 

[Suezoled]

The anecdotal reports that have caused the FDA so much concern are the ones that suggest mildly-depressed non-suicidal people suddenly became suicidal with little warning. It would be difficult to show that more seriously depressed people became suicidal after they began taking a particular antidepressant.

It makes as much sense to go to a psychologist for a broken knee as it does to go to a psychologist for a mental disorder.

are you quoting the MSN source?

"We don't know that the drugs are responsible for these behavioral changes, but nonetheless we're telling physicians and families to be aware of this and that if the behaviors do emerge, to get treatment right away,"

and

However, closer examination has shown that the accounts are unclear -- whether certain behaviors reported were actual suicide attempts or other self-injurious behavior that was not suicide-related.


"As we've gone into the studies in detail, it's become evident that the terms used were highly varied and [the studies] not very well done," Temple said.

are tentative speculation.

 

[Wrath of the Swarm]

People have been suggesting that some antidepressants might be associated with the sudden onset of suicidal ideology for years now. The latest bursts have been given the most attention because they involved teenagers and young adults who weren't considered at risk for suicide.

 

[Hellbound]

People have been suggesting that some antidepressants might be associated with the sudden onset of suicidal ideology for years now. The latest bursts have been given the most attention because they involved teenagers and young adults who weren't considered at risk for suicide.

Just to pipe in my two cents here (refunds available), I think the majority of teenagers are at risk of suicide, just because of the changes they're going through at the time. In fact, suicide (or at least attempts and contemplation of suicide) tends to be higher during these years. I do believe most people tend to blow off a lot of teenage ansgt, but what we often forget is that, for example, the fear and shame of wearing unknown label clothes when everyone else has name brand is as serious to the teenager as losing a job might be to an adult. They may have a time link between medication and suicide, but I think it would be more informative to compare rates of suicide between the medicated group and the population at large. Not to say there isn't an effect, just that this is an extremely tenative link.

Now, as for these studies not being done on severely depressed people, I have to disagree. Drugs are generally not described for mild depression, because therapy and support works well without the risk of addiction or side effects these drugs bring. If they are taking some of these antidepressants, it is a moderate to serious case. It may be a case without suicidal thoughts, but these tend to come later in depression in any case (at least in my experience). And the patients are not generally monitored, except possible by close family/friends (if the patient has informed any of them of his/her troubles). I was treated for depression at the beginning of this last military deployment; even there where my confidentiality ends as the outside of my skull, no one in my chain of command was notified of my issues, except by me.

Basically, I'm, not saying there isn't a link. I think the warning is useful because depressed patients should be monitored a bit closer anyway, because these things can develop. However, as to drawing ANY sort of casual link between the drugs and the suicidal tendencies, there simply is not nearly enough information to make any sort of rational judgement on the matter. It does, however, suggest there might be something to look into. I'd imagine, however, that in ANY case this would be hard to prove: there are literally millions of factors affecting our psychology and mood daily, there are too many variables at work, there's no good, accurate objective way to measure depression level or the level of suicidal thoughts, the effect seems to occur in a very small (relative to the total) number of patients, etc. I don't think there'll be any definitive answer on this for at least a year, more possibly three to five.

 

[Suezoled]

People have been suggesting that some antidepressants might be associated with the sudden onset of suicidal ideology for years now. The latest bursts have been given the most attention because they involved teenagers and young adults who weren't considered at risk for suicide.

In a crude analogy, just as selective serotonin reuptake inhibitors don't make a person's brain secrete the "right amount of chemical" like serotonin, they only help the brain better utilize what it available, they have not necessarily been found to create suicidcal ideology. SSRI's cannot work with what is not there. An incorrect dosage could trigger this, as mental difficulty would override ability to cope.

It's terribly hard to tell who is and who is not at risk for suicide, as people already hold a knee-jerk stimga (in the US anyway) about suicide, even going so far as to blame the victim. Is it small wonder people who admit depression will lie about how suicidal they feel?

 

[Wrath of the Swarm]

Now, as for these studies not being done on severely depressed people, I have to disagree. Drugs are generally not described for mild depression, because therapy and support works well without the risk of addiction or side effects these drugs bring.

Antidepressants are not generally prescribed for subclinical depression, but not because they carry a risk of addiction. (In actuality, that's a half-truth: they are habit-forming, just not addictive.)

If they are taking some of these antidepressants, it is a moderate to serious case.

I think you're underestimating the degree to which antidepressants are overprescribed.

Suezoled: I don't have time for this now. I'll start a thread dealing with your inaccurate representation of antidepressants' method of action later.

 

[epepke]

It's quite dangerous to give manic-depressives unopposed antidepressants, because it can trigger a manic state.

Manic states aren't usually associated with suicidal behavior, but they are often associated with self-destructive behavior. This can lead to death, and since the person is doing it, perhaps that gets called suicidal as well.

It would depend on the character of what's called suicide. I would doubt claims of antidepressants leading the overdose-of-downers-and-wine kind suicide more than the leaping-off-a-bridge kind of suicide.

 

[Dancing David]

The risk of acting on suicide does rise dramaticaly after the start of treatment with ADs although I have never seen a study that says the same for talk treatment.

In the old days the risk with tricyclics was severe because they have a high toxcicity, and therefore Prozac and the others were perscribed when there was a high risk of suicide, to not make a toxic medication available.

This leads to a high coorpelation between SSRIs and suicide.

The highest coorelation is with gun ownership.(Because they are lethal more than many other means)

 

[Eos of the Eons]

Oh bother, it's just like the argument that says all people who get cancer therapy have cancer 'tendencies'. Or saying people who take ritalin get ADHD 'tendencies'.

I've been on Zoloft, Celexa, and now Wellbutrin. On the meds I was definitely less suicidal. Wellbutrin is the most awesome stuff on the planet, and haven't had suicidal tendencies in years.

I went off for a few months, and I felt like I did before. Well, I felt like that for 15 years, so you can hardly blame taking Anti-depressants for only 2 years on any of my depression while on medication or not.


From the article:

The warning signs are the same as the warning signs in depressed people not taking antidepressants

Well, then common sense says try a different med or dose since that one obviously isn't working. Duh.

Even on meds you can reach a point where it stops working as well because of increased stress or whatever. Once the stress goes down, you get better.

Need more proof before blaming the medicine for the problem you had before taking it.

 

[BillyJoe]

As a matter of interest, the Australian medical authorities (sorry, forget who they are) have rejected the FDA statement and say there is no evidence to support the view that antidepressants increase the risk of suicide in children and adolescents.