Congress: Antidepressants and Suicide

[Dancing David]

Congressional hearings are occuring concerning the risk of suicide and antidepressants. Much anecdotal evidence is being presented. And of course the alleged link of the alleged lack of a link between suicide and antidepressants.

First off : nomenclature!
[nomenclature]
Suicidal tendancies do not exist! It is a very inaccurate picture of what happens. There are no suicidal tendencies in clinical pseech and you will get chewed out in clinical review if you say it.

Suicidal ideation : thought of the act of ending ones life.
The thought 'I wish I was dead' is not suicidal ideation, it is a thought stating a number of thinsg, which needs to be investigated carefully in assesment. That thought usualy means the person has pain that they want to stop. It is a low risk thought, but follow up needs to be done.
The thought 'I should kill myself' is suicidal ideation, it always needs to be followed up and a safety plan set in place.
The thought'I should kill myself by taking a knife and stabbing myself' is suicidal ideation with a plan. A very dangerous situation, and needing a safety plan or intervention.
There is current suicidal ideation, as in having the thoughts in the moment. Then there is past or recent suicidal ideation. Also a risky situation depending on the time frame, rate of occurance and severity of the plan.

Suicide plan any plan to end one's life. A means to end one's life being considered.

Suicidal intent stated intention of taking one's life.

Suicide attempt any act made by a person that they feel may end thier life.

Often people will call the statement "I wish I was dead" a suicidal statement, this is not accurate, although it should be followed up on.
The use of the phrase 'suicidal tendancies' is inaccurate and misleading, it does not state thoughts, plans, acts and intent.
[/nomenclature]

There are many things in the media right now wehere ppeople quote other people saying things about 'antidepressants causing suicide' or 'causing suicidal tendancies'.

I am saying that these statements need to be examined criticaly and carefuly, in some population antidepressants may increase thoughts of suicide. But one can not assume causality just because someone says so.

1. Antidepressants are perscribed to depressed people. Many of whom have already expressed suicidal ideation. There is an association between ADs and suicide, but it may be acorrelative, like diabetes and insulin medication.

2. ADs defintily increase the risk that someone will act upon suicidal ideation. If a person is depressed and has low energy and low motivation and has suicidal ideation, they lack the energy and motivation , at times, to act upon the thought. You begin to treat them with ADs and they get more nergy and more motivation, they have a bad day and they are now more likely to act upon the suicidal ideation.

3. There are a number of risk factors when assesing someone for depression and suicide risk. Very often there are mood altering substances involved in a person's life. People are often not truthful during assesment about thier subsatnce abuse and use. In the ED people will deny any alocohol or dreug use until you tell them the test results. Even then some will contnue to deny substance abuse.

So the ball is in the air, there are people who say that ADs caused their family member to kill themselves, and they are very heartwrenching to hear. But criticaly there are a couple questions that need to be asked:

a. Is it accurate to say that this person did not have suicidal ideation prior to taking ADs? What baseline is there and how valid is it?
b. Are there any substances being abused and used by this individual?
c. Is there any psychosis?
d. Is there any sociopathy involved?
e. Are there past suicide attempts and ideation?

In other words, what was the baseline risk prior to the individual being exposed to ADs?

When comparing a statisticsl sa,[ple, you can not compare it to the attempted suicide rate in the general population, that would be skewing the results, you have to copare it to the population of people seeking mental health treatment, or is the diagnosis is available, to the attempted suicide rate in the population with that diagnosis.

People living with schizophrenia commit suicide at a lifetime rate between 16% and 20%, we can not say that this is caused by the use of anti-psychotics.


On the other hand:
a. Any psychotropic drug should be monitored carefully during the first two weeks of treatment and for the following three months.
b. Children and young adults should have therapy before they are perscribed medication.
c. There are severe side effects to most psychotropic medication, monitoring during the begining of treatment is crucial.
d. Substance abuse can not be tolerated during the perscription of psychotropics.
e. Assesment needs to be careful and ongoing, misdiagnosis is common and careful monitoring is needed in the beggining of treatment.

There is a distinct effect that ADs increase suicide risk, that needs to be explained to the patients and a safety plan put in place.

 

[Solus]

I've heard antidepressants can possibily increase the risk of suicide in teens but that's about it. I wish congress would just butt out of this issue, all they can do is mess things up for the rest of us.

I'll tell you what would cause suicide, denying antidepressant medication to people who need it. Although other end of the spectrum sometimes antidepressants are over prescribed to people who don't really need them. There is difference between the mental illness depression and feeling the blues. Most people are woefully ignorant when it comes to mental health issues.

The real question to ask is would those people still have commited suicide without taking antidepressiants.

Bottom line just stay away from my MAOIs congress.

 

[Crazycowbob]

I/my family have had a very recent experience with this. My father had gone to the doctor regarding feeling depressed lately. The doctor made the diagnosis and prescribed an antidepressant (I'll have to ask what it is, I'll update later). Soon after he started taking them, his depression became far more severe, to the point of him at times wanting to kill himself/others. He has never shown any desire to end his life previously, quite the opposite, he has battled through several severe diseases and shown a strong desire to survive. The doctor quickly switched him to a different antidepressant, and he's doing very well now.

I know it's only anectdotal evidence, but I think it shows a very strong correlation between the antidepressant and the situation becoming worse.

That said, the occurance is very, very rare, and it doesn't mean someone should give up on antidepressants completely. As stated in the OP, it just means that when being given a new medication, it is very important to watch for behaviorial changes and catch them quickly, so corrective action can be taken. After all, antidepressants are helping my father greatly, we just had a bad experience with one that was, fortunately, caught.

 

[drkitten]

The real question to ask is would those people still have commited suicide without taking antidepressiants.

Many of them would not. Just as some people die in hospital as a result of a botched appendectomy, but that doesn't make appendectomy less appropriate as a treatment. It's simply a recognition that any treatment comes with risks.

As the OP pointed out, many people with suicidal ideation are too depressed to make or carry out plans, they probably won't kill themselves. GIving them more energy and motivation can open a window during which they should be carefully watched....

 

[Katana]

Many of them would not. Just as some people die in hospital as a result of a botched appendectomy, but that doesn't make appendectomy less appropriate as a treatment. It's simply a recognition that any treatment comes with risks.

As the OP pointed out, many people with suicidal ideation are too depressed to make or carry out plans, they probably won't kill themselves. GIving them more energy and motivation can open a window during which they should be carefully watched....

This is true, but we knew this a long time ago. Why is it making news now?

 

[drkitten]

This is true, but we knew this a long time ago. Why is it making news now?

Because if you don't give the press shiny toys to distract them, they ask inconvenient questions about other subjects.

 

[Katana]

Because if you don't give the press shiny toys to distract them, they ask inconvenient questions about other subjects.

 

[supercorgi]

Bottom line just stay away from my MAOIs congress.

Whoa, you're still taking MAOIs? Of all the anti-depressents that they've tried on me, the only ones that ever worked were MAOIs and Prozac. Was I happy when Prozac came along - I could eat bananas and aged cheeses again!

I don't think you need to worry about someone outlawing MAOIs since they've been around so long. If they'd been going to pull those meds, they would have pulled them due to the deaths that occurred before the tyramine connection was figured out. It seems like it's some of the newer drugs that are under attack.

 

[ChristineR]

Here's how my doc explained it to me. This may or may not be accurate, but it does make sense.

Antidepressants take at least a few weeks to work. In the meantime, they may increase agitation and energy without actually decreasing depression. In fact, they may never do anything positive. During this time, the risk of suicide (and other extreme behaviors) is increased.

Persons who are prone to bipolar disorder may have a manic phase triggered by the antidepressants. This can happen in people who have never had a manic episode before, and will never again have one again once they get off the antidepressants. Manic people can do all sorts of unhappy things, like deciding that they can fly and proving it by jumping off a roof.

Any antidepressant can cause these problems, and it may or may not be the case that the newer ones (notably Prozac) cause them more often. What can be said about the newer antidepressants is that they are safe. Thirty tablets of a tricyclic like Desipramine will kill you. People have taken thousands of Prozac capsules and walked away with seizures and very bad diarrhea.

Because of this, depression until fairly recently was almost always treated in a hospital. The nurses gave out one pill at a time and checked under patients tongues. If the patient was still dangerously depressed after a few weeks, or had a manic episode, they'd just try something else.

IMHO the real problem is the tendency of drug companies to recommend antidepressants for everyone from babies to dogs, and the tendency of insurance companies to require GPs to prescribe them to everyone who presents with even the possibility of depression. Even though this won't help many of these people, it won't hurt them much either. It's that very small group that actually get worse that are paying the price.

 

[Dancing David]

I/my family have had a very recent experience with this. My father had gone to the doctor regarding feeling depressed lately. The doctor made the diagnosis and prescribed an antidepressant (I'll have to ask what it is, I'll update later). Soon after he started taking them, his depression became far more severe, to the point of him at times wanting to kill himself/others. He has never shown any desire to end his life previously, quite the opposite, he has battled through several severe diseases and shown a strong desire to survive. The doctor quickly switched him to a different antidepressant, and he's doing very well now.

I know it's only anectdotal evidence, but I think it shows a very strong correlation between the antidepressant and the situation becoming worse.

That said, the occurance is very, very rare, and it doesn't mean someone should give up on antidepressants completely. As stated in the OP, it just means that when being given a new medication, it is very important to watch for behaviorial changes and catch them quickly, so corrective action can be taken. After all, antidepressants are helping my father greatly, we just had a bad experience with one that was, fortunately, caught.

Yow, that is a really bad reaction, I have read the literature in the past, usualy they can make people anxious or sedated.I will have to read the recent reveiw literature.But more depressed, ouch.

 

[Dancing David]

This is true, but we knew this a long time ago. Why is it making news now?

Apparently during the Lilly trial there was 'supression of evidence' or something like that. I googled Lilly suicide and got a lot of hits all related top the same report. And then there were Congressional Hearings this week.

 

[skeptifem]

A Lilly document dated from March of that year even quantifies the problem, suggesting a rate of suicide for Prozac 5.6 times higher than for the antidepressants that were popular before the rise of the SSRIs -- the tricyclics. "The benefits vs. risks considerations for fluoxetine [Prozac] currently does not fall clearly in favor of the benefits," the document concludes. By 1986, clinical-trial studies comparing Prozac with other antidepressants showed a rate of 12.5 suicides per 1,000 users compared to only 3.8 per 1,000 on older, non-SSRI antidepressants, and 2.5 per 1,000 on placebos.

I posted this before but got no replies.

http://www.suicidereferencelibrary.com/test4~id~1002.php

also, I do not think its safe to say that all the people prescribed ssris are depressed. Ssris are dished out like candy for all kinds of issues including anxiety.

 

[Dancing David]

Thanks nials!

Although you should cite your source to bolster your arguments, most people won't read links.

I agree that any SSRI and any psychotropic should be perscribed with care and monitoring, and a lenthy substance abuse assesments.

From your source, just the opening, not the last 3/4s

Twenty volunteers with no history of psychiatric problems were recruited, half of whom were given the drug Zoloft, an antidepressant from the Prozac family of drugs known as the SSRIs, or "selective serotonin reuptake inhibitors."
…
And the rate of 10 percent made it clear that such results were not so rare as to be incidental.

This is just , um, some sort of assertion, twnty people is avery small sample. And should the effcets of perscribing to healthy people a drug be ascribed to depressed people. I think that would be a great longitudinal study!

But the 10% is bogus, and it makes no mention of methodology.

There he discovered an unpublished study from the 1980s in which healthy female volunteers were given either Zoloft or a placebo. The study was canceled four days later, after all those taking Zoloft began complaining of agitation and apprehension. Healy's case was not so bad; in fact, some of his volunteers rated Zoloft positively.

And again no methodology, how were the volunteers chosen, what were the doses.
Side effects yes, but no methodology. I would expect people with normal brains to have severe problems with an SSRI

…
the case of William Forsyth.
…

Anecdotal, no longitudinal base line.

Minutes from Lilly's Prozac project team in that year noted, "Some patients have converted from severe depression to agitation within a few days; in one case the agitation was marked and the patient had to be taken off [the] drug ... There have been a fairly large number of reports of adverse reactions." As the Forsyth case and others would go on to show, Lilly's internal records revealed considerable awareness within the company. A letter sent to it from the British Committee on Safety of Medicines in 1984 reads: "During the treatment with [Prozac] 16 suicide attempts were made, two of these with success.
As patients with a risk of suicide were excluded from the studies, it is probable that this high proportion can be attributed to an action of the preparation."

And again no methodlogy, what were the sample sizes , how did they asses suicide risk, what was the history like?
A conclusion without the data. We don't knwo what part of the paper it came from. I am not excusing Lilly BTW, but we need more data.

Similar concern was expressed by German authorities in 1985, where Prozac is sold as "Fluctin," and with required warnings of possible akathisia and suicide.
A Lilly document dated from March of that year even quantifies the problem, suggesting a rate of suicide for Prozac 5.6 times higher than for the antidepressants that were popular before the rise of the SSRIs -- the tricyclics.

And the sample is matched , how? You don't perscribe tricyclics to people having suicidal ideation because of the lethality, unless they are in a controlled enviroment.

"The benefits vs. risks considerations for fluoxetine [Prozac] currently does not fall clearly in favor of the benefits," the document concludes. By 1986, clinical-trial studies comparing Prozac with other antidepressants showed a rate of 12.5 suicides per 1,000 users compared to only 3.8 per 1,000 on older, non-SSRI antidepressants, and 2.5 per 1,000 on placebos.

Same concern, if TCA are not perscribed to people expressing suicidal ideation, except in a controlled enviroment, then there is no sample control to compare base rates.

In 1990, a report appeared in the American Journal of Psychiatry on the "Emergence of Intense Suicidal Preoccupation During Fluoxetine Treatment." Two Harvard psychiatrists and a registered nurse described cases in which patients developed serious preoccupations with suicide soon after being given Prozac. "We were especially surprised to witness the emergence of intense, obsessive, and violent suicidal thoughts in these patients," they commented.

Anecdotal, and likely very true, SSRI should not be percribed without careful instructions and monitoring. But they also don't give a baseline or history of the pateints, like diagnosis.

Two years later, in July 1992, another article appeared, this time in the Archives of General Psychiatry. Again, the article had two senior researchers among its authors, one of whom was a leading expert on akathisia. The psychiatrists stressed in the report that, prior to going on Prozac, none of their patients had a history of significant suicidal behavior.

That is an anecdotal statement, it might or might not be true, that is why history is imporatant, how do they define 'significant' what data were used.

"All described their distress [while on Prozac] as an intense and novel somatic-emotional state; all reported an urge to pace that paralleled the intensity of the distress; all experienced suicidal thoughts at the peak of their restless agitation; and all experienced a remission of their agitation, restlessness, pacing urge, and suicidality after the fluoxetine [Prozac] was discontinued."

And that is very dangerous, if you haven't seen akesthesia it is horrible, it is like a panic attack combined with a crawling sensation of the skin. It varies but most people describe it as miserable.

So again, you should monitor someone on a SSRI very carefully and give them intructions about what to do if X, Y or Z happens.

Do most psychiatrists do this, maybe. Do most doctors do this, probably not.

The finding that these problems emerge soon after an SSRI drug is taken, and then disappear soon after the drug is withdrawn, provides compelling evidence that the problem is often the drug and not, as the makers of SSRIs have insisted, the depression.

That is proof of a side effect, it would take much more to prove anything else.

Anthony Rothschild and Carol Locke, also of Harvard Medical School, reported three such cases in the Journal of Clinical Psychiatry in 1991. All three individuals had previously attempted suicide while being treated with Prozac -- in fact, each had jumped from great heights and had managed to survive. In turn, all three had been put back on Prozac, only to complain of the same strange desire to kill themselves.
"I tried to kill myself because of these anxiety symptoms. It was not so much the depression," said one of the individuals, a 25-year-old woman. Another, a 47-year-old man, complained that "this is exactly what happened the last time I was on [Prozac], and I feel like jumping off a cliff again." Reflecting on these cases, the Harvard researchers stressed that patients need to know that such overwhelming symptoms are the side effects of medication, and are treatable. "Our patients had concluded their illness had taken such a dramatic turn for the worse that life was no longer worth living."

Three anecdote, regarding certain patients, no history, no baseline.

And again not a statistical study.

And again good reason to monitor people very carefully at the start of treatment.

I agree very much that doctors should be very careful perscribing psychotropics, but, these citations point to the need for careful monitoring.

Without patient baselines, history, sample matching the data re lacking and inconclusive.

I feel the greatest danger with psychotropics is perscribing to individuals engaged in substance abuse.