SSRIs, Skepticism, Suicide and Suicidality.

I knew there was a reason I loved Christina.  I ask people to learn something new about SSRIs or mental illness and do a post and she cranks it up to eleven.  Did I mention she’s an occupational therapist for a living?  Women with lots of brains = sexy.

This is cross-posted from her blog.

I heard an interesting bit of information about SSRIs (a class of compounds used to treat depression and other mental illnesses) twice while at Skepticon. People (especially the media) have unfairly linked SSRI’s to suicide, especially among people under 25. Here’s how my friends explained this effect to me: Apparently SSRI’s work in a certain way, by both making you feel more motivated and by reducing depression. When an individual first starts taking SSRIs, the feeling of motivation often hits first before they ease the depression, giving the individual the ability to start completing items on their big long checklist of things to do. If “kill myself” happens to grace that list, then sometimes individuals finally find the motivation to kill themselves. Hence, an increase in suicidality/suicide crops up in the first few weeks of SSRI use.

The skeptical community has not trained many skeptical eyes upon SSRIs and suicidality/suicide. I find this rather unfortunate. I wanted to explore this bit of information myself to see what research literature actually says about suicidality/suicide. I have a stake in such a subject for many reasons, among them being because many of my friends take SSRIs. So does my husband. I have a mental illness that I have never treated chemically. Whether I should treat my illness chemically, I have not yet decided. I have not, therefore, based my information on my own personal experience.

Not wanting to jump to conclusions about why SSRIs cause suicide, I decided to look at the originating premise:

SSRIs cause suicide, or suicidal ideation, in some people.

Really, there are two separate premises here:

SSRIs cause suicide in some people.

SSRIs cause suicidality (suicidal thoughts or behavior) in some people.

Another interesting aspect of this question is the some people part of it. Studies typically look at age differences, so some people includes children/adolescents, adults, and older adults.

On to suicide and SSRIs. When you look at actual suicides, we get a pretty unconvincing picture. In analyzing the data the FDA used to establish its position on the relationship between SSRIs and suicide, researchers (Khan, et al, 2003)  found actual, completed suicides were no different among SSRI treatment, comparison and placebo groups. Age mattered not. People aren’t killing themselves as a consequence of being on SSRIs.

What would the skeptical community say about some acupuncture, homeopathy or chiropractic trial in which the results regarding a particular variable were the same whether you participated in the active treatment group, the comparison treatment group or the placebo group? We would conclude that the active treatment group had no effect with regard to that variable. We would conclude that we did not refute the null hypothesis (that SSRIs do not increase suicidality).

Another study on adolescents specifically showed that among young people who do kill themselves, only 1.6% of them had exposure to SSRIs (Dudley, et al 2010)

If the FDA warned people that SSRIs caused suicidality, and that caused a reduction in antidepressant prescriptions, what we might find is that in the general population of young people, suicides go down, assuming that SSRI’s really do cause suicide.

Except we find the exact opposite. A study done in 2003-2004 showed a decrease in SSRI prescriptions for youth, and a corresponding increase in suicide. (Gibbons, et al 2007)

At the same time, we find that as the overall rate of antidepressant prescriptions go up, the suicide rate goes down.

Why the difference? How can it be that a drug can increase suicidal thoughts, impulses and attempts, but no increase in crude suicides? The answer may lie in the inclusion criteria, which typically excludes people with suicide attempts, for obviously ethical reasons. This alone cannot account for the lack of supportive data, though excluding people with a prior history of suicide attempts does confound things, as prior suicide attempts predict future suicide attempts.

Regardless, we can’t establish that SSRI’s contribute to suicide. Perhaps, however, SSRIs cause an increase in suicidal thoughts and behaviors.

I thought Petulant Skeptic put this question to rest pretty well:

Owing to this, clinicians use suicidality as their metric instead. Suicidality generally includes suicidal ideation or planning as well as self-harming behaviors. These events are more common than actual suicide and thus much easier to catalog and compare. In a large meta analysis conducted by the BMJ they found that 0.54% of patients in clinical trials expressed “suicidality.” Helpfully, they even break down these incidences by indication group. If you do the math (they did not) 64% of the suicidality events were accounted for by those with major depressive disorder (MDD) and a further 28% had a condition categorized as “other psychiatric” (which explicitly excluded non-MDD depression). Completely unsurprisingly research has found that MDD and “other psychiatric” conditions have a very strong correlation with suicide (and, to use researcher’s own proxy here, suicidality).

What this means is that 99.5% of patients (who are high risk) never even considered suicide. Where is this number supposed to go from 99.5%? The occurrence of suicide itself in the general population is 11.4 per 100,000 (0.01%) and we’ve already covered that suicide is incredibly rare compared to suicidality. Moving on.

The BMJ trial referred to in the above quote is Stone, et al (2009). Neuroskeptic said about the same.

In a general cohort study (of 4,848 people) of the general population, the incidence of suicidal ideation was 2.7% and the incidence of suicide was .9% over a 3 year period. (ten Have, et al 2009).  Clinical trials are of a shorter duration than 3 years and include people with a clinical diagnosis warranting the use of antidepressants, but comparing the numbers doesn’t convince me that SSRIs cause suicidality.

In another study of people with depressive spectrum disorders (Spijker, et al 2010), 16.6% report suicidal ideation while 3.2% make a suicide attempt. So, those in the BMJ meta analysis are actually much less likely to have suicidal ideation or attempts while using SSRIs.

There really isn’t a link between SSRIs and suicidal ideation generaly. Yet, here we have this:

[5/2/2007] The U.S. Food and Drug Administration (FDA) today proposed that makers of all antidepressant medications update the existing black box warning on their products’ labeling to include warnings about increased risks of suicidal thinking and behavior, known as suicidality, in young adults ages 18 to 24 during initial treatment (generally the first one to two months).

Okay. Notice the FDA does not warn of a risk of suicide – no risk of suicide exists given the many studies. The FDA does not warn of the risk of suicidal ideation for adults, nor for older people. The warning only applies to suicidality of young adults.

The FDA came to this conclusion because their data show that while 1.62% of people under 25 in a placebo treatment group experience suicidality, 2.3% of people under 25 in an active SSRI treatment group experience suicidality. That’s double the risk of suicidality, which sounds scary. However, that’s a vanishingly small amount of people. Apparently, this suicidality isn’t leading to suicide. I think this small risk of suicidality is worth the help that antidepressants give to people. For the record, the studies also show that there is no increased risk of suicidality in people aged 25-59, and a decreased risk for those over 60.

Of course, one could also question whether antidepressants work at all.

A 2010 meta analysis (Fournier et al 2010) lit a fire under the media. Articles abound, but a good example is this Newsweek article titled, “The Depressing News About Antidepressants“. Most media outlets reported that this meta-analysis concluded that antidepressants do not work.

The meta-analysis concluded no such thing. The meta-analysis concluded that antidepressants had a large clinically meaningful effect over placebo for severe depression, and only a small clinically meaningful effect for mild to moderate acute depression. If I could make journalists who write about science understand one thing, I would make them understand effect size.

In other words, SSRIs work for people who have a problem between their ears, not in their external world. SSRIs won’t help you if you are grieving over the end of your relationship or if you feel sad occasionally. A lot of the time, depressive episodes surrounding environmental factors will resolve when the issue in the environment resolves. Major depression follows you around, crushing you even if you consider your life otherwise completely awesome. In depression, your brain gets in the way of your life.  Treat depression with SSRIs and most people see results. Treat depression brought about by environmental triggers and you might not, unless your brain is concurrently imbalanced.

I’m pretty convinced this fear that SSRIs cause suicide does far more harm than good. The data do not establish causality and barely establish a link between suicidality among young people. Get your friends, family or yourself the help you need.

TL:DR – The data do not support the notion that SSRI’s cause an increase in suicide. It does support a slight increase in suicidal thoughts in young people under 25. There exists much evidence that SSRIs help people with chemical depression. If we dispel the myth  that SSRIs cause suicide, people may fear them less.

References:

Khan A, Khan S, Kolts R, Brown W. Suicide Rates in Clinical Trials of SSRIs, Other Antidepressants and Placebo: Analysis of FDA Reports. Am J Psychiatry 2003;160:790-792. Online here.

Fournier JC, DeRubeis RJ, Hollen SD, Dimidjian S, Amsterdam JD, Shelton RC, Fawcett J. Antidepressant Drug Effects and Depression Severity: a Patient-Level Meta-Analysis. JAMA 2010;303(1):47-53. Online here.

Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM, Mann JJ. Early evidence on the effects of regulators’ suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 2007 Sep;164(9):1356-63. Abstract here.

ten Have M, de Graaf R, van Dorsselaer S, Verdurmen J, van ‘t Land H, Vollebergh W, Beekman A. Incidence and Course of Suicidal Ideation and Suicide Attempts in the General Population. Canadian Journal of Psychiatry. 2009;4:824-833 Online here.

Spijker J, de Graaf R, ten Have M, Nolen WA, Speckens A. Predictors of suicidality in depressive spectrum disorders in the general population: results of the Netherlands Mental Health Survey and Incidence Study. Social Psychiatry & Psychiatric Epidemiology May2010, Vol. 45 Issue 5, p513-521 Abstract here.

Dudley M, Goldney R, Hadzi-Pavlovic D. Are adolescents dying by suicide taking SSRI antidepressants? A review of observational studies. Australas Psychiatry. 2010 Jun;18(3):242-5. Abstract here.

Stone M, Laughren T, Jones ML, Levenson M, Holland PC, Hughes A, Hammad TA, Temple R, Rochester G. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ. 2009 Aug 11;339:b2880. doi: 10.1136/bmj.b2880. Abstract here.

P.S. Yes, I know that there are problems with the pharmaceutical industry, and I am not holding the industry up as bastions of good ethics. Physicians often prescribe antidepressants for people without a psychiatric diagnosis. I question the ethics of direct-to-consumer marketing, for example. I also highly disapprove of coupons for brand name pharms when generics would suffice and are much cheaper to you and your insurance.

  • Richard

    Hunh. Learn something new and fascinating every day. This goes right next to “sugar is not a stimulant” and “spinach does not have a higher than normal iron content”, things I thought were true that simply aren’t.

    Also, I’m with you JT that the sexiest organ is the brain. :-P

  • http://pharyngula.wikia.com/ ahs ॐ

    doi: 10.1136/bmj.330.7488.396 http://www.bmj.com/content/330/7488/396.short

    Results: Seven hundred and two trials met our inclusion criteria. A significant increase in the odds of suicide attempts (odds ratio 2.28, 95% confidence 1.14 to 4.55, number needed to treat to harm 684) was observed for patients receiving SSRIs compared with placebo. An increase in the odds ratio of suicide attempts was also observed in comparing SSRIs with therapeutic interventions other than tricyclic antidepressants (1.94, 1.06 to 3.57, 239). In the pooled analysis of SSRIs versus tricyclic antidepressants, we did not detect a difference in the odds ratio of suicide attempts (0.88, 0.54 to 1.42).

    Discussion: Our systematic review, which included a total of 87 650 patients, documented an association between suicide attempts and the use of SSRIs. We also observed several major methodological limitations in the published trials. A more accurate estimation of risks of suicide could be garnered from investigators fully disclosing all events.

  • http://saltycurrent.blogspot.com SC (Salty Current), OM

    This isn’t all that skeptical. You’ve simply crossposted a (rather confused and inaccurate) piece with which you were already inclined to agree. If you really want to take a skeptical approach, you could maybe begin by reading Irving Kirsch’s book The Emperor’s New Drugs.

    As it happens, I posted this morning at Pharyngula about the chemical-imbalance notion. One of the articles I quoted there, by Leo and Lacasse, is available online. It talks about the deceptive DCTA for antidepressants.

    • http://www.ziztur.com ziztur

      That’s funny SC. I didn’t actually address the chemical imbalance issue at all. I only addressed whether the data supported the hypothesis that SSRIs cause suicidality and whether the data support the hypothesis that SSRIs help mitigate depression in a clinically meaningful way.

      I concluded that SSRIs do cause an increase in suicidality for adolescents but not suicides and that they help people with major depression. I made no claims about the mechanism, because I myself am not convinced of the mechanism.

      You can say that my writing is confused and inaccurate all you want, but unless you provide some substance to back up such claims, you’re merely hurling insults.

  • http://pharyngula.wikia.com/ ahs ॐ

    doi 10.1001/archpsyc.60.9.978 http://archpsyc.ama-assn.org/cgi/content/abstract/60/10/978

    Conclusions: An inverse relationship between regional change in use of antidepressants and suicide raises the possibility of a role for using antidepressant treatment in youth suicide prevention efforts, especially for males, older adolescents, and adolescents who reside in lower-income regions.

  • http://pharyngula.wikia.com/ ahs ॐ

    doi: 10.1503/cmaj.081514 http://www.cmaj.ca/content/180/3/291.full

    Interpretation: Based on data from observational studies, use of SSRIs may be associated with a reduced risk of suicide in adults with depression. Among adolescents, use of SSRIs may increase suicidality.

  • http://pharyngula.wikia.com/ ahs ॐ

    doi: 10.1136/bmj.330.7488.385 http://www.bmj.com/content/330/7488/385.short

    Conclusion: Increased risks of suicide and self harm caused by SSRIs cannot be ruled out, but larger trials with longer follow up are required to assess the balance of risks and benefits fully. Any such risks should be balanced against the effectiveness of SSRIs in treating depression. When prescribing SSRIs, clinicians should warn patients of the possible risk of suicidal behaviour and monitor patients closely in the early stages of treatment.

  • http://saltycurrent.blogspot.com SC (Salty Current), OM

    (My comment went into moderation, probably because I had a couple of links, so I’ve removed the link to the Leo and Lacasse article and I’m trying again. Apologies if it turns into a double post:)

    This isn’t all that skeptical. You’ve simply crossposted a (rather confused and inaccurate) piece with which you were already inclined to agree. If you really want to take a skeptical approach, you could maybe begin by reading Irving Kirsch’s book The Emperor’s New Drugs.

    As it happens, I posted this morning at Pharyngula about the chemical-imbalance notion. One of the articles I quoted there, by Leo and Lacasse, is available online. It talks about the deceptive DCTA for antidepressants.

    • http://langcogcult.com/traumatized DuWayne

      And if you wanted to be skeptical about it, you might take a serious look at Kirsch’s bibliography. Kirsch crunches numbers that have no business being crunched together. Studies that are using different operational definitions are thrown into an aggregate, along with studies that support the exact assertion made in the post above; namely that SSRIs are not particularly likely to help people with mild to moderate or situational depression – but are likely to help people suffering from severe clinical depression – Kirsch takes a lot of figures that not only don’t belong together, but in some cases actually contradict his assertions and claims they support his bullshit.

      They do not and he is either abysmally ignorant, or blatantly dishonest. Either way, he is verging into fear mongering that borders on conspiracy crankery. He is very little different than the folks who peddle anti-vax crankery. He manipulates data to make it appear to support his unfounded assertions. He convinces people that they should avoid medications that might actually save their lives.

      None of the tools that we use to combat depression and other mood disorders, be they pharmaceutical or talk therapy, are good enough for or appropriate for everyone. Unfortunately we end up with people who slip through the cracks either because they don’t have access to all available options, or because nothing available seems to help them. Personally, I would like to help change that and will, in the context of clinical psychological treatment. I will also be looking forward to continuing advances on the neurobiology front, in understanding depression so we can more effectively treat it – both pharmacologically and in talk therapies.

      But that they are not as effective as we would like is not a reasonable excuse for asserting that they are ineffective and dangerous. Like all things in medicine, we do the best we can within the limitations placed on us by our tools. What we don’t do, is throw out a effective treatments, because they don’t help everyone.

      • http://saltycurrent.blogspot.com SC (Salty Current), OM

        So, you still have a choice. You can listen to DuWayne’s assertions and vague, rambling criticisms and simply dismiss contrary arguments. Or you can read the works in question and form your own views. I’ve read the books and much of the supporting documentation, several critical responses, and the responses to the responses. So you could read Marcia Angell’s article, the critical reaction, and her response to the critics. But I would recommend starting with the Kirsch book and then moving on to the criticisms.

        Of course, you’re not obliged to read or engage with any of this, but you really should if you’re going to say that you’re approaching the subject skeptically.

        • http://langcogcult.com/traumatized DuWayne

          Vague rambling criticism? What exactly is vague or rambling about “Kirsch is aggregating figures that cannot reasonably be aggregated and is, whether through ignorance or outright dishonesty, misrepresenting several of his citations?” All one has to do is actually look at his source material. He lumps figures from studies that concluded that people suffering moderate to severe depression are likely to benefit from the use of SSRIs, while people with mild to moderate depression will not, with studies that didn’t differentiate between mild to moderate and moderate to severe depression – thus concluding that SSRI’s are not significantly more effective than placebo.

          And I am not telling people not to be skeptical, I am simply suggesting that they look at the source material for his atrocity of a book for themselves – rather than just taking his and your word for it. I get rather pissed off about it because most people who listen to the bullshit you and Kirsch are peddling aren’t likely to be skeptical about your claims.

          Like people who listen to Jenny Mccarthy about vaccines, they are predisposed to distrust medical science – especially when so called scientists are telling them they should. They don’t make the distinction between a psychologist who is fudging figures and actual neurobiologists who are running the studies from which those figures are derived. They give the psychologist equal weight and, because he is making assertions they are inclined to agree with, they will assume he is correct.

          So in your passive aggressive way of arguing here; For those who want to REALLY be skeptical, by all means, take the time to read Kirsch’s book. And when you have read his book, read through his source material – pay attention to the operational definitions of the studies he cites (when they are not defining specific terms, such as “depression,” “mild,” “moderate,” “severe,” etc. the same way, the figures don’t belong together), read through the results and conclusions and finally, read through the methodologies used in the studies cited. Please, do not take my word for it. Just don’t take SC or Kirsch’s word for it either.

          They are dead wrong and all you need to prove that is to look through the source material.

  • http://pharyngula.wikia.com/ ahs ॐ

    doi: 10.1176/appi.ajp.163.1.41 http://ajp.psychiatryonline.org/article.aspx?articleid=177990

    RESULTS: In the 6 months after the index prescription of antidepressant treatment, 31 suicide deaths (40 per 100,000 treatment episodes) and 76 serious suicide attempts (93 per 100,000) were identified in the study group. The risk of suicide attempt was 314 per 100,000 in children and adolescents, compared to 78 per 100,000 in adults. The risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. When the 10 newer antidepressants included in the FDA advisory were compared to older drugs, an increase in risk after starting treatment was seen only for the older drugs.

    CONCLUSIONS: The risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000 treatment episodes, and risk of serious suicide attempt is approximately one in 1,000. Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs.

  • http://pharyngula.wikia.com/ ahs ॐ

    doi: 10.1136/ebmh.10.1.20 http://ebmh.bmj.com/content/10/1/20.extract

    Conclusions: Antidepressant use including selective serotonin uptake inhibitors increases the incidence of suicidal behaviour and ideation compared with placebo in children.

  • http://pharyngula.wikia.com/ ahs ॐ

    “The Risk of Suicide With Selective Serotonin Reuptake Inhibitors in the Elderly”

    doi 10.1176/appi.ajp.163.5.813 http://intl-ajp.psychiatryonline.org/article.aspx?Volume=163&page=813&journalID=13

    Results: Of 1,329 suicide cases, 1,138 (86%) were each fully matched to four comparison subjects using propensity scores. During the first month of therapy, SSRI antidepressants were associated with a nearly fivefold higher risk of completed suicide than other antidepressants (adjusted odds ratio: 4.8, 95% confidence interval=1.9—12.2). The risk was independent of a recent diagnosis of depression or the receipt of psychiatric care, and suicides of a violent nature were distinctly more common during SSRI therapy. Numerous sensitivity analyses revealed consistent results. No disproportionate suicide risk was seen during the second and subsequent months of treatment with SSRI antidepressants, and the absolute risk of suicide with all antidepressants was low.

    Conclusions: Initiation of SSRI therapy is associated with an increased risk of suicide during the first month of therapy compared with other antidepressants. The absolute risk is low, suggesting that an idiosyncratic response to these agents may provoke suicide in a vulnerable subgroup of patients.

  • http://pharyngula.wikia.com/ ahs ॐ

    Hope those were useful. I’m bored now. If anybody needs a PDF, drop me a note on Pharyngula’s endless thread.

  • http://itsmyworldcanthasnotyours.blogspot.com WMDKitty

    If it weren’t for SSRIs, I’d be in hospital.

    Doesn’t mean I don’t still go into depressive episodes, but they’re not as bad as they would be without the meds, and I don’t think about self-harm or suicide near as much as I used to. (I still get the urge to cut now and then, usually when I’m under severe stress.)

  • Aquaria

    You know, I already had a low opinion of therapists before one spouted off, and this didn’t help. It seems that she wants to make up why we go suicidal than actually, you know, LISTENING to us–a common failing among a lot of so-called therapists.

    Despite having severe and chronic depression all my life, I’d had maybe five instances of wanting to kill myself from my teen years on, but I had never–ever–acted on them until I took Prozac in my mid-30s. I’d never wanted to act on any of them. I knew those were flitting ideas that were stupid and not worth considering. I knew it wouldn’t solve anything, that the depression was making me overreact to stressful situations. Stressful as in: my first marriage falling apart when my then-husband got strung out on cocaine. Or having two miscarriages within a few months. Or having my second marriage crumble before my eyes. Those were times that really pushed the suicidal trigger for me. But those were infrequent, and easily overcome.

    At the time of my suicide attempt, I had every reason to be on top of the world (by my standards), and happy. I was happy, with a new and fantastic job that I loved, a boyfriend who wasn’t an egomaniacal control freak (my usual type–ugh) and a son I adored. But my idiot therapist thought Prozac could help with “unresolved” issues I’d had for a while. So I stupidly took the crap. Only a few weeks into taking it, this wave of depression worse than any I’ve ever had engulfed me, and driving my car off the highest level of a freeway mixmaster seemed like a really good idea. That had never–ever–been my philosophy, no matter how depressed I was in the past. I talked myself out of taking that plunge (funny, I thought–don’t hurt somebody innocent!), but I went home that sane day and slashed my wrists instead.

    It wasn’t my suicidal “to do” list that I was acting out. I didn’t fucking have one of those. It was the quack medication that was telling me to hurt myself!

    How fucking insulting to think that we’re “acting out” a suicidal “to do” list. As if every depressed person who’s gone bonkers on their quack medicine is to blame, and not the medications themselves!

    The medications might work for some people, but they can be dangerous for others. Sorry, but there’s no getting around that, because the reality is that these are medicines designed to alter brain chemistry, and no one knows for sure exactly what that will do to every individual until they’re driving off the damned mixmaster, or slashing wrists. They can’t know!

    I don’t take the crap anymore. SSRIs do not work for me, especially when they’re trying to kill me.

    • http://www.ziztur.com ziztur

      “You know, I already had a low opinion of therapists before one spouted off, and this didn’t help. It seems that she wants to make up why we go suicidal than actually, you know, LISTENING to us–a common failing among a lot of so-called therapists.”

      I was repeating something that I heard from two people at Skepticon who have mental illnesses. Because I, you know, listened to them.

      I did not make up this information; I repeated it to explain my origins for researching SSRIs.

      For the record, I am an occupational therapist (http://www.aota.org/consumers.aspx). Not a psychologist. Not a counselor.

      “How fucking insulting to think that we’re “acting out” a suicidal “to do” list. As if every depressed person who’s gone bonkers on their quack medicine is to blame, and not the medications themselves!”

      You’re misunderstanding. I made no mention of a “suicidal to do” list and don’t think any “acting out” is going on. What I meant was that my friends told me that SSRIs sometimes give people the motivation to kill themselves. But again, that’s just what I was told.

      Read my post again without automatic negativity because “therapist” is in my title. Two friends explained to me why THEY thought suicide increased with SSRI use, and I decided to see if the data supported their claim.

      • http://www.ziztur.com ziztur

        In other words, in order of events:

        1. I hear two people say something about SSRIs
        2. I research what they said.
        3. I come to different conclusions based on the data.
        4. I write a blog about it.

        So, it’s not a matter of me not listening, spouting off and/or blaming.

  • julian

    jesus christ, ahs, heads up before you spam paper abstracts.

    Apparently SSRI’s work in a certain way, by both making you feel more motivated and by reducing depression.

    I realize this is going to come off as really snide and probably insulting but, did your friend also explain how SSRI’s help you feel more motivated and help reduce depression?

    I understand that in medicine that isn’t always required (convincing evidence that the pros of a treatment outweigh any cons is what I understand in generally required) but, from my very limited understanding, SSRI’s have basically been shown to work better than in a placebo for severe cases of depression. That’s a pretty far cry from any real explanation as to how or why they work.

    But this is pretty off topic as the post is about suicide rates and not how the drugs work.

    • Orri

      SSRIs seem to have an effect on inhibition. When you start taking them it usually takes awhile for your mood to get significantly better, anywhere from 2-6 weeks in most cases. However pretty early in the process many report a feeling of slight disinhibition. Wich for someone who is depressed or anxious is usually a good thing, they get out a little more, talk a little more, have a little more initiative, etc (sometimes they also a get a little more hostile and aggressive…). However a disinhibited person that is also severely depressed can be a recipe for disaster, although as this excellent post discusses, that is rare. This does seem to more of an issue in children (see here for example: http://www.canadianmedicaljournal.ca/content/170/4/489.short)
      But we should always remember the bottom line. These drugs work pretty well for adults. Not perfectly, not always, not for everyone. But in general they certainly do work.

    • http://www.ziztur.com ziztur

      True, which is why I didn’t discuss the mechanism for their action: I am not convinced of the mechanism.

      • Orri

        Nor am I. No one is really sure of the mechanism, except maybe Big Pharma advertising departments. Research in this area provides some confusing results…

  • Angel

    Forgive me if someone already addressed this, but what I brought up with Christina was the role anti-psychotics play in this data. Where it was noted that suicidal thoughts actually increased off of anti-depressants, I wonder if this has anything to do with the rise of anti-psychotic prescriptions. See, here’s my thing. When I was in Child Psych, my teacher spent a lot of our semester discussing issues with the medicated child, so I had to do some research and we watched several documentaries looking at the issue from numerous sides, and here’s some things noted. Doctors were prescribing anti-depressants to children at high rates, anti-depressants which had never been tested on children. This concerned many, so there was research done to test how they affected children. The conclusions from this research led to a black box warning on anti-depressants in regards to children. What was the reaction to this? Parents were concerned about this black box warning and leery of having their kids on anti-depressants. So, doctors started prescribing anti-psychotics at high rates, anti-psychotics that have not been tested on children. As a skeptic, it concerns me to not have information for potent chemicals being given to children. Besides increases in suicidal thoughts from anti-depressants and no research with anti-psychotics, there is the issue of a side effect spiral. They prescribe potent medicines to these kids which have bad side effects which require more potent medicines which have more bad side effects which require more potent medicines and so on and so on. What has been shown to be most affective is actually a mix of medicine and behavioral therapy, but since doctors can prescribe these medicines without any therapeutic intervention and at high levels, I worry. Not so much about adults, but about kids. I don’t think it should be discounted that there was an increase in those thoughts in kids at all because the little research that was done on kids provided some sober results in that arena, and they are a large chunk of those being prescribed these meds, anymore, although, as previously noted, there has been a shift toward the far less researched anti-psychotics. I just want to see more data on how kids are affected before we pump them full of medicines that can very much affect their growing selves.

  • Angel

    *Note: I am discussing purely effects on children and young adults because that is where I especially feel more research needs to be done and is not addressed as much in this piece. I also think it is very important to consider because of the high rate of prescriptions of anti-depressants and anti-psychotics for kids.

  • http://potatoesarenotvegetables.blogspot.com Ashton

    I’ve always been skeptical of the anti-depressant suicide like. It seemed like the original warning was based on a lack of knowledge. My own anecdotal experience is that anti-depressants got rid of suicidal thoughts for me. Once I went off them, they came back. They are thoughts that I have never had any particular desire to act on and I’m pretty sure that I never will, but it was nice to have them gone for a while. The thoughts were not my main reason for going on them, but it was a nice bonus.

  • http://pharyngula.wikia.com/ ahs ॐ

    jesus christ, ahs, heads up before you spam paper abstracts.

    Sorry, julian. I’ll try to remember to warn of the coming deluge next time.

    Here’s one more:

    +++++
    I came across this Richard Smith in his comment section. He thought it was useful to his general argument about peer review.

    http://www.nejm.org/doi/full/10.1056/NEJMsa065779

    METHODS: We obtained reviews from the Food and Drug Administration (FDA) for studies of 12 antidepressant agents involving 12,564 patients. We conducted a systematic literature search to identify matching publications. For trials that were reported in the literature, we compared the published outcomes with the FDA outcomes. We also compared the effect size derived from the published reports with the effect size derived from the entire FDA data set.

    RESULTS: Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.

    CONCLUSIONS: We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.

    DISCUSSION: We found a bias toward the publication of positive results. Not only were positive results more likely to be published, but studies that were not positive, in our opinion, were often published in a way that conveyed a positive outcome. We analyzed these data in terms of the proportion of positive studies and in terms of the effect size associated with drug treatment. Using both approaches, we found that the efficacy of this drug class is less than would be gleaned from an examination of the published literature alone. [...]

  • StinkyPete

    Maybe its a marketing thing?
    I consider myself to be well close to suicide (just a few things to wrap up, maybe need to replace some gas canisters), and everytime I see a commercial for anti-depressants and they say that warning the first thing that comes into my mind is something along the lines of “maybe thatd finally let me get it done.”

    So maybe its a kind of trap, they say it can make you kill yourself, and people decide to go ahead and try because it’ll either work and you feel better, or you kill yourself, either way problem solved and they get their money.

  • http://pharyngula.wikia.com/ ahs ॐ

    *whine*

    JT, I still have a comment stuck in moderation on this thread. Halp!

  • http://pharyngula.wikia.com/ ahs ॐ

    Impatience becomes me. I’m just reposting it in sections.

    jesus christ, ahs, heads up before you spam paper abstracts.

    Sorry, julian. I’ll try to remember to warn of the coming deluge next time.

    Here’s one more:

    +++++
    I came across this Richard Smith in his comment section. He thought it was useful to his general argument about peer review.

  • http://pharyngula.wikia.com/ ahs ॐ

    http://www.nejm.org/doi/full/10.1056/NEJMsa065779

    METHODS: We obtained reviews from the Food and Drug Administration (FDA) for studies of 12 antidepressant agents involving 12,564 patients. We conducted a systematic literature search to identify matching publications. For trials that were reported in the literature, we compared the published outcomes with the FDA outcomes. We also compared the effect size derived from the published reports with the effect size derived from the entire FDA data set.

    RESULTS: Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.

    CONCLUSIONS: We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.

    DISCUSSION: We found a bias toward the publication of positive results. Not only were positive results more likely to be published, but studies that were not positive, in our opinion, were often published in a way that conveyed a positive outcome. We analyzed these data in terms of the proportion of positive studies and in terms of the effect size associated with drug treatment. Using both approaches, we found that the efficacy of this drug class is less than would be gleaned from an examination of the published literature alone. [...]

  • Natasha

    Just to throw a couple things in:

    1. This is where a support system comes in handy. Most competent Dr’s will tell you that you need to keep in touch with them, and be open to and rely on your support system, while adjusting to SSRI medications. They outline possible risks and side affects and it’s your job as a patient to remain conscious of your changes. It is often recommended to keep a journal or chart during this period so you have a reference.

    2. SSRI medications are, not infrequently, used as an aid to diagnose bipolar disorder. In short, BP is tricky to diagnose sometimes, because patients most often seek treatment during depression, so the Dr. is only seeing one side of the coin. However, if you give most BP patients an SSRI on it’s own, it sends them over the edge, and thus indicates to their Dr that they may have something more going on and need a mood stabilizer in conjunction with or instead of an SSRI. This is one of the reasons there is caution.

    3. Pretty much all medications come with a “watch yourself” footnote. I don’t really see the difference with SSRI meds when compared to anything else. Some anti-anxiety meds have the exact opposite effect on certain patients, some insomnia meds just make people trip balls and not sleep… the list is long. You still have to use your brain for practical things while in treatment, say, for monitoring yourself. Dr’s aren’t magicians, and we often expect them to operate flawlessly on limited information, then get pissed-off when treatment isn’t perfect. Do yourself and your Dr a favor and take good notes, do your homework, and act like you have some responsibility in your care outside of just driving to an office, and the risks for disaster become pretty negligible most of the time.

  • Jen

    My sister was on Lexapro for 5 days and took her life in a very impulsive and violent way. She was not suicidal prior to the medication. She became extremely agitated. She could not sleep and was very restless. She also got a strange look in her eyes like she wasn’t there. Unfortunately we had no idea how dangerous these drugs could be. We did not know what to look for or that they could cause suicide. She definitely became worse when she got on them. So, your research may conclude no increase in suicide from SSRI but I can tell you from experience these drugs do increase suicides. America needs to wake up and get informed. The majority of people on SSRI’s should not be on them. A pill is not a quick fix to life’s problems. Two years ago I was getting a physical and my DR asked if I was stressed. I said yes. He told me I didn’t have to live that way and tried to give me SSRI meds on the spot. I told him NO THANK YOU. I don’t deal with my problems by popping pills. I have overcame anxiety by changing my diet and changing my focus and taking captive my thoughts. I hope anyone considering SSRI’s will research all of the real life stories of people who have been on them or have lost a loved one because of them.

    • Beenaround

      The drug did not cause your sister’s suicide. I am sorry to hear you lost her but it wasn’t the drug. People blame the drug: but, they fail to realize they have been missing signs of mental illness for years. I am sorry for your loss-but, don’t blame the medication. Also, you do not say how old or young she was when she went on the medicaiton. Nor did you mention what type of doctor she saw. Nor, did you mention the reason(s) she was given this medication. I know people who have been on it for a long time-with no ill side effects-except for being thirsty.


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