Anti-depressents increase risk of suicide

[Easy Mac]

I mean seriously, WTF? Aren't these drugs meant to reduce the risk of suicide? How do these things get on the market? Yeah, they help people, but if one of their side effects potentially causes the things its supposed to prevent, how can it be considered working?

WASHINGTON (AP) -- The Food and Drug Administration issued a second public warning Friday that adults who use antidepressants should be closely monitored for warning signs of suicide, especially when they first start the pills or change a dose.

Much of the concern over suicide and antidepressants has centered on children who use the drugs. The FDA last fall determined there is a real, but small, increase in risk of suicidal behavior for children and ordered the labels of all antidepressants to say so.

A year ago, the FDA issued a warning that adults, too, may be at increased risk. The agency began reanalyzing hundreds of studies of the drugs to try to determine if that's the case, and told makers to add or strengthen suicide-related warnings on their labels in the meantime.

Since then, several new studies have been published in medical journals about a possible connection. Citing them, FDA issued a new public health advisory reminding doctors and patients to watch closely for suicidal thinking or worsening depression and seek medical care if it happens.

It's a difficult issue to sort out because depression itself can lead to suicide and studies show that antidepressants have helped many people recover.

But there are concerns that antidepressants may cause agitation, anxiety and hostility in a subset of patients who may be unusually prone to rare side effects. Also, psychiatrists say there is a window period of risk just after pill use begins, before depression is really alleviated but when some patients experience more energy, perhaps enabling them to act on suicidal tendencies.

In addition to the advisory, the FDA also updated its Web site with a notice about a higher-than-expected rate of suicide attempts in research with the nation's newest antidepressant, Eli Lilly's Cymbalta. Those studies were in women trying Cymbalta as an incontinence treatment; it was never approved for that use. The FDA insisted when it approved Cymbalta last year that studies of depressed patients showed no suicide link.

[jeff061]

I don't get these studies. These are depressed people so they were at risk to commit suicide anyways. I'm assuming they must of had a control group of equally depressed people with no pills? Maybe its some sort of placebo effect?

It's the same thing with the Accutane studies. Does Accutane cause suicide or is it that really bad acne can spark a lot of issues that end in deep depression.

[timmynausea]

I've also thought the studies were kind of weird. It seems like a hard thing to measure.

[Eaglesfan27]

These studies are HIGHLY flawed. Jeff you are right on the money. Depressed people are at risk for suicide. They do not have good control groups in these studies.

However, these studies do point out one important fact: Depressed and particularly patients with a history of suicidal thoughts/acts need to be monitored closely (sometimes much more closely than a Primary Care Physican is able/willing to do.)

[duckman]

My understanding is that if the depression is severe enough, some suicidal people can't carry out their plans to take their own lives. Once they are receiving treatment and are "strong" enough, they will attempt suicide.

[timmynausea]

My understanding is that if the depression is severe enough, some suicidal people can't carry out their plans to take their own lives. Once they are receiving treatment and are "strong" enough, they will attempt suicide.
Yeah, I've heard that, too. Up until they begin to get better, they don't have the energy to do it.

[Glengoyne]

My understanding is that if the depression is severe enough, some suicidal people can't carry out their plans to take their own lives. Once they are receiving treatment and are "strong" enough, they will attempt suicide.

That is how I've heard it explained as well. The theory goes that some individuals taking these anti-depresants are so depressed that they can't even get it together enough to kill themselves. They are suicidal, but not motivated enough to do anything about it. Give them a little medication, and they start to feel better, because the meds are working. Then before the meds are allowed to really have their full effect, the individual feels motivated enough to act on their suicidal feelings.

[Eaglesfan27]

You are all right that this is a common belief and does occur at times. Again, this is another reason that patients with severe depression have to be monitored very closely.

[QuikSand]

These studies are HIGHLY flawed. Jeff you are right on the money. Depressed people are at risk for suicide. They do not have good control groups in these studies.

I find this staggeringly difficult to believe... and only take the suggestion seriously because of the source.

Is there anything to back this up? I honestly find this hard to imagine that there could be such an obvious omission in a highly-monitored and high-stakes matter such as this. Pharmaceutical companies obvious derive huge profits from sales of antidepressants... if the FDA-sponsored studies (or the ones they are depending on, in any event) are without merit -- wouldn't we be hearing a lot about that from those who have so much to lose?

I just have to think that any reputable study being done would have some reasonable degree of control. But I'm willing to be corrected if there's some evidence to the contrary.

[Eaglesfan27]

I find this staggeringly difficult to believe... and only take the suggestion seriously because of the source.

Is there anything to back this up? I honestly find this hard to imagine that there could be such an obvious omission in a highly-monitored and high-stakes matter such as this. Pharmaceutical companies obvious derive huge profits from sales of antidepressants... if the FDA-sponsored studies (or the ones they are depending on, in any event) are without merit -- wouldn't we be hearing a lot about that from those who have so much to lose?

I just have to think that any reputable study being done would have some reasonable degree of control. But I'm willing to be corrected if there's some evidence to the contrary.
The FDA is under a TREMENDOUS amount of pressure from various outside sources. As a result, they release warnings to cover their own asses, on less than ideal data. I don't follow the literature in other areas of pharmacology, but some of the studies that prompt an official warning by the FDA are staggering in the holes in them. I don't know exactly what studies the FDA are using as a basis of their decisions, but I do know that there is no good randomized double blind studies with controls for the issue of Anti-depressants causing suicidal ideation. These warnings come from political pressure much more than they come from good science.


Edit to correct: I know and read some of the studies and with a critical eye find them rather poor, but I don't know of all of the studies because there is a great deal of secretiveness around this as well.

[QuikSand]

Okay, I can connect the dots ("follow the money") and see how there would be political pressure to scuttle or obfuscate studies suggesting that highly profitable products are dangerous.

What is the source of the political pressure pushing this stuff out into the open? Sending out public warnings based on sketchy data seems to benefit... hmm... what am I missing? Is there a deeply monied lobby for traditional non-medicinal psychotherapy?

Is Tom Cruise somehow behind all this?

[Eaglesfan27]

However, I actually think in some ways the FDA warning is good. It might scare some Primary Care Physicians who use antidepressants in some careless ways. However, I also worry that it might cause patients who are truly depressed to not seek treatment.

Really, all the FDA is saying at this point is that patients with depression and suicidal ideation should be watched closely by their health professional. I definitely agree with that statement.

[Eaglesfan27]

Okay, I can connect the dots ("follow the money") and see how there would be political pressure to scuttle or obfuscate studies suggesting that highly profitable products are dangerous.

What is the source of the political pressure pushing this stuff out into the open? Sending out public warnings based on sketchy data seems to benefit... hmm... what am I missing? Is there a deeply monied lobby for traditional non-medicinal psychotherapy?

Is Tom Cruise somehow behind all this?
Tom Cruise is a vocal outspoken person, but there has been a HUGE movement for years that say psychiatrists are overmedicating patients, particularly children. When I went to the APA meeting in San Francisco two years ago, there were thousands of protestors. There is a signifcant amount of pressure in the common media as well. Time for example has had several articles suggesting that patients are being overmedicated, and certainly as an offshoot there is a wide spread belief that ADHD is overdiagnosed and perhaps even entirely contrived.


I could say many negative things about Tom Cruise, but the fact is that he isn't the only person with money who is very negative about psychiatry and the pharmaceutical industry.

Furthermore, to be fair, the profession has done some things that haven't exactly helped it in the past and currently. Many residencies rely too much on pharmaceutical companies to pay for Resident's lunches, their trips, etc. Many doctors rely on gifts from pharmaceutical companies far too often. That is not really confined to psychiatry. I certainly can see how it can cause the appearance of a conflict of interest and impropriety.


Edit: Actually, I doubt it was thousands (but it was hundreds of protestors.)

[QuikSand]

In case I'm not being clear... I don't have any problem with the warning. (Nor do I have any basis to criticize it pro or con)

I just have to believe that any reputable study would make at least a reasonable effort to normalize its results -- compare the suicide rates for patients with similar initial diagnoses who either do or do not begin to take certain medications, and compare/contrast their outcomes. I'm no clinician -- but the suggestion that some guy on an internet message board might be the first person anywhere along the line of academic inquiry to think "hey... depressed people are likely to commit suidice anyway. this study is bullshit!" sounds deeply suspect to me.

Perhaps I have too much inherent faith in the academic/research community.

[Eaglesfan27]

In case I'm not being clear... I don't have any problem with the warning. (Nor do I have any basis to criticize it pro or con)

I just have to believe that any reputable study would make at least a reasonable effort to normalize its results -- compare the suicide rates for patients with similar initial diagnoses who either do or do not begin to take certain medications, and compare/contrast their outcomes. I'm no clinician -- but the suggestion that some guy on an internet message board might be the first person anywhere along the line of academic inquiry to think "hey... depressed people are likely to commit suidice anyway. this study is bullshit!" sounds deeply suspect to me.

Perhaps I have too much inherent faith in the academic/research community.

I can see how it is confusing. The problem is that VAST source of funding for research is coming from pharmaceutical companies and there are inherent bias in these studies. For example, this most recently outcry came because of some studies done by the company that makes Prozac (or maybe it was Zoloft - it was a few years ago) stating that Paxil caused an increased risk of suicide in people. Paxil responded with a study that showed Prozac caused increased risk of suicide. By the time you are done, all of the drug companies have accused all of their competitors.

Do antidepressant's increase the risk of Suicide in patients? I don't know. I do know that I've never read one good study that really addresses this issue. I also know that I'll never get the funding for that study. Hopefully, the NIMH does do some good studies that explore this issue.

[QuikSand]

Hopefully, the NIMH does do some good studies that explore this issue.

Just don't mess with those cute little rats...

[Izulde]

It's not just antidepressants that cause problems. It's other drugs in the mental treatment category, including a few of the antipsychotics. Zyprexa, one of the ones I used to be on before I got straightened out without them, has been linked to diabetes and pancreatis (sp).

Bipolar people, I would imagine, are also at risk for increased suicide due to antidepressants. Because when we bipolars are put on antidepressants alone, we tend to have a lot more extreme manic swings... and since mania is inevitably followed by a crash into depression... it gets really ugly, because usually the higher you are at the mania, the harder and deeper you fall when you drop out into the depressive cycle.

[Eaglesfan27]

It's not just antidepressants that cause problems. It's other drugs in the mental treatment category, including a few of the antipsychotics. Zyprexa, one of the ones I used to be on before I got straightened out without them, has been linked to diabetes and pancreatis (sp).

Bipolar people, I would imagine, are also at risk for increased suicide due to antidepressants. Because when we bipolars are put on antidepressants alone, we tend to have a lot more extreme manic swings... and since mania is inevitably followed by a crash into depression... it gets really ugly, because usually the higher you are at the mania, the harder and deeper you fall when you drop out into the depressive cycle.
Now that Zyprexa data is MUCH stronger and is a very real phenomenon (it is a potential side effect and not a case of everyone on Zyprexa developing these probems.) Actually, most of the newer antipsychotics have the risk of diabetes and other metabolic disturbances. However, despite that, it can easily be argued that they are less dangerous than older antipsychotics which have their own potential side effects. If someone is psychotic it is a matter of determining if the risks outweigh the benefits. However, any psychiatrist or other physician who doesn't really do a good informed consent is a fool IMHO.

[Izulde]

Now that Zyprexa data is MUCH stronger and is a very real phenomenon (it is a potential side effect and not a case of everyone on Zyprexa developing these probems.) Actually, most of the newer antipsychotics have the risk of diabetes and other metabolic disturbances. However, despite that, it can easily be argued that they are less dangerous than older antipsychotics which have their own potential side effects. If someone is psychotic it is a matter of determining if the risks outweigh the benefits. However, any psychiatrist or other physician who doesn't really do a good informed consent is a fool IMHO.

That would be most of them. The informed consent they give is almost minimal, and the pharmacists aren't much better I've noticed.

We really need to a better job of educating physcians on the various side effects of each specific drug of psychopharmacology (sp) I've come to discover in my trips through ye olde mental health system.

[Eaglesfan27]

That would be most of them. The informed consent they give is almost minimal, and the pharmacists aren't much better I've noticed.

We really need to a better job of educating physcians on the various side effects of each specific drug of psychopharmacology (sp) I've come to discover in my trips through ye olde mental health system.
I agree with the first part of your statement. Most physicians I trained under gave very little informed consent. Fortunately, one of my attendings when I was an intern was as she called herself "The Informed Consent Nazi." She demanded that I tell the patient the top 10 side effects (along with the percentage of chance of occurring) for every medication I prescribed, give them a lithograph on the drug, and document the conversation including risks, benefits, alternative treatments, prognosis, etc.

She made me a better physician. I'm soon going to be known by a similar moniker as I start teaching my residents in a few weeks ;)


As far as the 2nd part of your statement, I think many psychiatrists are well trained and know about the potential side effects of the medications they prescribe. (Of course, there are a subset who aren't well trained and don't know the side effects. Also I think it is less common for internal medicine/family practioners to know the side various side effects.) I think there is a great deal of laziness about informed consent and the economic pressure to produce, produce, produce and I think informed consent is one of the corners that some physicians sometimes cut and give short shrift to. A very foolish decision in my opinion.

That is part of why I love my new job (which I started this past Friday,) since I work in a free care clinic for a set determined salary I don't have that pressure and I can spend as much time as needed with each patient to make sure they understand informed consent (along with whatever else is important.) Of course, I also have my nurse reinforce it when I'm done.

[Izulde]

I agree with the first part of your statement. Most physicians I trained under gave very little informed consent. Fortunately, one of my attendings when I was an intern was as she called herself "The Informed Consent Nazi." She demanded that I tell the patient the top 10 side effects (along with the percentage of chance of occurring) for every medication I prescribed, give them a lithograph on the drug, and document the conversation including risks, benefits, alternative treatments, prognosis, etc.

She made me a better physician. I'm soon going to be known by a similar moniker as I start teaching my residents in a few weeks ;)


As far as the 2nd part of your statement, I think many psychiatrists are well trained and know about the potential side effects of the medications they prescribe. (Of course, there are a subset who aren't well trained and don't know the side effects. Also I think it is less common for internal medicine/family practioners to know the side various side effects.) I think there is a great deal of laziness about informed consent and the economic pressure to produce, produce, produce and I think informed consent is one of the corners that some physicians sometimes cut and give short shrift to. A very foolish decision in my opinion.

That is part of why I love my new job (which I started this past Friday,) since I work in a free care clinic for a set determined salary I don't have that pressure and I can spend as much time as needed with each patient to make sure they understand informed consent (along with whatever else is important.) Of course, I also have my nurse reinforce it when I'm done.


I'm glad you're doing that and especially that you're passing on those habits to the residents you'll be receiving... even if they hate you and curse your name for it at the time. :D

Though I have to say, while I understand the pressure for production, I would think that with the litigious nature of our society and the escalating costs of insurance that doctors of all stripes in the medical community have to pay for, that they would be especially certain to make certain that they give full and complete informed assent as possible, so as to protect their backside from lawyer dragon flame breath weapon.

[NoMyths]

Just don't mess with those cute little rats...Now this made my night. We just christened the mouse that lives in my friend's wall Nicodemus. :)

[ThunderingHERD]

The masses' skepticism of psychiatry and, specifically, psychiatric medication, is rooted in self-interest (the same motive that informs critics of plastic surgery and "eugenics" [both of which I dislike, for admittedly selfish reasons.]). Either "I'm ok and don't want more people ok to knock down my relative ok-ness" or "I'm not ok and dammit, I don't want anybody getting the jump on me." The common jab of psychiatry making you into someone your is blatantly self-serving and false. A person seeks help because they do not feel like "themself". Anyone who felt like "themself" would be tolerant of their situation.

But the masses want to fix you in a formulated phrase. They want you pinned and wriggling on a wall.

[BigJohn&TheLions]

Basically if you're depressed and feeling suicidal, but you're not down enough to go past the "if I were dead..." stage into actually doing something about it you should be in therapy where you can talk about it. By just medicating the problem you might end up with someone who actually has the balls to step in front of that bus...