Friday, April 18, 2014

Antidepressants and Suicide: A History

Do antidepressants prevent suicide, or do they cause it?


Well, maybe.

It's a no-brainer, right?  People who commit suicide are depressed.  Take away the depression, and how better than with an anti-depressant, and you decrease the risk of suicide.

So what's with the question?  Here is the story:

History of Antidepressants

The first modern medications used to treat depression were imipramine and its imitators, developed in the 1950s.  Nortriptyline is a currently prescribed example.  They worked great, but had harsh side effects, plus one major draw-back.  Overdoses are lethal.  A lot of doctors were reluctant to hand them to people who had announced their intention to off themselves.

Then came Prozac.

Debuting in 1987, Prozac had less severe side effects and was deemed safer.  An overdose might make you sick, but was not fatal.

It was soon followed by a host of other medications that worked the same way (for us brain geeks: by inhibiting the reuptake of serotonin).  These include Celexa, Lexapro, Zoloft, Paxil, and Luvox, and half siblings Cymbalta, Effexor, and Pristiq.

Over the next 20 years, antidepressant use increased by 400%.

Today, 11% of people in the US, aged 12 years and older, take antidepressants.  Among women in their forties and fifties, 23%.

Evidently, a lot of doctors overcame their reluctance.

Bad News and Prozac

However, an occasional news story began to appear.  People on Prozac claimed the medication was responsible for irrational behavior, even violent crime.

The Prozac Defense in court was usually rejected out of hand.  But troubling claims about suicide, particularly among teenagers, would not go away.

Suicide and Statistics

Research about suicide risk for antidepressants is plagued by problems with method.  The biggest issue is that clinical trials, designed to determine whether a medication works, do not enroll enough participants to yield significant results about suicide risk, either positive or negative.  (Significant in research lingo means that the results reach a certain level of probability, that they didn't happen by chance.)  It doesn't take as many participants to establish efficacy.

Researchers record what they call Adverse Events, AE.  Suicide would be a Serious Adverse Event, SAE.  Ya think?  person with clinical depression has a 10-15% risk of suicide over a lifetime.  But pick any random two-month period out of that whole lifetime, say April and May, and chances are really good that person will survive to June.  That's as long as a clinical trial lasts.  So the odds are friendly to drug companies who do not want people to die while they are testing their newest money maker.

In 2003 the British equivalent of the FDA (Medicines and Healthcare Products Regulatory Agency - MHRA) conducted a meta-analysis -- they put together the data from several clinical trials.  With these greater numbers, they did establish a significant risk of suicide for teenagers taking antidepressants, and banned the use of all antidepressants except Prozac for teens and children.  Prozac dodged this particular statistical bullet, though in the US, the FDA would later find against them.

Well, you can imagine how that went over among doctors who want to prescribe these drugs, not to mention the drug industry that wants to sell them. 

FDA Weighs In

After the MHRA raised the alarm, the FDA conducted its own meta-analysis, addressing objections raised to how the MHRA counted suicidal events.  They came to similar conclusions as the MHRA, but stopped short of banning anything.  Instead, in 2004 they required that a black box warning be added to the prescribing information.

All medications have risks, even when prescribed by doctors who know what they are doing.  A doctor (should) educate the patient about risks and the more frequent side effects.  Some doctors are more conscientious about this responsibility than others.

A black box warning is the strongest caution the FDA gives for a medication that it allows to be sold.  It tells the doctor to inform the patient about the risk included in the warning.  In addition, the box is printed right up top on the paper that comes with the medicine bottle from the pharmacist.  So patients (might) see it, even if their doctor fails to provide adequate information.

Here is the template for the current version:

Again, you can imagine how that went over.

Why a Black Box Warning?

The value of these black boxes might reasonably be questioned.  Patients do not see them until they have the medication in their hands.  The simpler one-sheet that lists what it is for, how to use it, and what its potential side effects are begins with another line, something like: This information should not be used to decide whether or not to take this medicine or any other medicine.  Only your health care provider has the knowledge and training to decide which medicines are right for you.

Well, okay.

Meanwhile, the patient's ten minutes with the doctor are over, and the doctor is no longer available for further discussion.

And even assuming that anybody is reading any part of what has become a several page insert in tiny print, what does clinical worsening, suicidality, or unusual behavior mean, anyway?

John Grohol of summarizes the medical profession's problem with this warning by suggesting that shallow reporting of the issue scares people off of effective treatments, and leaves them no better informed about their specific risks and benefits.

And with that we move next week to what doctors and drug companies have to say, The Defense, and after that what I wish doctors and the FDA were saying, Collateral Damage.  Stay tuned...

The Death of Chatterton by H. Wallis, in public domain
photo of Prozac by Tom Varco, used under creative commons license
photo of pancakes by Jacks and Jason's Pancakes, used under creative common license
photo of gavel from Luke Air Force Base by Airman 1st Class Grace Lee, in the public domain
image of black box warning in public domain
flair from

Thursday, April 3, 2014

How To Tame Your Mind -- Ruby Wax

It's like training a dragon, only harder.

Ruby Wax nails depression: when your personality leaves town, and suddenly you are filled with cement.

She nails the problem: our brains don't have the band width for the 21st century.  Nobody's brain does.  Yours doesn't, either.

And she nails the solution: learning how to apply the brakes.

Monday, March 24, 2014

Richie Cox, Rest Easy Now

Any story worth telling is worth improving.

Richie had a fisherman's philosophy when it came to story telling.  He inspired, or provoked, or was co-conspirator in many of the Bar Tales of Costa Rica.  The following excerpt is my tribute to this cowboy/hippie/mystic who will be sorely missed.


There is one particular table at the Pato Loco where deals get made over American breakfast.  Mama, who has overheard a lot of deals being made, said, “It gets so you can tell the real ones from the ones who are all talk.  Paul, he never talks about his deals.  He’s one of the real ones.  But that Jerry who reneged on the house, you could tell he was all blow.”

Saturday, March 8, 2014

Christina the Astonishing!

Basil the Great vs. Christina the Astonishing – Lent Madness begins.

Saints and Lent – is Prozac Monologues straying from its mission, reflections and research on the mind, the brain, mental illness and society?  Hardly.  First, note the Madness in Lent Madness.  Then wait ‘til you see the saints.

Lent Madness

The forty days before Easter are traditionally a time to focus on one’s spiritual growth.  But there is a looniness built in from the start.  Ash Wednesday to Holy Saturday – count them – 46 days.  Oh yeah, Sundays don’t count.  Does that mean I can smoke and eat chocolate on Sunday?  Opinions vary.

And once you are debating whether you can smoke on Sunday (does it depend on what you’re smoking?), you have already leaned in the direction of madness.  Leaning, leaning…

Wednesday, March 5, 2014

Suicide Is Not a Choice

I peered over this very overpass on the Eisenhower Expressway.  Years ago, there was no the fence along the top, just a rail.  It was pie that brought me there.  Yes, pie.  It was Thanksgiving night, and the holiday was ending without pie.

Of course, it wasn't a reason to commit suicide.  Of course, suicide is a permanent solution to a temporary problem.  Don't treat me like an idiot with your clever lines.

No, pie brought me there, but that was not why I would jump.  Pie was a match, a tiny little three letter match.  My problem was a brain filled with gasoline.  And one tiny match, that I should have been able to snuff with my fingers, threatened to ignite it and send me over the edge.  The shame of being powerless over one tiny match poured on more gasoline.

Wednesday, February 26, 2014

Suicide Immoral? WTF?

Guilty pleasure: Eavesdropping on psychiatrists talking with each other about us loonies.  Like many guilty pleasures, it is not always good for my well-being.  But I am endlessly curious.  And it has yielded a number of blogposts in the OMGThat'sWhatTheySaid thread.

My go-to source for blog material is Psychiatric Times.  It reports the latest news and research in Loony Land.  It reflects on the practice of psychiatry.  Sometimes it turns to mud wrestling.  Oh, the good ol' DSM days!

A couple months ago, one of the editors, Ron Pies wrote a brave (foolhardy?) editorial inspired by Jennifer Michael Hecht's book, Stay: A History of Suicide and the Philosophies Against It.  Intending to provoke, he titled it, Is Suicide Immoral?  Let the rumble begin.

Saturday, January 11, 2014

Andrew Solomon on Depression

I want to be Andrew Solomon when I grow up.  Only briefer.  And funny.

In the absence of blood tests, people with depression have words.  And Solomon has a lot of them.

Solomon's book The Noonday Demon: An Atlas of Depression sits by my bedside. I'll get through it someday soon, because I want to tell potential publishers that Prozac Monologues is Noonday Demon, only briefer.  And funny.

Solomon went around the world to report how the world experiences depression.  Yes, he found it everywhere.

Last week when I told my doctor I was going to Costa Rica, he asked if I would feel better there.  You know what? People in Costa Rica get depression, too.  Hard to imagine, I know.  But it's true. They have psych wards and therapists and ECT and everything in Costa Rica.  I have a card for a psychiatrist in San Jose, just in case.