It comes from an article (Suicide Attempts Among Patients Starting Depression Treatment With Medications or Psychotherapy) and an editorial (Antidepressants and Suicidal Behavior: Cause or Cure?) in the latest (July 2007) issue of the American Journal of Psychiatry.
The main finding of the article was this: the temporal pattern of suicide attempts was the same regardless of treatment modality, and it was the same regardless of the age span of patients studied. Note that the pattern was the same, although the rates were different...
The three treatment modalities were: antidepressants
prescribed by primary care physicians (N=70,368),
antidepressants prescribed by psychiatrists
(N=7,297), and individual psychotherapy
(N=54,123). The discipline of the practitioners providing
psychotherapy was not specified.
In interpreting this study, it is important to note that it was done in a large population of subscribers to a particular health plan: the Group Health Cooperative, a mixed-model prepaid health plan serving approximately 500,000 members in Washington state and northern Idaho. It is not clear how generalizable the findings might be. The total patient population studied included the 109,256 who were treated for depression.
Basically, the risk was highest in those referred for treatment by a specialist, and lower for those kept in primary care. That is pretty much what one would expect. The risk is highest in those referred to a psychiatrist, and intermediate in those referred to a psychotherapist. Again, that is what one would expect.
What was not clear before, is that the risk of suicide attempts peaks before the onset of treatment, is still high in the month after treatment begins, and declines thereafter.
The editorial makes some good points:
In interpreting this study, it is important to note that it was done in a large population of subscribers to a particular health plan: the Group Health Cooperative, a mixed-model prepaid health plan serving approximately 500,000 members in Washington state and northern Idaho. It is not clear how generalizable the findings might be. The total patient population studied included the 109,256 who were treated for depression.
Suicide Attempts Among Patients Starting Depression Treatment With Medications or Psychotherapy
Gregory E. Simon, M.D., M.P.H. and James Savarino, Ph.D.
Am J Psychiatry 164:1029-1034, July 2007
doi: 10.1176/appi.ajp.164.7.1029
OBJECTIVE: This study compared the time patterns of suicide attempts among outpatients starting depression treatment with medication or psychotherapy. METHOD: Outpatient claims from a prepaid health plan were used to identify new episodes of depression treatment beginning with an antidepressant prescription in primary care (N=70,368), an antidepressant prescription from a psychiatrist (N=7,297), or an initial psychotherapy visit (N=54,123). Outpatient and inpatient claims were used to identify suicide attempts or possible suicide attempts during the 90 days before and 180 days after the start of treatment. RESULTS: Overall incidence of suicide attempt was highest among patients receiving antidepressant prescriptions from psychiatrists (1,124 per 100,000), lower among those starting psychotherapy (778 per 100,000), and lowest among those receiving antidepressant prescriptions in primary care (301 per 100,000). The pattern of attempts over time was the same in all three groups: highest in the month before starting treatment, next highest in the month after starting treatment, and declining thereafter. Results were unchanged after eliminating patients receiving overlapping treatment with medication and psychotherapy. Overall incidence of suicide attempt was higher in adolescents and young adults, but the time pattern was the same across all three treatments. CONCLUSIONS: The pattern of suicide attempts before and after starting antidepressant treatment is not specific to medication. Differences between treatments and changes over time probably reflect referral patterns and the expected improvement in suicidal ideation after the start of treatment.
Basically, the risk was highest in those referred for treatment by a specialist, and lower for those kept in primary care. That is pretty much what one would expect. The risk is highest in those referred to a psychiatrist, and intermediate in those referred to a psychotherapist. Again, that is what one would expect.
What was not clear before, is that the risk of suicide attempts peaks before the onset of treatment, is still high in the month after treatment begins, and declines thereafter.
The editorial makes some good points:
Antidepressants and Suicidal Behavior: Cause or Cure?I don't consider the matter settled, by any means. The previous data were examined very carefully, so a couple of articles cannot settle the matter. No doubt there will be more. We do need more. The people who are most qualified to study the issue may have a bias toward finding that the treatments they have advocated for years do not hurt people. The only way to overcome a bias like that is by replication and careful peer review.
David Brent, M.D.
Am J Psychiatry 164:989-991, July 2007
doi: 10.1176/appi.ajp.164.7.989
A decade of declining adolescent suicide rates came to an end in 2004 with an 18% increase in adolescent suicides from the previous year (1). This disturbing increase in the adolescent suicide rate coincided with publicity about the relationship between antidepressant treatment and suicide risk in children and adolescents and a subsequent decline in antidepressant prescriptions...
...Simon and Savarino provide an elegant illustration of the need to consider the previous history of suicidal behavior and its role in referral when evaluating the relationship between treatment and subsequent suicidal behavior...
...Observational studies can never definitively demonstrate causality. However, the results of both studies by Gibbons et al. and Simon and Savarino are consistent with a protective role of treatment against emergent suicidal behavior, and perhaps just as important, these data show a pattern that is exactly the opposite of what one might expect if antidepressants were associated with increased suicidal risk...
Comments
An interesting thing to me is the implication that a large number of people have to make a suicide attempt before they get treated.
This counters the idea that physicians are prescribing antidepressants willy-nilly -- looks like, if anything, they might be more liberal. Of course, it's a bit more complicated, since it may be that one of the features of depression is that depressed people do not seek help with milder symptoms, but wait until a crisis forces the issue.
Posted by: Greg P | July 11, 2007 8:42 AM
I wonder what the graph would look like if treatment were occurring before, rather than after, suicide attempts. So, is the lower rate after treatment a result of the fact that the people with unsuccessful attempts are less likely to try again in the short term because they attempted?
I guess that's basically asking whether failed suicide attempts are associated with more or fewer suicide attempts in the following month. I know suicide attempts are good predictors of future suicide attempts, but I don't know if that's true over all timespans.
Posted by: resonance | July 11, 2007 9:30 PM
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Posted by: complex41 | April 16, 2011 9:16 PM
Before anyone in the UK gets Pychothreapy they have to be very ill. Usually having a pattern of suicide attempts.
How can anyone on $1,0000 a week treat someone on $63 a week.
Of couse a lake of money can make anyone depressed
Posted by: Billy | April 17, 2011 7:36 PM