More on Antidepressant-Suicide Link

This
is starting to look like a never-ending saga, and I have written
about it extensively before.  But this latest update certainly
deserves some attention.



It comes from an article ( href="http://ajp.psychiatryonline.org/cgi/content/abstract/ajp;164/7/1029">Suicide
Attempts Among Patients Starting Depression Treatment With Medications
or Psychotherapy
) and an editorial ( rev="review"
href="http://ajp.psychiatryonline.org/cgi/content/full/ajp;164/7/989">Antidepressants
and Suicidal Behavior: Cause or Cure?
) in the
latest (July 2007)
issue of the href="http://ajp.psychiatryonline.org/">American
Journal of Psychiatry
.
 


i-b5ac1a807cd8d8ae54195653a2477326-Suicide_risk_graph.gif



The
main finding of the article was this: the temporal pattern of href="http://en.wikipedia.org/wiki/Suicide#Suicidal_gestures_and_attempts">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: href="http://en.wikipedia.org/wiki/Antidepressant">antidepressants
prescribed by href="http://en.wikipedia.org/wiki/Primary_care_physician"
rel="tag">primary care physicians (N=70,368),
antidepressants prescribed by href="http://en.wikipedia.org/wiki/Psychiatrist">psychiatrists
(N=7,297), and individual href="http://en.wikipedia.org/wiki/Psychotherapy">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 href="http://www.ghc.org/" rel="tag">Group Health
Cooperative, a mixed-model prepaid health plan serving
approximately 500,000 members in Washington state and northern Idaho.
face="Helvetica, Arial, sans-serif">  It
is not clear how generalizable the findings might be.
face="Helvetica, Arial, sans-serif">
 The total patient population studied included the 109,256 who
were treated for depression.
 



rev="review"
href="http://ajp.psychiatryonline.org/cgi/content/abstract/ajp;164/7/1029">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:



href="http://ajp.psychiatryonline.org/cgi/content/full/ajp;164/7/989">Antidepressants
and Suicidal Behavior: Cause or Cure?


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...

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.



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In 2004, the FDA assigned a "black box" warning on prescription of antidepressants to patients under 25. This was because of a flurry of anecdotal evidence linking the beginning of treatment with SSRIs to increases in suicide risk and because of placebo vs. drug trials that showed these increases…
The Treatment for Adolescents with Depression Study (TADS) is a major NIH-sponsored study of the treatment of adolescents with depression, in which href="http://en.wikipedia.org/wiki/Fluoxetine" rel="tag">fluoxetine-only, rel="tag">cognitive-behavioral therapy only, combination treatment,…
I chose three articles from this month's edition of Archives of General Psychiatry, upon which to comment.   For those not familiar with it, Arch Gen Psychiatry is an AMA journal, like JAMA, but for psychiatrists.  It's an influential journal. 1. href="http://archpsyc.ama-assn.org/cgi/content/…

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.

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.

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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