Reduction in Suicide Rates Since the Introduction of Prozac

PLoS Medicine is reporting a paper that compares the declining suicide rate in the US to the increasing number of prozac prescriptions since the drug's introduction in 1988. They find that the two are very well correlated:

The steady decline in suicide rates for both men and women is associated with an increasing number of fluoxetine prescriptions from 2,469,000 in 1988 to 33,320,000 in 2002. A cross-correlation analysis of fluoxetine use and suicide rates in the period 1988-2002 shows a significant negative correlation: rs = â0.92, p

Granted (as many of you will likely point out) correlation is NOT causation. The premise, however, that with better medical treatment of depression we have reduced the suicide rate is not unreasonable. The paper also estimates the number of lives that may have been saved by the reduction of the suicide rate since the introduction of SSRIs.

Using the total number of observed suicide deaths (with fluoxetine) per year and our time-series model, we estimated the approximate number of additional deaths we might have expected if pre-1988 trends were maintained. If the hypothesis that fluoxetine decreases suicide rates were to be accepted, then taking the difference between the predicted and actual suicide deaths would estimate the number of suicides that were presumably prevented by SSRIs such as fluoxetine. Figure 3 shows these estimates for each year (posterior median prediction with 95% BCIs). Summing of these values in the period 1988-2002 would, on that basis, result in an estimation that SSRIs may have saved 33,600 (22,400-45,000) lives since their introduction.

I guess my one concern with the data in this article is that prozac is not the only SSRI. I wouldn't even consider it the best SSRI. I wonder if the data would be better if they included the other ones. Also, I think you could go about proving the premise by doing longitudinal studies showing suicide rates in medicated and nonmedicated depressive patients. I imagine these may have been done already but I don't have time to look it up.

Hat-tip: Future Pundit.

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This is kind of an old story, I know.  Still, every once in a while it is good to revisit these things.  When the topic first came up in 2004, it was the subject of much newspaper space and blog commentary.  But now, it has pretty much faded from the national consciousness.  Has anything more come…
Prozac (aka fluoxetine) is one of the most successful drugs of all time. Since its introduction as an antidepressant more than 20 years ago, Prozac has been prescribed to more than 80 million people around the world. Currently, approximately one in ten Americans are on an anti-depressant, with the…

I had wondered about this in the face of the lawsuits about "Prozac-caused suicides". There's also the fact that ODs of SSRIs are much less likely to be lethal than ODs of tricyclics. As a pathologist, I see far fewer fatal ODs from prescription drugs than I saw even 10 years ago. I have never seen a lethal OD of an SSRI. Tricyclic ODs used to be common, now they are rare.

By Bruce McNeely (not verified) on 19 Jun 2006 #permalink

I am pretty sure that the consensus was that most SSRI deaths were related to children, and that they are not caused by OD but rather by akathisia. I think they are still sorting out the recommendations for children so that we can prevent that increase in suicides.

I would totally believe though that there has been a reduction in tricyclic ODs as they went out of favor because they do have way more side effects than SSRIs.

I don't think that there have been actual suicides clearly related to SSRI's, even in children. The kerfuffle in 2004-2005 had to do with findings that children and adolescents had increased rates of suicidal thinking and related behaviors, but that there were no actual suicides in the studies.

Note that, more recently, there was a study about the risk of suicidal thinking occurring shortly after starting psychotherapy. It turns out that there is an increased risk with psychotherapy, too. It wasn't a very big study, and I wasn't very impressed by it, and did not save the link, but it does at least make you stop and think.

Perhaps what is important here, is that the study showing correlation between increased SSRI prescribing and decreased suicide risk is a study that gives a long-term perspective. In contrast, studies that show correlation between starting an antidepressant and increased risk of thinking about suicide are short-term studies.

I'm tempted to hypothesize that an increase in risk is going to be seen when something upsets the psychological equilibrium in depressed patients. Any intervention, of any sort, is going to do that. But hopefully, once the treatment is applied and a new equilibrium is reached, the risk is decreased.

Most often, a decreased risk applied over a long period of time is going to more than offset an increased risk over a short period of time.

Current Depression Medications: Others Unaware of Deadly Risk?

Presently, for the treatment of depression and other what some claim are mental disorders, as some claim some mental disorders are somewhat questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers today, clearly. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications, which are the number 1 top therapeutic class of prescriptions presently. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others. Furthermore, adding an additional agent is presumed to increase the effect by some.
Some Definitions:
Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrists bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.
Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.
And depression is only one of those mood disorders that may exist in certain patients, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis or impression concluded by the patients doctor is dependent on subjective criteria, such as questionnaires. A social patient history is uncertain and tricky. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed? What is believed is that if one is disabled or impaired from a mental paradigm, treatment is necessary and appropriate. Psychology is such a soft and manipulative science, perhaps like religious denominations. Further disturbing is an article in Time magazine that stated that the military in the war are pounding down SSRIs. Everytime there is a new war, there is a new drug, it seems.
Several decades ago, less than 1 percent of the U.S. populations were thought to have depression, it has been said. Today, it is believed that about 10 percent of the population in the United States have depression at some time in their lives that may vary in severity and longevity. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds, as this industry clearly desires market growth of these products. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders are suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related disease states.
Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year now, along with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to be marketed for the treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, the happy pill. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
Furthermore, these meds have received and desired by their manufacturers for additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, which is disease mongering, by definition. As a layperson, I consider such activities dangerous and inappropriate for several reasons.
Danger and concerns by others primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically, as I recall. Furthermore, that drug is in the spotlight once again years later. Some believe the drug maker knew about possible risk to the youth as early as 1991.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the possible damaging effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities, along with the black box warning now on SSRI prescribing information for the youth since 1994.
Finally, if SSRIs are discontinued, immediately in particular method of avoid tapering the prescribed dose, or the gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.
SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patients well -being regarding the patients mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. And doctors praised trycyclics in a similar manner some time ago. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber. It is my hope that such a prescriber rules out possible deficiencies of a patient they diagnose as being mentally impaired, such as other diseases or meds that could cause a mental illness, imbalances with the patients hormones, deprivation of light and/or sleep, or life stressors. Rarely do prescribers consider such possibilities.

I use to care, but now I take a pill for that. --- Author unknown

Dan Abshear

Authors note: What has been written is based upon information and belief