there to do…

Posted on Tuesday 20 March 2012

When I first heard of this story I was too confused about it to comment. The study concluded originally that antidepressants decreased the incidence of suicide based on blood sample analysis, but I couldn’t follow the logic well enough to comment. This report from Retraction Watch makes it a bit clearer:
Authors retract paper claiming antidepressants prevent suicide
Retraction Watch
by ivanoransky
March 19, 2012

The authors of a study allegedly showing that antidepressants prevent suicide have retracted it over unspecified errors. Here’s the notice:
    At the request of the authors and in agreement with the Editor-in-Chief and Wiley-Blackwell, the following article “Antidepressant medication prevents suicide in depression”. Acta Psychiatr Scand 2010;122:454–460 has been retracted. The retraction has been requested and agreed due to unintentional errors in the analysis of the data presented.
The original paper linked “data on the toxicological detection of antidepressants in 18 922 suicides in Sweden 1992–2003″ to “registers of psychiatric hospitalization as well as registers with sociodemographic data.” It found:
    The probability for the toxicological detection of an antidepressant was lowest in the non-suicide controls, higher in suicides, and even higher in suicides that had been psychiatric in-patients but excluding those who had been in-patients for the treatment of depression.
Its conclusion was a bit convoluted:
    The finding that in-patient care for depression did not increase the probability of the detection of antidepressants in suicides is difficult to explain other than by the assumption that a substantial number of depressed individuals were saved from suicide by postdischarge treatment with antidepressant medication.
The paper has been cited just four times, according to Thomson Scientific’s Web of Knowledge. But we understand that other  studies by lead author Goran Isacsson are often used by those who support the idea that antidepressants cut down on suicides, and as evidence that the FDA’s “black box warning” on antidepressants should be rewritten. That warning reads, in part:
    Antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, and young adults when the medicine is first started.
Isacsson and a co-author debated the issue with Melissa Raven and a co-author in the June 2010 issue of the British Journal of Psychiatry. At one point, Raven and Jon Jureidini conclude:
    In summary, Isacsson & Rich’s premises are flawed and they have overstated their case with selective citation and biased interpretation of evidence.
We’ve contacted Isacsson as well as the editor of Acta Psychiatrica Scandinavica to find out what the “unintentional errors” were, and whether any other papers will be affected, and will update with anything we find out.

Update, 11:45 a.m. Eastern, 3/19/12: Isacsson tells us:
    We discovered lately that there was a coding error regarding diagnoses in the database we utilized for the 2010 paper. When corrected, antidepressants were detected in depressed suicides as often as could be expected and  not less than expected which was the crucial finding in the paper. This means that no conclusion can be drawn from the study regarding antidepressants’ effects on suicide risk in any direction. The database has not been used for other studies so no other papers are affected.
Hat tip: Bernard Carroll
Actually, this is an understatement, "But we understand that other  studies by lead author Goran Isacsson are often used by those who support the idea that antidepressants cut down on suicides, and as evidence that the FDA’s “black box warning” on antidepressants should be rewritten." A perusal of PubMed shows Issacsson to be a vocal and prolific "anti-black-box-warning advocate," even more that Dr. Gibbons here in the US. Also like Dr. Gibbons, he’s come at the issue from many different directions to try to debunk the FDA Warning. Here is the full text version of Isacsson’s debate in the British Journal of Psychiatry with the members of Healthy Skepticism on the topic. And speaking of understatements, this is another, "Its conclusion was a bit convoluted." I still can’t make sense of the original paper’s logic.

Also like Gibbons, Isacsson’s approach is epidemiological, attempting to say that the incidence of suicide is either not increased by antidepressants or actually lowered by their use. While there’s yet to be any credible evidence that is true, they just keep hammering with increasingly bizarre studies [and this one, even before retraction was pretty bizarre]. That aside, they miss the point by a mile. The Akathisia accompanied by violent thoughts and sometimes suicide is uncommon but very real. Independent of any epidemiologic evidence, when you see it, it’s dramatic and potentially lethal. The black box warning says:


It says that it’s something that can happen and people need to be aware of it, warn their patients, and keep a close eye. That’s simply the truth. If you’ve seen it as I have, you’re an immediate believer – epidemiology doesn’t matter in the n=1 world of caring for patients. The never-ending assault on the warning seems to me to be because it scares people who are seeing patients in a primary care setting where they can’t take the time to do what’s needed, and that impacts drug sales. That’s absolutely fine by me. It should scare them. Drug sales are not our concern. Isacsson and Gibbons have positioned themselves on the wrong side of this equation. One might legitimately question the warning if the antidepressant efficacy were a whole lot better – but it’s just not. That is absolutely clear. And even if they were more effective, the warning still ought to be there in my way of thinking to keep us vigilant.

The FDA is to be commended for finally issuing the warning, and is obligated to stand by it. It’s what the agency is there to do…

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