1 Boring Old Man

I’m about to hit the road to visit an old friend on the other end of the South for a few days and will be out of pocket, but I didn’t want to take off without linking to this article about the BMJ study at hand [Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study].

Did the FDA antidepressants warnings increased suicidality?

PLoS Blogs

By Adrian Preda M.D.

June 21, 2014

A new study just published in the BMJ makes this very point [Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study]

The title makes two claims:

1. That the  2003 black box  US Food and Drug Administration warning about possible increased risk of suicidality with antidepressants lead to a change in antidepressant prescriptions.
2. Further, that there were changes in suicidal behavior following the said US FDAwarning.

While the title does not indicate the direction of the changes, the study conclusions carry little ambiguity:

Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people.

This is obviously a big claim, with far reaching implications spreading from the level of primary care physicians who might consider changing their antidepressant prescription practices to the level of policy makers deciding on guidelines about antidepressants approvals and reimbursement. In this post we will discuss some of the study limitations that, for unclear reasons, seem to have been all but ignored by the over-excited welcome that study received in the mainstream media. Our goal here is to not discuss subtle academic limitations but rather obvious limitations which could have been picked even by a casual yet critical reader of the paper. We will then cursorily survey the media presentations of the paper and assess the quality of their review in terms of balance and fair criticism. Let’s start with some of the study most overt shortcomings:

1. The title is not entirely informative. The study reviews US data however the title seems to indicate world-wide findings.
2. The study uses a quasi-experimental design assessing changes in outcomes after the FDA  warnings, controlling for pre-existing trends. However the reliability of the controls is not entirely convincing.
3. Not much is known about the relationship (if any) between the individuals entered in the study because they were prescribed antidepressants and the individuals who took psychotropic overdoses.
4. The study uses psychotropic drug poising data as a proxy for suicide but is that a good proxi?
5. The study does not address the possibility that suicide has been on the raise for reasons having nothing to do with antidepressant prescriptions (such as the recent years economic crisis).

Big media enthusiastic welcomes

First the Washington Post (Dennis) reports:

As a result [of the FDA warnings] antidepressant prescriptions fell sharply for adolescents age 10 to 17 and for young adults age 18 to 29. At the same time, researchers found that the number of suicide attempts rose by more that 20 percent in adolescents and by more than a third in young adults.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

According to NBC News (Raymond) :

New research finds the warning backfired, causing an increase in suicide attempts by teens and young adults. After the FDA advisories and final black box warning that was issued in October 2004 and the media coverage surrounding this issue, the use of antidepressants in young people dropped by up to 31 percent.

Comment from a non-study affiliated expert? NO

How many limitations are discussed? NONE

Reuters (Seaman) reports that:

Antidepressant use decreased by 31 percent among adolescents, about 24 percent among young adults and about 15 percent among adults after the warnings were issued. At the same time, there were increases in the number of adolescents and young adults receiving medical attention for overdosing on psychiatric medicines, which the authors say is an accurate way to measure suicide attempts. Those poisoning increased by about 22 percent among adolescents and about 34 percent among young adults after the warnings. That translates to two additional poisoning per 100,000 adolescents and four more poisoning per 1,000 young adults, the researchers write.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? ONE (limitation #5)

According to USA TODAY (Painter):

Warnings that antidepressant medications might prompt suicidal thinking in some young people may have backfired, resulting in more suicide attempts, new research suggests.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

Forbes (DiSalvo) reports:

Antidepressant use fell 31 percent among adolescents and 24 percent among young adults after the FDA warnings, according to the study. Suicide attempts increased by almost 22 percent among adolescents and 33 percent among young adults in the same time period. Suicide attempts tracked in the study were largely the result of drug overdoses.

Comment from a non-study affiliated expert? NO

How many limitations are discussed? NONE

NPR (Stein) also reports on the story:

Antidepressant use nationally fell 31 percent among adolescents and 24 percent among young adults, the researchers reported. Suicide attempts increased by almost 22 percent among adolescents and 33 percent among young adults.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? ONE (limitation #5)

Finally, the Boston Globe (Freyer) concludes that

instead of declining as hoped, suicide attempts over the next six years showed a “small but meaningful” uptick among people ages 10 to 29, according to a study published Wednesday in the journal BMJ. That increase followed a substantial drop in the use of antidepressants.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

Final conclusions

Somewhat paradoxically, a study that tongue-in-cheek points to the media’s uncritical coverage of medical news as a possible contributor to a public health issue receives an almost universal and equally uncritical acclaim from the same media that it rightfully criticizes. In a past analysis of medical news reporting I stated that

In closing: my hope is that members of the media who cover [medical] debate[s] will realize that “first do no harm” is not only the duty of physicians; it is also the responsibility of anyone trusted with giving health information to the public at large.

More than 2 years later I found that this conclusion still stands…