Kids, Antidepressants & Suicide: Could The Stats Cancel Each Other Out? is a thoughtful blog post by a person who was apparently really helped by anti-depressant medication as an adolescent. Reading Dr. Gibbons’ article [Suicidal Thoughts and Behavior With Antidepressant Treatment], she asks, "Could The Stats Cancel Each Other Out?" After reading it, I think that I’ll weigh on the debate, in spite of saying I wouldn’t [changing one’s mind is one of the great prerogatives of human life – way under-utilized].
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Statistically, antidepressants aren’t a panacea for depression in adolescents [a book review…, tuning the quartet…].
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Sometimes they help [as in the case of Kaitlin, the blogger above].
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Sometimes they don’t.
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And sometimes, they can cause a real problem – an akathisia that can be accompanied by violent or suicidal thinking, like in my case in the last post [a book review…]. Even if we haven’t seen such a case, we know that can happen because there’s a Warning right there on the package insert provided by the FDA. It says, "Antidepressants increased the risk compared to placebo of suicidal thinking and behavior [suicidality] in children, adolescents, and young adults in short term studies of Major Depressive Disorder [MDD] and other psychiatric disorders." What "increased the risk" means is that it sometimes happens – not always, not frequently, but sometimes.
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We’ve looked into that risk and we know that the kind of problem that Warning is about occurs early in the treatment with these drugs. It’s an idiosyncratic reaction to the drugs.
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the people at the National Bureau of Economic Research [News coverage of FDA warnings on pediatric antidepressant use and suicidality]
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and now Dr. Gibbons with his ninth article related to the topic [Suicidal Thoughts and Behavior With Antidepressant Treatment].
So back to Kaitlin’s question, "Could The Stats Cancel Each Other Out?" – could the decreased suicidality in patients who respond to the medication equal or even exceed the incidence of suicides caused by reactions to the drugs? If that were the point, we’d have SSRI dispensers in convenience store bathrooms or packages lining the over-the-counter shelves of our pharmacies. We wouldn’t need doctors to be involved at all [Depressed? Try Paxil OTC!]. Medical statistics are just that – statistics. A better approach with real cases is to use medications with a statistical downside only in cases justified by the risk-benefit ratio, and then under circumstances that are appropriately mindful of that risk – no matter what the frequency. The solution is not to keep doctors in the dark about the risk.
“The solution is not to keep doctors in the dark about the risk.” well said. I would add, open and honest communicating with patients/public about the nature of a psychiatric diagnosis, potential benefits and possible risks of any treatment, needs to be valued; sacrosanct.
Some people drink a six-pack of beer, or have a few shots of liquor, and they’re everyone’s best friend… Telling jokes, the life of the party.
Another person has a six -pack of beer, or a few shots of liquor, and they’re full of rage, verbally abusive, ready to go fist-to-cuff with local law enforcement.
What has this got to do with psychiatric drugs?
Everything.
Antidepressants have the same effect.
Making one person more mellow… the person next to them, more angry.
But, they are not “medicinal”… not ever.
No more than alcohol is medicine.
An honest discussion on psychiatric drugs (including antidepressants) would involve coming to terms with some facts: nobody knows for certain what the “side effects” of a drug will be, because we cannot measure neurotransmission… and because we have no idea what effects will take place once somebody alters their mind with a drug – prescription or otherwise.
I’ve got no problem with adults who want to drink.
And no problem with adults who want to take psychiatric drugs (with informed consent)… which is very rare to say the least.
But neither are “medicine”… both are drugs.
Duane
While suicide is a tragic and terrible condition — in medical terms, death being the ultimate tragic and terrible condition — it is still rare.
In adults, the suicide rate is about .01%. It’s hasn’t changed in at least 25 years; widespread antidepressant use has not reduced this at all.
From 2007 statistics, the annual diabetes death rate is more than twice as high, and rising.
Proponents of antidepressant prescribing are always playing the suicide card as justification for doctors reflexively medicating anything that can remotely be described as depression. Yet should not serious side effects — increasing the diabetes rate, for example — also be factored in to the equation?
Should not doctors also be concerned with shortening the lifespan of their patients with unnecessary medication?
Adverse reactions that cause suicidal thinking and probably successful suicides also occur in adults, probably at a rate much higher than reported. See these patient stories http://tinyurl.com/3o4k3j5 and note how many people had serious adverse reactions from the very first, yet their doctors kept them on antidepressants anyway. Difficulties in withdrawal also bring thoughts of suicide.
The writer David Foster Wallace finally succeeded in killing himself after experiencing 1.5 years of undiagnosed Nardil withdrawal syndrome. He probably thought he had finally completely lost his mind.
It’s unfortunate that the myth about the overriding need to stamp out suicide has been promulgated by the depression industry, which includes NAMI and other organizations Astro-turfed by pharma, to eclipse any thoughtful consideration of the other health risks of psychiatric drugs.
This is another area where psychiatry has failed to lead in protecting public health.
Thanks for your thoughtful response to my post. Making sure both parents and patient are informed of the risks is crucial, as you say, for informed consent. With younger patients, who can only assent, it becomes a trickier proposition. I suppose it depends on the level of insight and sophistication of the kid, but certainly the younger he or she is, the more complex this calculation becomes. What level of disclosure about serious adverse antidepressant effects does a doctor owe a 12-year-old? A 10-year-old? An 8-year-old? Legally, we put parents in charge of their children’s medical care. But ethically and practically, medical treatment, including with psychopharmaceuticals, can have lasting psychological effects on kids. Cut them out of the equation, and you not only frighten them, but you can sour them on all therapies – therapies they may badly need, even if they do have an adverse reaction to one drug. I don’t know what the answer is, except to try to keep children in the loop about their treatment in a developmentally-appropriate way.
I think for perspective sake it’s important to know Kaitlin is an author of an interesting sounding book due out in April title “Dosed” about “the medicated generation growing up”.
http://kaitlinbellbarnett.com/
Where according to Amazon, she weaves the kids stories re being on meds together in the book.
Sounds like it might be interesting to see if any bad outcomes happened to those kids…
I have not read the book, or even part of it so I have no idea except what’s described on Amazon for details.
I’m glad to see Kaitlin find Boring Old Man blog, which is so good at details of study data etc.
PS–* my own disclaimer, being a parent of a medicated child who grew up on meds and had a bad outcome of disablement from that.
“What level of disclosure about serious adverse antidepressant effects does a doctor owe a 12-year-old? A 10-year-old? An 8-year-old?”
To begin with…we owe them the truth…not Teen-Screen or similar pharmaceutical marketing campaigns, not some unsupported hog wash about them having a chemical imbalance or a brain illness while casting sweeping phoney depression nets set up under the dubious veils of shill pseudo advocacy groups & medicine to in trap them.
We owe kids the gift of time, a maturation process, patient support, understanding, investment, and by using a common sense approach to use the least intrusive treatment models possible, always first and foremost…
We should not be using children as guinea pigs for drugs that have very little independent long term data or studies to prove their effectiveness or safety.
We can throw out pretty much all the pharmaceutical funded clinical data , trials, journal articles, including FDA approvals; because we have absolutely no idea what information is valid or not…from ghost writing, to pay offs, conflicts of interest, to evidenced criminal manipulation; we now know we have been served a tainted bill of goods in a never ending stream of toxic happy meal pill bottles designed not for better health or treatment…but to make money…..loads & loads of money….
One thing for sure; is we don’t need to be taking advice from paid writers for web sites that cater & profit directly from pharmaceutical industry funding (that’s called a gross conflict of interest and biased).
Children shouldn’t be made poker chips in a high stakes game of corporate profiteering….and yet that is exactly what we have made them in America…Shame is not descriptive enough…criminal doesn’t go far enough…pure evil barely touches the surface of what we have done & are doing to our children…
and just so you know….just because you may have dodged the pharmaceutical damage bullet personally…it does not make the high risk involved worth the benefit game of Russian roulette maybes being played today…
I do need to address Kaitlin’s comment “What level of disclosure about serious adverse antidepressant effects does a doctor owe a 12-year-old? ”
Back in 1999 it would have been nice if the doctor gave MY then 11 year old TRUE informed consent, or even to me the mother for that matter!
Unfortunately, my daughter found out the hard way that SSRIs and her worked out to be a paradox of suicide increased thinking and actions! attempting to jump from a moving vehicle on Zoloft is not what I ever expected to happen.
She has a medical chart that holds a red flag alert severe as an allergy alert for medical safety that says NO SSRIs so other docs won’t add any due to the severe threat and endangerment to her life that can happen as a result of how she reacts to those meds. That’s her story; I’m not here to debate efficacy of SSRIs. I am sharing the reason informed consent matters, in detail as well as to remind that in some states kids as young as 13 no longer need parental consent, and therefore doctors/psychiatrists do not even have to tell the parents this info. I’ve heard all of those excuses over the years from incompetent doctors. This is why I find Mickey’s blog refreshing because he writes how he THINKS before he medicates any patient and talks about it, and considers the big picture, life happenings, etc .
In the previous post [a book review… ] I mentioned a couple of cases from early on in the first days of the SSRI antidepressants – people who had a dramatic reaction to Prozac. Both described agitation, anxiety, and used the word “crazy.” At the time, I found nothing that described such things. I presumed it had something to do with Prozac, and just used another drug when the need arose [which wasn’t very often in the kind of practice I had]. What galls me is that I think they knew about such things back then, but didn’t talk about it. The same thing happened with the withdrawal symptoms. I learned about that from a good friend’s wife who’d started Paxil shortly after it came out, and it took her months to get off – miserable months. In both cases, the anecdotes came long before it was in the literature. In both cases, something they knew.
Physicians are often in situations where the risk/benefit equation points towards the use of a potentially toxic drug. Those decisions are difficult enough and call for careful monitoring. If you don’t know the toxicities, you can’t make an informed decision and you can’t inform the patient. So my biggest complaint is that they knew, and didn’t tell us.
I expect that a lot of doctors do what I’ve done, ride the ‘trailing edge.’ My part time clinic practicing these days has me prescribing more than I ever did in the past, but I only prescribe ‘old drugs.’ Part off the reason is cost as I treat poor people, but I think I’d do it anyway. I did that in the latter days of my practice.
I felt a like I might be being overly cautious back then. Nowadays, having reviewed so many studies, I’m thinking that there’s no such thing as ‘overly cautious.’ I make no claim to be any kind of psychopharmacology expert, but I get by just fine being a medication dinosaur – riding the ‘trailing edge.’
Mickey,
In 2001 I kept calling my daughter’s doctor telling him of her agitation (extreme) to the Zoloft and he said to INCREASE it. He had her up to 150 mgs it was only over weeks of this and appts, that an on call doc told me he questioned the Zoloft because he had another teen patient reacting the same way (in this office group). It was that on call doc that saw it for what it was and she was taken off of it, over 2 months of raging while that was reduced. Once off of it? all that suicide threat /behavior stopped. Her reaction is very predictable to the point of other meds giving her the same SSRI reaction, such as BuSpar and Seroquel.
Caution –is all I can say…
Let’s be sure to educate readers of what I feel was the fraud by Lilly perpetrated in their arrogance of “one size fits all” when it came out! They only had a 20mg capsule at first, for at least 2 or 3 years if I am correct, although they may have had the solution out fairly quick to access the pediatric and geriatric populations, but still to get people to that 20mg dose, if not higher.
I was the only resident in my program, if memory serves correct, who did not write for prozac early on until 2 things happened: one, a pharmacist educated me how to give split dosages by pouring in the capsule into an acidic drink like OJ, mix, and drink a half amount and save for the next day, and second, when they came out with the 10mg capsule and then tablet to allow for 5-10mg dosages with accuracy.
We as psychiatrists saw the same problems with Zoloft and Paxil if dosed too high too early on. Which is why this dynamic is a factor to the suicide debate of late, where you have non-psychiatrists writing scripts for dosages not appropriate for C & A patients and even adults. Take this one on for size: why are docs writing for 20 or more mg of Lexapro which is equivalent to 80 or more mg of Celexa, a dose of the latter no one would consider?
I’ll tell you why in two words: Forrest Pharmaceuticals. How they keep their drug below the reporting radar is endlessly fascinating, but, truth does and will come out for this SSRI too, sooner than later.
anything … and i mean ANYTHING coming from the lips of Dr. Charles Nemeroff is not to be trusted in any way, shape or form. His conflicts-of-interest are now legendary .. and finally documented thusly. See http://www.forbes.com/sites/paulthacker/2011/09/13/how-an-ethically-challenged-researcher-found-a-home-at-the-university-of-miami/
Katlin’s comments are interesting. One can only assume that a prescribing doctor offers these meds to 12,11,10 year olds because he deems them to have a mental disorder and that the script, when dispensed, will correct that mental disorder. Or, a cynic, like myself, could suggest that the doc prescribes them or offers samples because he/she wants a few more cupcakes or tickets to the game the next time the rep swings by.
The Pro-Prozac study by Gibbons serves only to feed his delusions that black box warnings put children at risk – it’s the other way around.
Putting kids on these host of drugs is absurd, bi-polar, ADHD and all the other terms used are merely ways of marketing the illness rather than the cure…of which there isn’t one by the way.
Adults need to take responsibility here. They need to step in and ask exactly how these drugs work and how they will rectify the problem of ADHD etc.
It’s called dumbing down, it makes life easier for the teachers and care-workers.
Once you see how these drugs are marketed you will see that this is not about treating and making better…it’s about reaching a maximum sales level.
Step out of the box of the ADHD campaign and look at the marketing.
Briefly spoke with Allen Jones this weekend, some interesting documents re Risperdal marketing will be hitting the internet soon – the Public are being conned, parents believe the hype… their children believe in it too.
Has anyone seen the latest Cymbalta ad on the TV. 3/4 of it are a list of side-effects…and yet people still walk into their doctor’s rooms and ask for it. That’s the power of marketing!
Thanks Fid,
I’m looking forward to those trial documents too. Watching them flash by at the trial was powerful – realizing the lengths they were willing to go to to hawk their wares…