Imagine that your best friend is really, truly depressed. And imagine that they are given a bottle of pills with the following label: “Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders.” Pretty scary, huh? You and your friend might think that the risk (suicide) outweighs the potential benefit (some relief from that depression). At the very least, you might think about an alternative treatment plan that does not involve such scary drugs. Evidently, a lot of doctors have been thinking the same thing, because the prescription rates for antidepressants have been falling ever since the FDA started requiring those labels.
It is easy to understand why. No one, whether they are a doctor, a parent, or a best friend, wants to contribute to a suicide. Everyone wants to be cautious when they are dealing with someone who is already at risk, for fear they will make things worse. The FDA labels speak exactly to that fear.
Where does this fear come from? There have been plenty of anecdotes about people, including teens, committing suicide shortly after starting an antidepressant. These anecdotes led to studies looking closely at teens in the first months following a new prescription to SSRI (selective serotonin reuptake inhibitor) antidepressants. In requiring new labels, the FDA was responding to studies showing a link between SSRI’s and increased suicidal thoughts.
You may be wondering why these studies track suicidal thoughts, and other indexes of “suicidality” and not suicides themselves. There is a very good reason, actually. Suicides are, thank goodness, very rare events, measured in the single digits per 100,000 patients. So for a study to find a statistically significant increase in actual suicides, even among depressed patients being prescribed antidepressants, it would need millions of subjects. Can’t be done. So even though suicidal thoughts are not the same as suicides, they do provide some measure of danger signs. Which is better than no data at all.
But was the FDA response to these studies just a healthy dose of caution? Maybe not. In fact, as prescription rates for antidepressants declined, suicide rates increased.
In hindsight, this might look pretty obvious. Being depressed is obviously a risk factor for suicide, after all. In fact, some researchers have been arguing since before the FDA required the warnings that they were a bad idea. Their data showed a very different side of SSRIs – a decrease in suicides in counties in the US where SSRIs were prescribed more heavily. Although these data were correlational, they suggested a net benefit to these newer antidepressants. And although a correlation can’t tell us much about cause and effect, it is really hard to argue that SSRIs cause more suicides if higher rates of use are correlated with lower rates of suicides.
Why did the FDA focus on the studies that showed a risk to SSRIs, and not on the studies that showed a benefit. One possibility is that they fell victim to a very common bias in the way people reason about risks and benefits. We have an aversion to risks, which is disproportional to our attraction to gains. When told that a new drug might kill one patient out of a thousand, we focus on that one. This is a more powerful force in our thinking than the idea that in the other 999 patients, there might be more than one that the drug saves.
So what about that friend looking at a “black label” warning on a bottle of SSRIs? Should they avoid the SSRIs altogether? In this case, a little caution may do a lot more harm than good. On the other hand, the data showing an increased risk when first taking the drug should not be ignored. I would speculate that for some depressed teens, the SSRI may provide just enough relief to allow them to carry out a suicide they were too apathetic to manage before. The critical period of risk seems to be the first weeks and maybe months of a prescription. So that is when your friend needs your support the most.
I find it interesting that people often use the words depression and sadness interchangeably. However, depression is much more than just feeling ‘down’ for a few days. It is a serious medical illness that involves the brain . Depression can run in families, and usually starts between the ages of 15 and 30. It is much more common in women, which is an observation I find to be quite interesting. (Why do women tend to suffer more from depression than men? I think this would be something interesting to research on.)
Some of the symptoms of depression include prolonged periods of misery, loss of interest or pleasure in activities that were once enjoyed, change in weight, difficulty sleeping, energy loss, feelings of worthlessness and thoughts of death and suicide. Over the years, depression has come to be considered as an illness like any other and as such, various medications have been created to relieve patients of their depression symptoms. These medications have been classified as anti-depressants. Essentially, when the person’s pain or other effects are lessened, the person suffering from depression can begin to look at ways of solving his or her problems .
Currently, SSRIs (Selective Serotonin Re-uptake Inhibitors) are the most commonly used antidepressants. They basically work by preventing the uptake of the chemical serotonin by the pre-synaptic nerve. Serotonin is a chemical found in the brain, which is believed to play a major role in the regulation of mood, sleep and appetite. A common example of SSRIs is Prozac. In recent times, SSRIs have been thought to lead to increase the risk of suicidal thought. The implications? What was once thought to be beneficial to those suffering from depression could now potentially aggravate the situation. Obviously, this is a matter of great concern to doctors, families of the depressed person and even the patient himself/herself. Essentially, the confirmation of this theory would affect how doctors prescribe medications for depression and the alternative methods families and patients would seek to deal with depression. But while investigations are on going, the FDA is living up to the saying “Better safe than sorry” by putting labels on the antidepressant drugs which warn of the possible increment in suicidal thoughts when the drugs start being taken.
Not surprisingly, people are shying away from these drugs. No one would want to administer or take a drug, which could end up pushing a patient even closer to suicide. However, in avoiding this, is more harm caused to the patients? Given the statistics available, the answer is yes. More suicides were said to be recorded once people decided not to use the anti-depressants as a result of the FDA’s warning. Does that mean the positive effects of taking the anti-depressants extend further than the negative ones? Possibly. I think another in the whole treatment equation is the patient himself/herself.
As is already known with other drugs, different people react differently towards drugs because all in all we are different from each other. This could explain the increase in suicidal thoughts of some of the patients on medication. Consideration I think also needs to be given to the placebo effect. As I understand it, the placebo effect arises when a person’s symptoms are altered as a result of their belief that the drug is would have the effect it is meant to. This can basically be seen as the mind controlling the body.
The question now is why would a patient expect that the drugs would increase his/her suicidal thoughts? Well for those people who started taking the drug following the FDA’s warning, it would be highly likely that they would think that way and so actually end up pushing themselves into having more suicidal thoughts. Now then how would we account for those patients who did have an increase in suicidal thoughts after taking the medication before the FDA started to issue the warning labels? In that case, the speculations of the negative drug effects now appear to be valid.
In order to benefit from these drugs but at the same time avoid its negative effects, some sort of balance would have to be reached. Definitely the best thing would be to monitor the patient taking the antidepressants closely for any changes in suicidal feelings. Moreover, drug treatment could actually be combined with ‘talk therapy’ so that potentially smaller amounts of the drug are used just in case the SSRIs do increase suicidal thoughts.
References:
http://en.wikipedia.org/wiki/Antidepressant
http://www.nlm.nih.gov/medlineplus/depression.html
http://www.depression-helper.com/medication.htm
Comment by Sena Quarm Goka — September 17, 2007 @ 1:39 pm
Upon reading the previous comment, I was interested by the question of why women tend to suffer more from depression than men. While no one has come up with a conclusive answer, it appears to have a lot to do with biological differences, gender roles, and the association of depression with other disorders. This information comes from “Why Women are More Susceptible to Depression: An Explanation for Gender Differences” by Christina M. Mulé.
Biological differences: hormones have a great effect on depression in women. Due to biology, women face more hormonal changes during their lives than men do, from PMS and menstruation, childbirth and postpartum depression, various hormonal birth controls, and menopause. Another theory is that depression, which is genetically linked, is transmitted on the X chromosome. Women, having two X’s as opposed to men’s one, would be more likely to be affected by this depression gene. A third possibility is that depression comes from a combination of genetics and environment, but women tend to be more aware of their surroundings and more closely connected to their family, causing greater effects of symptoms of depression in other family members.
Gender roles: In many stereotypes, women are held to a much higher standard than men. They are expected to be beautiful and the perfect wives and mothers. If a woman doesn’t live up to this expectation, she may be more likely to become depressed. The idea of women as “the weaker sex” may also lead to feelings of inferiority, which conflicts with the extensive jobs as mother/wife/successful working woman that they are also expected to fill.
In combination with other diseases: Depression often accompanies diseases like eating disorders and anxiety disorders, both of which are more common in women than in men.
I would also add that perhaps more women are diagnosed with depression than men because they are more likely to seek help. It can be difficult for anyone to admit that they may need help for depression instead of just dealing with it themselves, but men may be more likely to conform to the “be strong and deal with it myself” idea and consequently not seek help for depression.
Reference: http://www.personalityresearch.org/papers/mule.html
Comment by Psych 105 student — February 23, 2010 @ 11:38 am