Black Bart's Open Salon Blog

Dr. Dach What evidence for antidepressants and suicide risk?

Fri, 2 Jan 2009 17:01:02 -0500

ontact: Sonja Mak
s.mak@update.europe.at
43-140-557-340
European College of Neuropsychopharmacology

Antidepressants in suicide prevention
Presented at the 21st Congress of the European College of Neuropsychopharmacology 2008, Barcelona, Spain

Antidepressants and suicide risk: what is the evidence?

In numerous short-term randomized clinical trials (RCTs) of antidepressants for depression in children and adolescents (<19 years), antidepressants are found to be associated with a slightly higher proportion (0.7%) of patients reporting suicidal ideation or a suicide attempt than control patients receiving placebo (Bridge et al., 2007). It is important to note that there are no completed suicides in these studies. Adults treated with SSRI antidepressants in randomized clinical trials have a similar risk of either non-fatal self harm or suicidal thoughts than those on placebo (Gunnell et al., 2005 & 2006). It is undisputable that at least among children and adolescents, antidepressants have some potential of causing harm to a small subgroup of vulnerable patients, at least in the beginning of treatment. However, there are several reasons why such trials are likely to create a distorted view of the total balance of benefits and harms of antidepressants:

First, short-term clinical trials are designed to produce statistical evidence of efficacy for regulatory purposes, and their duration is only as long as necessary to produce this evidence. Thus, the trial ends when the drug response has evolved. During the trial patients spend most of their weeks with possible side effects, but not yet full antidepressant response. With regard to suicidal behaviour, the benefits come with the response, gradually over time.

Second, for ethical reasons, subjects who are severely suicidal at the time of evaluation for the trial must be excluded, since they might receive placebo. This changes the balance between observed negative and positive effects with regard to suicidal behaviour in these trials. Worsening of mild pre-existing or newly emerging suicidal behaviour can be usually detected. However, as most severely suicidal patients must be excluded before a trial starts, it remains unknown whether they would benefit from the active treatment. As naturalistic studies do suggest such improvement, this bias is not merely hypothetical. Antidepressant trials have not been designed to investigate suicidal behaviour, and they cannot provide unbiased information on their overall effects related to it.

Third, factors resulting in short-term suicidal ideation, or even less severe suicide attempts do not necessarily result in significantly increased risk for completed suicide, as mental disorders and their symptoms related to completed suicides are usually more severe. There is no evidence of increased rates completed suicides in antidepressant trials (Khan et al, 2003).

Fourth, clinical trials do not reflect usual treatment. In usual care, the attending doctor can promptly discontinue antidepressants that involve intolerable side-effects, adjust dosage, and switch and combine agents. Antidepressants are only part of treatment, which should always include a trustful relationship between the doctor and the patient, with necessary support and psychosocial treatments.

The most important test for the role of antidepressants in suicide prevention is real life: In contrast to these randomized clinical trials, observational studies of antidepressant treatment, which typically include abundantly highly suicidal patients, demonstrate a marked alleviation of suicidal behaviour in the vast majority of patients. In clinical practice, the benefits of treatment are seen over time as the drug response consolidates. Patient population studies of adolescents report lower rates of suicide attempts and of adults both attempts and completions over time as treatment continues (Valuck et al., 2004; Jick et al., 2004; Simon et al., 2007; Sokero et al., 2006; Simon et al., 2006).

In many western countries (e.g. Korkeila et al., 2007), increasing use of antidepressants on the national and regional level expectedly correlates with declining suicide mortality. Of course, such ecological studies do not prove that antidepressants have caused the observed decline in suicides, but nevertheless, they are consistent with a positive or at worst, neutral net effect on suicides. Most importantly, there is no evidence for increased national suicide rates due to increased use of antidepressants.

Antidepressants reduce the severity, and the time a patient spends in a depressive state, which are credible factors in reducing the risk for suicidal acts.

Clinical implications

Depression is the most important single factor predisposing to suicide, and more than half of all subjects completing suicide are known to have suffered from depression. Thus, any treatment that is widely available, safe and efficacious in alleviating depression is plausible for purposes of suicide prevention.

Register-based and observational studies have provided individual-level information on depressed subjects on and off antidepressants in real life conditions: Compared to randomized clinical trials these studies give a more realistic account of risk of suicidal behaviour, and suggest antidepressants to be beneficial for suicide prevention.

While antidepressants likely have a potential for provoking suicidal behaviour in some vulnerable individuals in the early phases of treatment, from a public health perspective, the epidemiologically much more important effect of antidepressants is to alleviate depression and thus reduce the risk of suicide.

Bernard Madoff arrested over alleged $50 billion fraud

Thu, 11 Dec 2008 21:12:22 -0500

He said it's "a big lie" and a "giant Ponzi scheme" and lost about $50 billion dollars. This is what we're dealing with and makes you wonder how low the averages will go. Compared to the Iraq war and the $700 billion bank bailout we're talking about chump change. We can print more money!

Beware false rallies!

Mon, 6 Oct 2008 20:10:12 -0400

No true comparison here. This is just a warning to beware false rallies.

Good luck!

Let's Hear it for Marcy Kaptur!

Mon, 29 Sep 2008 20:09:44 -0400

This is a great response to the mortgage bailout.

http://redstaterebels.org/2008/09/wall-streets-greed-game/

Perspectives on god?

Fri, 4 Jul 2008 11:07:26 -0400

Epicurean Paradox
God either wants to eliminate bad things and cannot, or can but does not want to, or neither wishes to nor can, or both wants to and can.
If he wants to and cannot, he is weak -- and this does not apply to God.
If he can but does not want to, then he is spiteful -- which is equally foreign to God's nature.
If he neither wants to nor can, he is both weak and spiteful and so not a god.
If he wants to and can, which is the only thing fitting for a god, where then do bad things come from? Or why does he not eliminate them?

Strange...a God who could make good children as easily as bad, yet preferred to make bad ones; who made them prize their bitter life, yet stingily cut it short; mouths Golden Rules and forgiveness multiplied seventy times seven and invented Hell; who mouths morals to other people and has none himself; who frowns upon crimes yet commits them all; who created man without invitation, then tries to shuffle the responsibility for man's acts upon man, instead of honorably placing it where it belongs, upon himself; and finally with altogether divine obtuseness, invites this poor, abused slave to worship him! ~Mark Twain, The Mysterious Stranger

Once upon a time, there was a king who, wishing to amuse himself, ordered the royal elephant to be brought before him. He ordered some blind men, blind from birth, to be brought near the elephant. He then asked these blind men to touch the elephant and describe what the elephant was like. The man who touched the tail said that the elephant was like a broom. The one who touched a leg said that it was like tree. The one who touched the body said it was like a wall. The one who touched the ear said the elephant was like a winnowing fan. Thus each described the elephant differently, but each was sure that his own version was the true description of the elephant. They did not realize that each one touched only a part of the elephant. Each blind person had only a one-sided or unilateral view of the elephant. Not knowing the whole truth, they started arguing with each other, each sticking to his own point of view. The argument ended up in quarreling and fighting. The king and his ministers rolled in laughter as the blind men continued to quarrel with each other.
The Buddha pointed out that philosophers dispute and quarrel with each other because similarly they see only one side of the truth and they dogmatically cling to their views maintaining that they alone had a monopoly of the truth. All Buddhas, considering and seeing all sides of the truth, only laugh at them. This proves that genuine Buddhism can in no way be called unilateral. According to this Buddhist way of thinking, experience is multifaceted and the Buddhist view is therefore multilateral. If truth is multifaceted, it cannot be stated in a unilateral way.
This creation is that of a mental image of a "self in the world". It is also the origin of all anxieties, worries and the whole host of suffering in the world. The cause of the suffering is the attachment to this mental construct and the effort to preserve this delusion through self-centered living. The end of suffering is the end of self-centeredness. The way to the end of suffering is to realize that there is no "self" to be centered on, to suffer, or to be satisfied, other than the mental construct of a "self in the world".
Buddhism is therefore not an escape from the real, temporal, material world into an illusory, dream world of wish-fulfillment, where there is life of eternal happiness. It is a freedom from the delusion that creates all unhappiness.