Thursday, July 08, 2004

More On Children's Mental Health
Support the Child Healthcare Crisis Relief Act

Yesterday, I posted a critique of the widespread practice of placing children with mental illness in detention centers, without adequate treatment.  This is just one consequence of a broad problem facing our country.  Not only is there a nationwide shortage of pediatricians, but there is an even greater shortage of psychiatrists who have specialized in treating children and adolescents (1  2). 

Regarding pediatricians, the Children's National Health Center report (linked previously) states:

A survey of more than 400 pediatricians located across the United States found that access to quality care for American children is the greatest concern facing pediatricians. The survey found that a large majority of pediatricians agree that time constraints on patient treatment is diminishing the quality of pediatric care in this country.

Importantly, pediatricians believe that this issue affects American children at all socioeconomic levels, in every part of the country. Access, which translates into time with pediatricians, is not just a problem for the disenfranchised and uninsured, but for all families.

They described a system that is seriously dysfunctional and about to fail under its own constraints. Many indicate that they are willing to be involved in defining changes needed to improve or reform the health care system. These pediatricians report that too many children are falling below the acceptable level of care.

Regarding child and adolescent psychiatrists, Psychiatric Times states:

Many children with mental health problems are either not being seen, or are being seen by professionals who have not been trained in the principles of development and childhood psychopathology, said Thomas F. Anders, M.D. He told Psychiatric Times, "We believe that the care that many of these kids are getting today is inadequate." [...]

The U.S. Bureau of Health Professions projects that at current recruitment levels, the nation will have only two-thirds of child and adolescent psychiatrists needed to meet the demand by 2020--8,312 child psychiatrists versus a need for 12,624.

A "severe maldistribution" of practicing child psychiatrists further exacerbates the problem. While Massachusetts has 17.5 child and adolescent psychiatrists per 100,000 youths, West Virginia has only 1.3, and the national average is 7.5.

These problems are known to have a serious negative impact on our country, even if expressed solely in monetary terms.  From the National Mental Health Information Center:

The annual prevalence figures translate into millions of adults and children disabled by mental illness. The disability toll can be quantified in a way that cannot be ignored: when compared with all other diseases (such as cancer and heart disease), mental illness ranks first in terms of causing disability in the United States, Canada, and Western Europe, according to a study by the World Health Organization (WHO, 2001). This groundbreaking study found that mental illness (including depression, bipolar disorder, and schizophrenia) accounts for 25% of all disability across major industrialized countries (Figure 1). In the US, the economy's loss of productivity from mental illness amounts to $63 billion annually (DHHS, 1999).

OK, there is a problem.  What is being done about it?  From the site, Caught on Film  (A chronology of Bush saying one thing then doing another), here is President Bush's stance on children's hospitals:

Bush Event

Bush Rhetoric



Children’s Hospitals


Bush touts the need to support children’s hospital at Egleston Children’s Hospital in Atlanta [3/1/01]



“This is a hospital, but it's also - it's a place full of love.  And I was most touched by meeting the parents and the kids and the nurses and the docs, all of whom are working hard to save lives.  I want to thank the moms who are here.  Thank you very much for you hospitality…There's a lot of talk about budgets right now, and I'm here to talk about the budget.  My job as the President is to submit a budget to the Congress and to set priorities, and one of the priorities that we've talked about is making sure the health care systems are funded.” – Egleston Children's Hospital, Atlanta, Georgia 3/1/01  



Bush’s first budget proposed cutting grants to children’s hospitals like the one he visited by 15% ($34 million). His 2004 budget additionally proposes to cut 30% ($86 million) out of grants to children’s hospitals.


From a NAMI website:

Plan Doesn't Address Gap in Community Services, Drops Important Support Programs

Washington D.C. February 19--President George W. Bush's federal budget plan for fiscal year 2003, released February 4, falls extremely short of the need in terms of mental health spending. Although the President has committed his Administration to implement the Supreme Court's Olmstead order to end unnecessary institutionalization, his $2-trillion budget plan (available at: http://www.whitehouse.gov/omb/budget/) fails to address the growing gap in community-based services for adults and children with serious mental disorders.

From a Howard Dean website, we see the following statistics pertaining the the State of Texas under governor Bush:
  • 48th in per capita funding for public health

  • 47th in delivery of social services

  • #1 in percentage of poor working parents without insurance

  • #1 in children without health insurance

In health care policy, there is a concept known as "parity."  In this context, parity refers to the practice of mandating that health insurance companies provide the same level of coverage for mental illnesses that they provide for somatic illnesses.  from one of Senator Kerry's websites:

Despite Promises to Support Mental Health Parity, Bush Lets GOP Leaders Kill Wellstone Mental Health Equitable Act. President Bush announced his qualified support for the Senator Wellstone Mental Health Equitable Act in April 2002, but only for “serious” mental illness which he chose not to define. The legislation has been blocked by Republican Speaker of the House Denny Hastert, who believes it would cost businesses too much to cover mental illness. When Senate Democrats tried to bring the bill up for a vote on October 25, 2003, the one year anniversary of Senator Wellstone’s death, Republican Senate Majority Leader Bill Frist refused to allow the bill to be considered. [National Journal, 5/4/02; Roll Call, 3/17/03; Star Tribune, 10/24/03]

To be fair, we cannot necessarily blame President Bush for everything that happens in the Senate, but clearly, if he had wanted to be true to his word, he could have had a positive influence in the situation described above.  More blameworthy is Senator Frist.  He's a physician, yet he doesn't seem to be concerned about health care.

From another portion  of Kerry's site:


At an April 2003 meeting of the Commission on Human Rights in Geneva, the United States stood alone in opposing a resolution urging countries to commit to realizing the universal right to the highest attainable standards of physical and mental health. The resolution calls on countries to enhance their efforts to eliminate discrimination in health care, prevent violence, promote sexual and reproductive health, take steps to protect the fundamental right to health for their own citizens, and assist developing countries in achieving higher standards of health. Among the 43 countries voting, the United States was the only one to vote against the resolution.

Senator Kerry has issued a statement  regarding his mental health policy:

[...] I believe we must make progress on mental illness and end this discrimination and stigma for once and for all. As President, here’s where I would start.

First, we have to make sure we require full mental health parity once and for all. Not just mental health parity for certain benefits or certain mental health conditions or with unnecessary loopholes that allow insurers to skirt their responsibility. We also need parity in our public programs. That’s why I have fought for mental health parity in the Medicare program – closing differences in cost-sharing for mental health benefits.

Second, let’s strengthen the Medicaid program. States are starving under the Bush economic policies and are forced to cut back on Medicaid as well as community mental health services. I will protect the Medicaid program. That means stopping the Bush so called "reform," which would essentially block grant the Medicaid program and threaten benefits and coverage. I have also proposed $25 billion a year in state relief for the next two years that would help protect the program.

Third, we not only need to strengthen Medicare and Medicaid we need to reform them. It makes no sense that the Medicaid program prevents people from working and receiving health care at the same time. We made some progress with the Jeffords-Kennedy legislation enabling people to receive Medicaid and work but it is three years later and we still have not passed the Family Opportunity Act. We need to pass it right away. And even that legislation does not fix all of the skewed incentives. Why does the Medicaid program often cover institutional care and not community-based care? That makes no sense.

I’ve worked to ensure that people with mental illness who are on the welfare rolls receive the services they need to get and stay employed. [...]

From Independents for Kerry:

Guaranteed Health Care for Every Child
Studies show that kids without health insurance are less likely to get checkups or treatment for ear infections or asthma. Kids without health care also have a harder time learning in school. In a new compact with the states, the Federal government will pick up the cost of Medicaid coverage for children in exchange for automatic enrollment of all school children eligible for the Children's Health Insurance Program. Eligibility for coverage will be extended to 300 percent of poverty-level incomes for children, and coverage will be extended to the six million single and childless adults who are uninsured and live below the poverty line. Independent experts estimate that the Kerry plan will cover 99 percent of America’s children.

Is there anything you can do?  Yes.  There is legislation pending that would help alleviate the shortage of child and adolescent psychiatrists.  The American Academy of Child and Adolescent Psychiatry has a website that makes it easy to send letters to your Senators and your US Representative.  Go to the site, and enter your zip code; this takes you to the page that enables you to send messages to congress, urging support for the Child Healthcare Crisis Relief Act, H.R. 1359. 

Oh, and remember to vote for Kerry.

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Oh, the stories he could tell!

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Children's Mental Health
A National Disgrace, and Another Scandal

Fifteen thousand children with mental illness are detained every six months, with no treatment.  What country? Cuba? Iraq?

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Mentally Ill US Children Held in Detention Centers

Reuters Health Information 2004. © 2004 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

By Joanne Kenen

WASHINGTON (Reuters) Jul 07 - Thousands of mentally ill American children, some as young as seven, are locked up in juvenile detention centers because there is nowhere else for them to go, a congressional report found on Wednesday.

The report painted a disturbing picture of children with mental illness and/or substance abuse warehoused in jail-like conditions where their mental health often deteriorates.

More than 160 of the 524 centers surveyed reported suicide attempts by youths held unnecessarily.

"The last place some of these kids need to be is in detention," the study quoted a Tennessee juvenile center administrator as saying. "Those with depression are locked up alone to contemplate suicide. I guess you get the picture."

The House-Senate bipartisan report was initiated by Maine Republican Sen. Susan Collins and California Democrat Rep. Henry Waxman. It was the subject of a hearing on Wednesday by the Senate Committee on Government Affairs, which Collins chairs.

Many families struggle to afford mental health care. Health insurers often provide little or no mental health coverage, or pay so little doctors don't want to take part in the health plans. Community clinics are stretched and cannot meet demand.

The study found that 33 states hold youths who have no charges against them of any kind in juvenile detention centers. On any given day, about 2,000 such young people are incarcerated, and over six months, the number is 15,000.

"Too often (children) are simply left to languish in juvenile detention centers which are ill-equipped to meet their needs while they wait for scarce mental health services," Collins added.

Right here is the United States of America, every six months, 1.5x104 children are held in detention centers without treatment.  This is a national disgrace, and it should be an issue in the US November 2004 elections.  So far, only one candidate -- Senator Kerry -- has anything useful to say about the subject. 

But wait, you say!  Didn't President Bush just announce a "sweeping mental health initiative?"  Yes,  but to understand the topic, you need to read a recent article in the British Medical Journal:

Bush plans to screen whole US population for mental illness
BMJ  2004;328:1458 (19 June)

Bush established the New Freedom Commission  on Mental Health in April 2002 to conduct a "comprehensive study of the United States mental health service delivery system." The commission issued its recommendations in July 2003. Bush instructed more than 25 federal agencies to develop an implementation plan based on those recommendations. 

[...] Dr Darrel Regier, director of research at the American Psychiatric Association (APA), lauded the president's initiative and the Texas project model saying, "What's nice about TMAP is that this is a logical plan based on efficacy data from clinical trials."

He said the association has called for increased funding for implementation of the overall plan.

But the Texas project, which promotes the use of newer, more expensive antidepressants and antipsychotic drugs, sparked off controversy when Allen Jones, an employee of the Pennsylvania Office of the Inspector General, revealed that key officials with influence over the medication plan in his state received money and perks from drug companies with a stake in the medication algorithm (15 May, p1153). He was sacked this week for speaking to the BMJ and the New York Times. [emphasis mine]

The Texas project started in 1995 as an alliance of individuals from the pharmaceutical industry, the University of Texas, and the mental health and corrections systems of Texas. The project was funded by a Robert Wood Johnson grant—and by several drug companies.

Mr. Jones told the BMJ that the same "political/pharmaceutical alliance" that generated the Texas project was behind the recommendations of the New Freedom Commission, which, according to his whistleblower report, were "poised to consolidate the TMAP effort into a comprehensive national policy to treat mental illness with expensive, patented medications of questionable benefit and deadly side effects, and to force private insurers to pick up more of the tab" (http://psychrights.org/Drugs/AllenJonesTMAPJanuary20.pdf). [...]

To be fair, it should be pointed out that often the newer drugs are legitimately preferred, because of greater efficacy.  Also, in some cases, they have been shown to be cost-effective. Even though they cost more, they have may have greater efficacy, and other benefits that offset the medication cost: fewer hospitalizations, office visits, and lab tests.  The comment about  is not scientifically valid: Mr. Jones is not qualified to make risk-benefit calculations, and besides, the newer drugs tend to be safer than the older drugs.  Even so, there are at least three problems here.  One, the involvement of the pharmaceutical companies at least creates the appears of impropriety; in some cases, it may have been illegal.  Two, Mr. Jones should not have been taken off the case.  He works in the Office of the Inspector General; it is his job to call attention to problems.  Third, the President's initiative calls for an unnecessary duplication of effort.  We do not need another survey.  We already know there is a problem (see the Surgeon General's report from 1999, for one example).  What we need is more funding for treatment. 

Here is an excerpt from Mr. Allen's whistleblower report, linked above:

As an OIG Investigator, I attempted to expose evidence of major pharmaceutical company wrongdoing. The industry was influencing state officials with trips, perks, lavish meals, transportation to and first-class accommodations in major cities. Some state employees were paid honorariums of up to $2,000 for speaking in their official capacities at drug-company sponsored events.

As I attempted to explore and surface these facts I met stiff resistance by OIG officials. I was told that pharmaceutical companies are major political contributors and that I should not continue my probe. The more I attempted to delve, the more I was oppressed by my supervisors. I was effectively threatened with loss of job, career and reputation if I continued to investigate the pharmaceutical companies.

In the words of the OIG manager who curtailed my investigation and participated in overt threats against me: “Drug companies write checks to politicians –they write checks to politicians on both sides of the aisle”.

I was removed from the drug investigation, forbidden to inquire further, and assigned to menial duties. However, I continued the investigation on my own as a private citizen.

The “Model Program” being implemented in Pennsylvania with drug industry hard-sell, misinformation and inducements has just been recommended by President Bush’s New Freedom Commission as a model program for the entire country.  The “Model Program” is the Texas Medication Algorithm Project” (TMAP-pronounced Tmap) and it began in Texas in 1995.

It appears that Mr. Bush is following the same model that Dick Cheney used to develop a national energy policy.  He called the most profitable companies in the world, and asked them what the government could do to transform them from being merely rich, to being filthy rich. 

When I get around to it, I will compare and contrast the health care position of the Bush-Cheney campaign with that of the Kerry-Edwards campaign.  Probably I'll get in on line tomorrow, but I can't promise that. 

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Wednesday, July 07, 2004

Why Bloggers Should Use Netscape
It's Not Just For Better Security

The first Internet browser I used was Mosaic.  That was in 1993.  The code eventually morphed into Internet Explorer, but by then, I had switched to using Netscape.  Later, as HTML became more complex, and Internet Explorer was bundled with Windows, there was a time that not all web pages would load correctly on Netscape.  Then I started using Explorer more often, but still preferred Netscape.  WIthin the past couple of years, though, I have not encountered a page that will not load in Netscape, so now I only use Explorer to run Windows Update.

Netscape, Firefox, and Opera are free, although the free version of Opera has an advertising banner.  Recent security flaws in Explorer have been publicized widely, causing more people to turn to alternative browsers.  The alternatives all have tabbed browsing, which enables you to have multiple web pages open at the same time.  This is great when reading several blogs and news articles,  and referring back to them when writing your own post.  Various bloggers have touted Opera or Firefox.  Indeed, they have their advantages.  Opera runs a little faster; Firefox has a cleaner look, because it has no advertising banner.   Still, I prefer Netscape.  Why?  Because it has an integrated email client.  SInce I like to be able to encrypt and/or digitally sign messages, web-based e-mail is not useful for me.  Also, Netscape comes with a WYSIWYG  HTML editor.  This is great for writing blog entries.

To use the Netscape editor to write blog entries, you open the editor by pressing control-4, or by using the Tools menu.  Then you write the post, much like using a word processor.  It is fairly simple to add photos and tables, use font effects, colors, and so forth.   Pressing alt-F7 runs a spell check.  Save (often) with control-s.  When done, switch to the HTML source view, select everything between the <body> and </body> tags, copy, and paste into your blogging software.  If using Blogger, you also have to go to the dashboard, click the Settings Tab, click on Formatting, and set the Convert Line Breaks setting to "No."   If you decide to try this, and if you don't know anything about HTML, go to one of the many HTML tutorials on the 'net (1  2  3).  It is not necessary to know HTML to use an HTML editor such as Netscape Composer, but it helps. 

All the alternative browsers have useful attributes, such as popup blocking, the ability to use mouse gestures, and the ability to add "extensions," little mini-programs that people write to extend the functionality of the browser.  Also, they all handle downloads better than Explorer does.  Another aspect of the alternative browsers is that they all are more customizable than Explorer. 

Back in the days when hard drive space was expensive, and most people routinely had to go through and delete old stuff to make room for new stuff, it was important to pick just one browser.  Now, most people have more hard drive space than they know what to do with, so it is feasible to have more than one one your system.  If you try one of the others, though, be sure to go to the browser's web site and read up on all the features.  I suspect that most people, once they have used one of the alternatives for a while, will have no interest in going back to using Explorer. 

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Sunday, July 04, 2004

British Medical Journal Article:
Antidepressants and Suicide

There has been some concern about the possibility that antidepressant medication could actually increase the risk of suicide.  I have written about this a few times in the past; use the freefind search function in the sidebar if you care to find the earlier posts.  Recently, a few more items of interest have appeared on the 'net.  Gregg Easterbrook wrote an article on the New Republic entitled Pills Bury

Pills Bury
by Gregg Easterbrook
Post date 06.21.04

[...] So if antidepressant use is rising, and antidepressants are associated with suicide, then suicide must be rising, right? It's the other way around. Suicide in the United States is in decline, and the decline syncs almost exactly with increased use of antidepressants. This is a little detail that's been skipped in the coverage.

[...] I'm going to put my money on what seems the most obvious explanation--the decline in suicide is being caused by increased use of antidepressants.

Mr. Easterbrook is a senior editor and a distinguished fellow at the Fullbright Foundation.  He goes on to tell of his hypothesis about why antidepressants might reduce the suicide risk for the majority of people who take them, you cause a significant risk in a subset of the population.  I must say, his hypothesis doesn't really explain anything, but I agree with the gist of his article.  He goes on to make a good point:

Public-health experts have long worried that anger and lawsuits regarding the minority of people who have horrible adverse reaction to vaccines will result in the undoing of vaccination, which would lead to a big increase in suffering. The same fear may apply to antidepressants. If people stop taking them, or manufacturers stop making them, because a few have horrible adverse reactions, overall emotional suffering may rise, and there may be more total suicides.

 Later the same day, Mark A. Kleinman picked up on Easterbrook's article, and delineated his own thoughts on the matter:

Two kinds of suicide
June 21, 2004

Gregg Easterbrook makes an argument about suicide and the selective serotonin reuptake inhibitors (SSRIs -- the class of antidepressants including Prozac and Zoloft) that seems plausible, though I'm not qualified to judge the underlying factual claims:

1. The use of SSRIs precipitates suicide in a small but non-trivial number of patients.

2. But widespread SSRI use has coincided with a decline in the overall suicide rate.

3. Untreated depression is a major cause of suicide.

4. Therefore, SSRIs probably prevent many more suicides than they cause.

5. Therefore, scaring people into no using them, or scaring manufacturers into not making them, with a combination of publicity and lawsuits would result in more suicides, not fewer.

Again, I'm not sure that's right, but it might well be right, and it shows how poorly adapted our existing journalistic and legal mechanisms are to making policy about health care.

Dr. Kleinman is being a little bit modest here; although he is not a physician, he is a professor of Policy Studies at UCLA, and the director of the Drug Policy Analysis Program.  While not an expert per se  on the topic, clearly he has greater expertise than most bloggers.  He goes on to argue that not all suicides are bad:

[...]The bad suicide -- the part of suicide that can reasonably be conceived of as a public-health problem -- is the impulsive suicide, committed by a person who didn't want to kill himself last week and who won't want to kill himself next week if his current attempt is prevented or fails. Victims of that sort of suicide tend to be younger and to be suffering from various diagnosable mental health conditions, especially depression and anxiety. This class of cases ought to be managed with suicide prevention combined with treatment for the underlying disorders. (In addition, there are impulsive suicides stemming from sudden disasters; for these, prevention is still in order but there may be no underlying disorder to treat.)

But some suicides don't look like that at all. They're committed by people who, due to intense and prolonged misery, have decided that their lives would be happier if they ended now rather than later. The subjects -- I see no reason to call them "victims" -- of such acts of voluntary termination tend to be older, have more physical and social problems, and to have fewer psychiatric problems than those who submit to a transient impulse to kill themselves. [...]

Update:  A reader points out that the distinction between considered and impulsive acts is at least partly misleading, since someone in the grip of depression or anxiety disorder may plan a suicide carefully over a long period. A suicide committed not on impulse, but with impaired decision-making capacity, can be just as tragic and just as preventable as an impulsive act. So the right distinction is between "well-considered" acts, planned over time with relatively unimpaired mental faculties, and "poorly-considered" acts done either rashly or under the burden of mental illness.

Ideally, those judgments would be made looking only at the form of the decision rather than its content. In fact our judgment about whether a suicide is well-considered or not will have to depend to some extent on the substance of the reasons assigned for it. 

This is an interesting point, although it is not pertinent, directly, to the question of whether antidepressant medication could actually increase suicide risk for some people.  I believe that the reader to whom he refers in his update was Lindsay Beyerstein, who has a related post:

[...] Patients with clinical depression may retain their rational faculties, but and yet be suffering from a biochemical brain disorder which distorts their affective responses. A depressed patient may rightly conclude that her current life isn't worth living. Nothing seems worth having or pursuing, she's unable to take pleasure in things she once enjoyed, etc. Unless the patient realizes that her condition is treatable, she may undertake a considered suicide based on her distorted view of the world.

Kleinman is right that we shouldn't build pathology into our definition of suicide. Rational suicide is possible. See an earlier post of mine for a link to compelling case studies We should not discount the possibility of rational suicide, but if someone starts exhibiting suicidal tendencies, our default approach should be medically, rather than existentially oriented. Simply put, we should maintain a clinical high index of suspicion towards people considering suicide. We should help the distressed person to rule out the possibility that she is suffering from a treatable illness before she takes any irrevocable steps. 

The recent debate started in the UK late last year, so it is not surprising that the British Medical Journal would have some follow-up articles.  The latest issue has such an article.  It was co-authored by David Gunnell, professor of epidemiology, Deborah Ashby, professor of medical statistics.  Note that neither is likely to have any financial interest in the debate.

Antidepressants and suicide: what is the balance of benefit and harm
BMJ  2004;329:34-38 (3 July), doi:10.1136/bmj.329.7456.34

Prescribing of antidepressants has increased greatly in England and elsewhere in recent years.1-3 This increase has coincided with a fall in rates of suicide, leading some researchers to suggest a causal association.2 4-6 Meanwhile, others are concerned that antidepressants may precipitate suicidal behaviour.7 8 A recent review of evidence from paediatric trials by the Committee on Safety of Medicines in Britain led to most selective serotonin re-uptake inhibitors (SSRIs) being contraindicated in people aged younger than 18.9 So how safe are they? In this article, we assess the data on the risks and benefits.

[...] Surprisingly, direct evidence that antidepressants prevent suicide is hard to find. A meta-analysis of data on the SSRI fluoxetine, funded by its manufacturer, found no evidence that suicidal acts were less frequent among adults taking antidepressants; the pooled incidences were 0.3% for fluoxetine, 0.2% for placebo, and 0.4% for tricyclics.14 In the most comprehensive synthesis of data from randomised trials, Khan and colleagues found no evidence of a beneficial effect of antidepressants on suicide.15 These findings are difficult to interpret as this was not a formal meta-analysis and relative risks were not derived separately for each trial on an intention to treat basis.

Suicide is rare, even among people with depression.16 Thus, most clinical trials have insufficient power to provide clear evidence on the effect of antidepressants on suicide.

The last point mentioned, in the above excerpt, may require some explanation.  The [phrase "insufficient power" refers to the concept of statistical power.  Statistical power is the probability that one can detect an effect if there really is one.  Let's say you wanted to determine if a coin toss really has an equal probability of coming up heads as opposed to tails.  If you conducted a study by flipping a coin ten times, you would not be able to detect any departure from randomness, because you did not conduct enough trials to see a small difference.  (In fact, it would take about 10,000 flips to detect the difference that does exist.)   Since the suicide rate is about 17 per 1000,000 persons per year, and most drug trials involve only a few hundred patients for a few months, a standard antidepressant drug trial is not going to be able to detect a risk with any reasonable degree of confidence. 

In the absence of clear evidence from clinical trials, researchers have investigated whether rises in antidepressant prescribing are associated with reductions in population suicide rates.2-6 17-19 With some exceptions,3 17 18 such studies conclude that recent rises in prescribing have contributed to falls in suicides. Interpretation of these findings is not straightforward. A range of factors influence population suicide rates.19 It is therefore challenging to distinguish the discrete effects of increased antidepressant prescribing from changes in other risk factors.

What they are saying is that Easterbrook's and Kleinman's analysis by intuition is not valid; it takes a complex statistical analysis to have any chance of establishing a causal relation between the rise in antidepressant prescriptions and the decline in suicide rate.  To provide an example, they point out one complicating factor:

The possible benefits of increases in SSRI prescribing are not limited to their effect on depression. Self poisoning accounts for around a quarter of suicides in England; 20% of these deaths are antidepressant overdoses.21 Tricyclic antidepressants are considerably more toxic in overdose than SSRIs.21 Consequently, it has been estimated that a switch from tricyclics to SSRIs as first line treatment for depression could prevent 300-450 overdose deaths a year through restricting access to the more toxic antidepressants.22 Of note, increased SSRI prescribing has not been accompanied by a fall in use of tricyclics (fig 2).

This raises another complication in the statistical analysis, one that the authors do not address.  Not all antidepressant prescriptions are given for the treatment of depression.  Quite a few of the prescriptions for tricyclic antidepressants are written fro treatment of chronic pain, migraine, urinary incontinence, or insomnia.  SSRI antidepressants are prescribed for migraine and anxiety disorders, in addition to the more common use for treatment of depression.  Antidepressants sometimes are used in persons with a primary diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder.  All of these conditions impose a risk of suicide, but the risk is different for different groups.  When analyzing aggregate antidepressant prescribing data, there is no way to know why any individual prescription was written.  This introduces a lot of statistical noise that would be difficult to factor out. 

Getting to the meat of the article:

Do antidepressants increase the risk of suicide?

Soon after the launch of fluoxetine, the most commonly prescribed SSRI, a series of reports were published suggesting worsening of depression and emergence of suicidal thoughts in some people.23 24 The issue has been hotly debated.7 8 Disentangling the evidence is problematic as much of the research is sponsored by the pharmaceutical industry.25 Review of data from paediatric trials of SSRIs shows that published findings present a more favourable risk-benefit profile than unpublished trials sponsored by industry.12 Table 1 summarises the evidence from clinical trials on the adverse effects of SSRIs on suicidal behaviour in children, abstracted from information recently released by the Medicines and Healthcare Products Regulatory Agency.26 No suicides occurred in these trials. The pooled estimate of increased risk of suicidal thoughts or behaviour from these data is 1.66 (95% credibility interval 0.83 to 3.50). Interpretation of this apparent increase in risk is problematic as people taking SSRIs may be more likely to report adverse effects, perhaps because the drugs could have a disinhibiting effect. In addition, response to treatment may lead to reactivation among people whose depression previously prevented them from acting on suicidal impulses.27 Furthermore, any increased risk may be counterbalanced by a longer term reduction in suicidal behaviour; such benefits would not detected in the trials as they generally lasted 10 weeks or less, whereas the mean duration of treatment in clinical practice is three to four months.28

Reassuringly, time trends for suicide (England and Wales)29 and non-fatal self harm (Oxford)30 in children and adolescents provide no consistent evidence of adverse trends paralleling increased prescribing in the 1990s, although there is some evidence of a rise in non-fatal self harm in young females. Furthermore, in the United States, recent research suggests that areas with the largest increases in antidepressant prescribing to 10-19 year olds experienced the greatest falls in suicide.6

If rare adverse effects of antidepressants on suicide exist, recent large scale increases in prescribing might be expected to affect suicide trends. But, as detailed above, recent suicide trends have generally been favourable, and so it is likely either that benefits outweigh the risks in adults or that any excess risk is small. Nevertheless, antidepressants may have precipitated some suicides in susceptible individuals, and it is important to estimate the number of such deaths. Table 2 outlines a model to estimate the number of excess deaths that may have occurred in 2002 compared with 1991 as a result of their increased use in England.

The authors then go into a moderately complex analysis of the statistics they used, leading them to these conclusions:


There is no strong evidence that increases in antidepressant prescribing lie behind recent reductions in population suicides. Furthermore, data from paediatric trials suggest that SSRIs are associated with an increased risk of suicidal behaviour and most SSRIs seem to be ineffective for childhood depression. However, current concerns about the safety of SSRIs come from clinical trials both of too short duration (< 10 weeks) to identify longer term beneficial effects and are carried out in children and adolescents, among whom suicide is rare.

From the population perspective, the balance sheet of risks and benefits of SSRIs is unclear. Any antidepressant induced suicides may be offset by the beneficial effects of antidepressants on depression and long term suicide risk associated with untreated depression. The low toxicity of SSRIs in overdose will have prevented some suicides. The balance of risks and benefits may vary depending on an individual's underlying suicide risk. For patients with conditions that have a high risk of suicide, such as severe depression,33 the risk-benefit balance may be more favourable than for patients with conditions such as anxiety and mild depression, in which suicide is rare. It is in these lower risk conditions, however, that much of the recent rise in prescribing has probably occurred.

Depression is a common and disabling condition, and so the safety of drugs used in its management is crucial. Future trials of antidepressants should be of sufficient duration to detect longer term benefits of this class of drug and balance these against possible risks. They should also systematically collect data on suicidal thoughts and behaviour. Long term studies are required to assess the effect on population health of recent rises in antidepressant prescribing.

There are two elements missing from their conclusions.  First, the usual way of assessing a risk vs. benefit balance is to assess both the risks and the benefits.  The authors allude to the benefits of the medications, but make no attempt to compare the risk versus the benefit.  I do not fault them for this: after all, how does one weight the risk of suicide in one group versus the improved level of function and quality of life experienced by a different group -- those who have a positive response to the medication? 

Second  -- and this is an even thornier issue -- if you assume their worst-case estimates of risk are correct, but if you also acknowledge that psychiatry is a field that is advancing rapidly, how do you then weight the current risks of treatment against possible future benefits from subsequent treatment advances?  If we declare that the risks right now are not worth the benefits, does that mean we should just stop what we are doing, and forego any future advancements? 

Today, there are a lot of people walking around, leading normal lives, because of great technological advances in orthopedic surgery.  If our ancestors had looked at the problems that surgical patients had 100 years ago -- using the same kind of critical analysis that is now being applied to psychiatry, they might very well have decided that surgery was not worth it, and put an end to it.  If they had, all those people walking around today would have no legs.  Or maybe only one leg. 

Some persons with depression will respond to treatment with placebo, or to psychotherapy, or to lifestyle interventions such as improved nutrition.  But many will not.  Are we going to just let them suffer, or do we want to give them another chance? 

This leaves us with the most important question of all: if there is another chance to be given, who gets to decide whether or not the chance is worth the risk?

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