Suicide Findings Question Link to Antidepressants

By NICHOLAS BAKALAR
Two large new studies in The American Journal of Psychiatry suggest that treatment of depression, either with psychotherapy or drugs, reduces the risk of suicide attempts in all age groups, especially during the first months of treatment. The findings raise further questions about possible links between antidepressant drugs and suicide.
In 2005, the Food and Drug Administration, faced with evidence from controlled studies, mandated a “black box” notification on all antidepressant drugs, warning that their use in children and adolescents could increase the risk of suicide. In May, after reviewing controlled data from all age groups, the F.D.A. required an updated version to include a warning about suicide risk in young adults 18 to 24.
The studies the F.D.A. analyzed, in which patients were followed closely and matched to controls, are considered the most direct way to analyze results. The two new studies were based on retrospective reviews of medical records.
In one, researchers led by Dr. Gregory E. Simon, a psychiatrist with the Center for Health Studies in Seattle, reviewed the records of 109,356 people being treated for depression in a large prepaid health plan serving 500,000 people in Washington State and northern Idaho. They found that suicide attempts were most common in the month before treatment began, declined sharply in the month after it began, and tapered off in the following six months. All treatments — psychotherapy, medication or both — showed the same pattern, suggesting that treating depression reduced suicide risk regardless of technique.
The authors acknowledged that they had no way to assess the severity of illness either before or after starting treatment, and that about a third of patients dropped out of treatment within a few weeks, two factors that may have influenced the results. Dr. Simon has received research grants and consulting fees from pharmaceutical companies.
Dr. David Shaffer, a professor of pediatrics and psychiatry at Columbia who was not involved in the study, said the results should prove reassuring to people taking antidepressants. “The study provided no evidence that starting an antidepressant increases the likelihood of a suicide attempt,” he said. “Starting treatment, regardless of which kind, seems to reduce suicide attempts.”
The second study was led by Robert D. Gibbons, director of the Center for Health Statistics at the University of Illinois at Chicago. Using medical data from the Veterans Health Administration, researchers found that among 226,866 adults with depression, the overall rate of suicide attempts after beginning treatment with a selective serotonin reuptake inhibitor, or S.S.R.I., was about one-third the rate of those who received no antidepressant at all. This was true for men 18 to 25 as well as for older adults.
“The V.A. has a very good electronic medical record system, so this is likely to be reliable data,” said Dr. Nada Stotland, a professor of psychiatry at Rush Medical College in Chicago. “That makes these results even more powerful.” Dr. Stotland had no part in the study.
The risk of suicide attempt was significantly higher before S.S.R.I. treatment than immediately after starting it, a finding that coincides with that of the Simon study. The scientists acknowledged that their patients were almost all men, and that they did not include any suicide attempts that did not result in contact with the Veterans Health Administration medical records system. One of the six authors has been a paid adviser to pharmaceutical companies.
The authors of both papers worried that extending the boxed warning to young adults might discourage people from seeking effective treatment. “The F.D.A. didn’t say anything wrong in the warning,” Dr. Simon said. “I am 100 percent in support of the message that we need better follow-up care. But my concern is that the warning may scare people away from treatment.”
Dr. Gibbons expressed similar concerns. “These two studies clearly show that the greatest risk for suicide is depression,” he said. “Failure to treat depression, either using pharmacotherapy or psychotherapy, will lead to dramatic increases in the rate of serious suicide attempts and completions in the U.S. and in the world.”