CNS Spectrums 2010;15(6):348-349
Dr. Nierenberg is professor of psychiatry at Harvard Medical School, co-director of the Bipolar Clinic and Research Program, and associate director of the Depression Clinical and Research Program at Massachusetts General Hospital (MGH) in Boston.
Faculty Disclosures: Dr. Nierenberg consulted to or served on the advisory boards of Abbott, Appliance Computing, Brain Cells, Bristol-Myers Squibb, Eli Lilly, EpiQ, Forest, GlaxoSmithKline, Janssen, Jazz, Merck, Novartis, Pamlab, Pfizer, PGx Health, Pharmaceutica, Schering-Plough, Sepracor, Shire, Somerset, Takeda, and Targacept; has received research support from Cederroth, Cyberonics, Forest, Medtronics, the National Alliance for Research on Schizophrenia and Depression, the National Institute of Mental Health, Ortho-McNeil-Janssen, Pamlab, Pfizer, Shire, and the Stanley Foundation through the Broad Institute; has received past support from Bristol-Myers Squibb, Cederroth, Eli Lilly, Forest, GlaxoSmithKline, Janssen, Lictwer Pharma, Pfizer, and Wyeth; has received honoraria from the MGH Psychiatry Academy (MGHPA activities are supported through Independent Medical Education grants from AstraZeneca, Eli Lilly, and Janssen); earns fees for editorial functions for CNS Spectrums through MBL Communications, and Psychiatric Annals through Slack; receives honoraria as a CME executive director for the Journal of Clinical Psychiatry through Physicians Postgraduate Press; has been on the speaker’s bureaus of Bristol-Myers Squibb, Cyberonics, Eli Lilly, Forest, GlaxoSmithKline, and Wyeth; has received royalties from Cambridge University Press and Belvoir Publishing; owns stock options in Appliance Computing; and owns the copyrights to the Clinical Positive Affect Scale and the MGH Structured Clinical Interview for the Montgomery Asberg Depression Scale, exclusively licensed to the MGH Clinical Trials Network and Institute.
With the best of intentions to protect military personnel and veterans, Congressman Robert Filner (D-CA) held hearings on February 24th, 2010 to explore whether antidepressants should be prescribed for those who are depressed.1 Filner’s concerns were about the rising rate of completed suicides in the military and wanted to explore if antidepressants were hurting rather than helping. The basic and highly emotional issue was that given the black box warning about antidepressants and their possible link to an increased risk of suicide, antidepressants could be dangerous enough that Congress might want to consider banning them in the military. There was a spirited discussion that ranged from strongly held opinions to dispassionate facts. To get the real flavor of the hearings, I urge you to visit the site (http://veterans.house.gov/hearings/hearing.aspx?NewsID=525), and click on the multimedia link to see the actual testimonies.
I am bringing up these hearings here because they emphasize how important it is that clinicians and policy makers interpret data with nuanced critical thinking and a minimum of ideological bias. Pay particular attention to the testimony and exchanges between Peter R. Breggin, MD, and Andrew C. Leon, PhD. Beginning with the former, here are some excerpts from their written statements:
My conclusions in this testimony are based on dozens of citations listed in the scientific paper I have written specifically for this hearing, “Antidepressant-Induced Suicide and Violence: Risks for Military Personnel.” My conclusions are further based on hundreds of scientific citations in my published papers and in chapters 6 and 7 of my 2008 medical book, Brain-Disabling Treatments in Psychiatry, Second Edition (New York: Springer Publishing Company).
My other recent book, Medication Madness (2008, New York: St. Martin’s Press) presents more than 50 cases in which I have personally evaluated the medical and police records, and interviewed perpetrators and survivors. Based on voluminous scientific data and clinical experience, individuals with no prior tendencies toward suicide, violence, or mania can be driven into these states by antidepressants.
– P.R. Breggin
My main points today are paraphrased from the FDA Black Box warning on all antidepressants: (1) Depression increases risk of suicide; (2) To reduce suicide risk, clinicians must carefully monitor veterans with depression, whether treated or untreated.
I will discuss three types of scientific studies: randomized controlled clinical trials (comparing antidepressants and placebo), observational studies, and post-mortem studies. Three types of suicidality are reported in these studies: suicidal thinking, suicide attempts, and suicide deaths.
In 2004, the FDA reviewed 25 pediatric clinical trials for antidepressants involving over 4,400 subjects and found that patients randomized to antidepressants were about twice as likely to report suicidality. However, only 3% reported suicidality—mostly suicidal thinking. There were no suicide deaths.
In 2006, the FDA reviewed 295 clinical trials of antidepressants for adults involving over 75,000 participants. Less than 1% reported suicidality, mostly suicidal thinking. Unlike pediatric trials, adults randomized to antidepressants were NOT more likely to report suicidality. In fact, antidepressants conveyed significant protection from suicidality for ages 65 and higher.
At least one large longitudinal observational study of mood disorders, funded by the NIMH, extended the clinical trial conclusions, finding that antidepressants significantly reduced risk of suicide attempts and suicide deaths in adults.
Our research group at Cornell conducted postmortem studies of suicide deaths in New York City. Ninety-five percent of the youth suicides and 77% of adult suicides had NOT taken antidepressants immediately before their deaths. This suggests that prevention of suicide requires intervention primarily among patients who are not receiving antidepressants.
– A.C. Leon
Dr. Breggin appears to have a preconceived notion for which he seeks confirmation. Dr. Leon appears to have a dispassionate assessment of the extant data. Take a look at their conclusions:
There is overwhelming evidence that the SSRIs and other stimulating antidepressants cause suicidality and aggression in children and adults of all ages. The evidence suggests that young adults aged 18–24 (the age of many soldiers) are especially at risk for antidepressant-induced suicidality. There is a strong probability that the increasing suicide rates among active duty soldiers are in part caused or exacerbated by the widespread prescription of antidepressant medication. In addition, antidepressants frequently cause manic-like reactions, including loss of impulse control and violence, posing potentially grave risks among military personnel. Little will be lost and much will be gained by stopping the prescription of antidepressants to military personnel. The military should rely upon the psychological and educational programs that are currently under development for preventing suicide and ameliorating other psychiatric disorders among service members. Antidepressants should be avoided in the treatment of military personnel.
– P.R. Breggin
A cause and effect relationship has not been established between antidepressants and suicide. In light of the suicide risk in depression, a prudent recommendation is that veterans, whether treated or untreated, must be appropriately monitored by clinicians. In conclusion, I would like the committee to recognize that depression is itself a risk factor for suicide. To leave these men and women untreated is to accept suffering from the disorder itself.
– A.C. Leon
Lest we forget, our research is noted, debated, and used by policy makers. The results of our studies can also be distorted to fit into preconceived ideologies. Reasonable people can disagree and have different interpretations of data. But in this case, the faulty and rigid reasoning by Dr. Breggin is no match for the clear and flexible assessment of complex data by Dr. Leon. I have faith that reason and clearheadedness will prevail on this particular debate. I recommend that you take a look at the videos and come to your own conclusion. CNS
1. Exploring the relationship between medication and veteran suicide. Committee on Veterans’ Affairs, U.S. House of Representatives. Available at: http://veterans.house.gov/hearings/hearing.aspx?NewsID=525. Accessed May 17, 2010.