Dr Yolande Lucire SSRI SUICIDE STATISTICS
Some very interesting observations and articles regarding SSRIs on Dr Lucire's site which is here:
Dr Lucire's home page
And this her article titled:
Do SSRIs Cause Suicide
(converted from a PowerPoint presentation)
"Antidepressants form two major groupings: New SSRIs and older TCAs, which I’ll call TricyclicsSSRIs act on Serotonin and have profound effects. They are capable of changing people profoundly and not always for the best. Contrary to popular opinion, there is no scientific evidence that serotonin is abnormal in depression.Having more of it floating around makes for a lot of change.
SSRIs (the Accused) TCAs (the Comparator) Prozac Tryptanol Zoloft Tofranil Aropax Prothiaden Efexor SinequanCipramilLexaproLuvox
Caution:Do not stop taking an antidepressant without medical supervision.Complications occur on starting, stopping and with irregular dosing. Withdrawal can start up to four weeks after stopping the drug and can go on for three months Complications include agitation, mania, psychosis and self harm and suicide and violence and homicide.
The possibility that a drug was causing the effects it was supposed to cure was unthinkable, especially by clinicians.But it is accepted: SSRI-induced akathisia is in the latest Diagnostic and Statistical Manual, the ever expanding list of mental disorders. DSM
How common is it?A 2001: Yale: 8% of patients admitted ‘may suffer’ from SSRI-induced mania or psychosis.Higher levels of prescribing in OZ and including agitation, suicidal thoughts and attempts, its more like 20%.
I will give you Daubert competent science. Science that has passes 6 Daubert Hearings.Scientific (as opposed to opinion) evidence is the only kind of expert evidence admissible in American and Australian courts Scientific evidence that SSRIs cause: Suicidal thinking Suicidal acts Completed suicide.
The 1993 US Supreme Court Decision in Daubert v. Merrell Dow Pharmaceuticals altered the criteria by which scientific testimony is admitted as evidence in court. The unanimous ruling states that the criterion of the scientific status of a theory is that it can be tested, refuted and falsified.Scientific method is based on generating a null hypothesis, a conjecture that something does not exist, and testing it to see if it you can prove the contrary.The unicorn does not exist. The prisoner is not guilty. These are respectively good science and good law Disproving the negative differentiates science from other forms of inquiry William Daubert, et ux., etc., et al., Petitioners v. Merrell Dow Pharmaceuticals, Inc.Supreme Court of the USA, June 28, 1993.
We need to watch two numbers RELATIVE RISK RR SUICIDE RATE /100,000
A Relative Risk, RR, is how many more times SUICIDE and its precursors THINKING OF SUICIDE AND SUICIDAL ATTEMPTS occur in SSRI-TREATED PATIENTS over and above those treated with a Tricyclicor not treated at all.
If a medicine saves some depressed patients from committing suicide, the RR between that medicine and no treatment should be less than 1.Tricyclics generally had an RR of 0.5 against no treatment, in "hospital" depressions, in which suicides were a known risk. Tricyclics halved the number of suicides in a seriously depressed population.
Tricyclics were known to cause suicide by energising the depressed, but RR was still favourable.If the relative risk equals 1.0, the risk in treated individuals is the same as the risk in untreated ones. If the relative risk is more than 1.0, the risk in treated is greater than in untreated.As we are trying to prevent suicide, an RR of 1 would be ominous.
Eli Lilly (Prozac) Pfizer (Zoloft) and GSK (Aropax) proposed in 1999, the cut off point of SIGNIFICANCE, Relative Risk, RR, be 2.0. Ridiculously HIGH by any standard. Corporate chutzpah.
Exposure to asbestos is deemed contributory to cancer if the RR is only 1.2 which is 20% higher. Asbestos was never expected to PREVENT cancer. AN RR OF 2 IS FIVE TIMES THAT.
The evidence for suicide induction can be found in many areas of research1. CLINICAL PSYCHIATRY Observations and mechanisms Challenge-Dechallenge-Rechallenge experiments Studies of NEW suicidal ideation, (Fava)2. SUICIDE EPIDEMIOLOGY SUICIDES BY PRESCRIBED DRUG JICK, UK DSRU DONOVAN POPULATION STUDIES , PRIMARY CARE HEALY AND BOARDMAN3. HEALTHY VOLUNTEER STUDIES 4. RANDOM CONTROL TRIALS (RCTs) The evidence from all these sources is overwhelmingly supports a relative risk of suicide by SSRI users of greater than 2, and sometimes as high as 8 or 10.
CLINICAL PSYCHIATRY 1990 American Journal of Psychiatry. 147(2):207-10, 1990 Feb.Abstract Teicher Glod and Cole. Six developed intense, violent suicidal preoccupation after 2-7 weeks of Prozac which persisted 3 days to 3 months after Prozac was stopped. None had ever experienced a similar state .Drug companies called this ‘anecdotal’ and said "It’s the disease not the drug, doctor" Now scores of such reports, patients treated for anxiety, eating disorders,OCD and menstrual problems and children
CLINICAL PSYCHIATRYTeicher and Cole (1993) delineate 9 "clinical mechanisms" by which SSRIs can induce or exacerbate suicidal tendencies by: (1) energizing depressed patients, (2) paradoxically worsening their depression , (3) inducing akathisia, (4) inducing panic attacks, (5) switching patients to mania or hypomania, (6) causing insomnia or interfering with sleep architecture (esp. with REM sleep), (7) inducing an organic obsessional state, (8) promoting personality disorder with borderline traits, (9) producing EEG or other neurological disturbances.
Those at risk of suicide are agitated,in turmoil, nervous, sleepless, pacing, energized, almost manic, and they reject their obsessive suicidal thoughts as ‘strange’, ‘weird,’‘not me’.This can go on for weeks or can turn into suicide unpredictably in a matter of minutes.Teicher and Cole, 1993 Healy, Langmaak, and Savage, 1999;’
The traditional suicidogenic triumvirate of psychotropic drug reactions are 1) akathisia, (2) emotional blunting, also called psychic numbing "I cannot feel anything, do not care" and/or (3) psychotic decompensation Akathisia is turmoil, feeling numb as if nothing matters, and feeling one is going mad. It can happen over weeks or days, or very very quickly, in a matter of minutes. Teicher and Cole, 1993 Healy, Langmaak, and Savage, 1999;
CLINICAL PSYCHIATRY1991: Suicidal thinking (out of the blue)Fava and Rosenbaum found suicidal thinking developed in patients who had never been suicidal before, more on Prozac than on other drugs. Prozac v TCAs = RR = 2.7Scores of reportsFava, M. & Rosenbaum, J. 1991. Suicide and 3 fluoxetine. Journal of Clinical Psychiatry, 52-5.
CLINICAL PSYCHIATRYSUICIDAL ACTS 2 of 26 depressed patients overdosed in the first 2 weeks when Prozac was increased quickly. 7.6% is an extremely high rate. M. Muijen, et al., A Comparative Clinical Trial of Fluoxetine, Mianserin, and Placebo in Depressed Outpatients, Acta Psychiatrica Scandinavica, Vol. 78 (1988), pgs. 384-390).
CLINICAL PSYCHIATRYChallenge-Dechallenge-Rechallenge CDRThere are many Challenge-Dechallenge-Rechallenge studies. Suicidality starts on drug, clears up when it is stoppedand Reappears on re-exposure, even to another SSRI.
SUICIDE EPIDEMIOLOGY: JICK Against concerns that Britain’s most popular TCA antidepressant, Prothiaden, dangerously toxic in overdose and being labeled as a ‘dirty drug by SSRI mfrs.Jick examined 172,598 persons and 1.2 million scripts for 10 antidepressants, old and new, general practice patients 143 had committed suicide.Jick S, Dean AD, Jick H (1995). Antidepressants and suicide. British Medical Journal 310: 215-218
SUICIDE EPIDEMIOLOGY : JICK Prothiaden turned out to be the safest as only 14% of suicides involved antidepressant overdose. RR of SUICIDE Prozac v all TCAs RR = 6.6 Prozac v Tofranil RR = 1.9 Prozac v Amitriptyline RR = 4.0 Prozac v Prothiaden RR = 2.1 Prozac v Lofepramine RR = 4.04 SSRI overdoses are not fatal. SSRI suicides tend to be violent: hanging, drowning, shooting, jumping, stabbing or cutting, dying on a railway, burning, electrocution, or deliberate road accidents.
SUICIDE EPIDEMIOLOGY: JICK Jick was embarrassed and suggested that ‘selected’ patients may have been given Prozac, which had a high suicide rate attached.
SUICIDE EPIDEMIOLOGY : DRUG SAFETY RESEARCH UNIT UK (50,000 pop.)The DSRU follows up drugs in the community it looked at completed suicides and what medicines they had been prescribed.Suicide rate on SSRIs = 219/100,000.Prozac 244/100,000 Aropax [PAXIL/SEROXAT] 269/100,000 Luvox [FAVERIN] 183/100,000
Boardman and Healy investigated 475,000 over 5 years counting all the mood disorders in all the private practices and suicide rates for these disorders
SUICIDE EPIDEMIOLOGY: Boardman & Healy PRIMARY CARE SUICIDE RATES All mental disorders < 27-67/100,000. Fits in with other primary care mood disorders suicide statistics Holland 30/100,000 Sweden 0/100,000Antedating SSRIs Simon, von Korff 30/100,000 Highest UK rate 68/100,000Boardman AP, Healy D. Madeley suicide risk in primary care primary affective disorders. European Psychiatry. 2001; 16: 400-405.
SUICIDE EPIDEMIOLOGY: DONOVAN again sought to establish the safety of SSRIs against TCAs which were toxic in overdose. Examined 222 COMPLETED SUICIDES, and the medicines they had been taking, and found SSRIs v TCA RR= 2 Donovan S, Kelleher MJ, Lambourn J, Foster R. The occurrence of suicide following the prescription of antidepressant drugs. Arch Suic Res. 1999; 5: 181-192.
SUICIDAL ACTS: DONOVAN At the same time, DONOVAN looked at 2776 acts of DELIBERATE SELF HARM in 1954 persons presenting to emergency and what they were taking Aropax v Tryptanol (TCA) RR = 4.0 Prozac v Tryptanol (TCA) RR = 6.6 Zoloft v Tryptanol (TCA) RR = 4.9 Aropax v Tofranil (TCA) RR = 1.9 All SSRI v Tofranil (TCA) RR = 5.5 Donovan S, Clayton A, Beeharry M, Jones S, Kirk C, Waters K, Gardner D, Faulding J, Madely R. Deliberate self-harm and antidepressant drugs. Investigation of a possible link. Brit J Psychiatry. 2000; 177: 551-556
HEALTHY VOLUNTEERS Healy: 2 of 20 healthy volunteers suicidal on Zoloft.
2 healthy volunteers have suicided: 19 year old Traci Johnston, a healthy volunteer, suicided February 7th 2004 in a trial of Eli Lilly's new Serotonin drug - duloxetine [CYMBALTA/YENTREVE], for incontinence aborting the trial Reported in Sydney Morning Herald Lilly had been doing clinical trials in Australia
Result:You cannot set up a trial to see how many people kill themselves as a consequence of the drug you are testing It would be impossible to get insuranceor ethics approval. Or informed consent? Have to make do with information we have.Emergence of antidepressant suicidality, published in 2000 in Primary Care Psychiatry (Vol. 6, No. 1).
RANDOM CONTROLLED TRIALS (RCTs)SUICIDES AND SUICIDAL ACTS2003, Khan et al. looked atBLIND CLINICAL TRIALS from 1986-90 Presented to the US Federal Drug Administration, to get SSRIs licensed. FOR9 Serotonin ANTIDEPRESSANTS against comparators and placebos.
Kahn found NO DIFFERENCE in suicides and suicidal acts between those on SSRIs or on COMPARATOR DRUGS or PLACEBOS48,277 depressed patients participated in the trials,and 77 committed suicide. That’s a lot. Am J Psychiatry. 2003 Apr;160(4):790-2.
RANDOM CONTROLLED TRIALS SSRIs had failed to demonstrate usefulness in hospital depressions. (We still give as much ECT as we ever did) so ‘hospital patients’ carrying suicide risk were not recruited into these trials.SSRIs were aimed at general practice. ‘Samples of convenience’ patients under stress, with minor disorders, The Valium using population of the 1970sWith suicidal patients filtered out.
In September of 2003, Healy and Whittaker re-evaluated the same, original FDA studies. They published a watershed paper in September 2003. Antidepressants and suicide:risk–benefit conundrums David Healy, MD; Chris Whitaker, MScHealy — Department of Psychological Medicine, University of Wales College of Medicine, Hergest Unit; Whitaker — Department of Informatics, University of Wales Bangor, Bangor, United Kingdom. J Psychiatry Neurosci 2003;28(5):331-7
Whereas Kahn had coded as ‘placebo suicides’ those within 2 weeks of stopping an SSRI Healy and Whittaker recognised these 5 SUICIDES and MANY SUICIDAL ACTS AS ‘SSRI WITHDRAWAL SUICIDES’.
Khan had counted suicides per number of patient years exposed to the drug, PEYs .Healy counted suicides per number of patients treated
Healy argued that the risks of SSRIs resembled the risks of space travel which, mile for mile, was the safest form of transport available. But going up and coming down are the danger periods for both.
But landing and re-entry occurs each time a dose is forgotten, not absorbed, taken with alcohol or if a co-prescribed medicine is added or removed.
Summary: Incidence of Suicides and Suicide Attempts (combined) in Antidepressant Trials From FDA Medical Reviews
FDA TRIALS SUMMARY 26,000 subjects SUICIDE RATES ALL DRUGS SUICIDE = 232/100,000SSRI SUICIDE = 186/100,000 PLACEBO SUICIDE = 64/100,000RELATIVE RISK FDA TRIALSSUICIDE ON SSRI RR = 2.4 (CI 0.6-10.2)SUICIDAL ACT ON SSRIS RR = 2.2 (CI 1.4-3.5)S/ ACTS ON NEW ANTIDEPRESSANTS RR = 4.3 (CI 1.1-17.8)
SUICIDE RATESDRUG SAFETY RESEARCH UNIT SSRI SUICIDE = 212/100,000JICK PROZAC in first 30 days of treatment 274/100,000 PEYsPROZAC 93/100,000
SUICIDE EPIDEMIOLOGY: Boardman & Healy and many othersAntedating SSRIsPRIMARY CARE SUICIDE RATES < 27-68/100,000 MAXIMUM ANY POPULATION STUDY 68/100,000Boardman AP, Healy D. Madeley suicide risk in primary care primary affective disorders. European Psychiatry. 2001; 16: 400-405.
Healy and Whittaker’s conclusion was modest: It is no longer possible to support the null hypothesis that SSRIs do not cause suicide The null hypothesis has been falsified.
Any way you look at available information, clinical settings,emergency rooms, morgues, clinical trials,SSRIs as a general cause of suicide would pass the scientific standard of proof.The BMJ issued warnings on February 5 2004.FDA on March 23Most manufacturers put on Websites on May 3, 2004. Only in USA.
WARNING MAY 3 2004… patients being treated with antidepressants should be observed closely for clinical worsening and suicidality, especially at the beginning of a course of drug therapy, or at the time of dose changes, either increases or decreases.
WARNING MAY 3 2004 Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and non-psychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers
Unlike smallpox, depression has not been disappeared since a cure became availablePotentially fatal complications of any treatment might be acceptable if the treated population were small, dangerously ill, at high riskthe availability of a remedy has increased the diagnosis of depression a thousandfold.and lethal side effects have increased by the same multiplier.
The drug manufacturers promote the medicalization of stresssubsidize psychiatrists, journals, conferences. Encourage moral entrepreneurs of health whotalk about cases undiagnosed, and so untreatedJohn Merson calls this phenomenon ‘epistemic capture’: the control of knowledge by vested interests.
200/100,000 represents 1 death in 500 people treated with SSRIs in primary care.68/100,000 v 200/100,000A least 100 suicides per 100,000 over treatment with other drugs or non treatment.By 2003, over 28 million people had started Prozac since its launch in 1988.
6,664,960 prescriptions for SSRI written 2003 by Australian doctors.Twelve times the annual number studied by Donovan40% of first prescriptions remain unfinished, because of side effects. PBS spends $160 million a year on SSRIs.Cui Bono?
I in 500 too rare for clinicians to see.They need advice from suicide epidemiologists and statisticians.Opinion evidence is not admissible. ‘We are not convinced’ and ad hominem arguments do not get admitted as evidence. 1 in 500 is well above Rogers and Whittaker’s, 1 in 14,000 and demands a duty to warn of a catastrophic side effect.
Someone has that duty.Who will tell the prescribing doctor? The manufacturers have not done so in Austrlalia. The Therapeutic Goods Administration has not issued warnings. The Federal Drug Administration in USA argues that its role is licensing drugs, not protecting the public.Psychiatrists, all clinicians, are ‘not convinced’.
Some more alarming informataion has emerged from David Healy's re evaluation of the clinical trials of antipsychotic drugs presented to the FDA.It concerns commonly prescribed antipsychotic drugsThe regulator, the FDA, just did not notice in the late 1980s that one in 208 or 12 in 2,500 clinical trial subjects committed suicide while Zyprexa was being trialled and only one on placebo and one on a comparator, most likely haloperidol did that.
The subject numbers are so small that relative risk cannot be calculated, but Zyprexa (Olanzepine) trials had the highest rate of suicide in clinical trial history. Suicidal Acts have not been reportedRisperdal was not far behind Zyprexa. The mechanism is thought to be similar,through causing akathisia and doing these drugs synergistically with SSRIs. Doctors have not been warned.
All Truth passes through Three Stages: First, it is Ridiculed... Second, it is Violently Opposed... Third, it is Accepted as being Self-Evident.Arthur Schopenhauer (1778-1860 )
In Friedson’s account, moral entrepreneurs in medicine are commonly part-time practitioners who crusade in health matters. The thrust of their activity is towards political power as they seek to implement measures designed to improve what they see as public health. They give press interviews and try to give testimony in court.
They are often responsible for legislation. They want to place jurisdiction for their concerns in the hands of health professionals rather than leave them with society. Freidson identified lay interest groups, sometimes led by, and always including, prominent physicians, whom he described as ‘the most flamboyant moral entrepreneurs of health, untrammelled by professional dignity, crusading against the menace of a specially chosen disease, impairment or disease-producing agent’
Such moral entrepreneurs, essential players in any moral panic, are ubiquitous. Professional entrepreneurs are creating panics about the consequences of child sexual abuse, others about failing to have professionals attend immediately on persons involved in traumatic events and about depression which had become the greatest scourge of modern society.
They advert to cases of undiagnosed and untreated post-traumatic stress disorder and depression, which medication would surely cure. They attribute to these evils a status of being important causes of personal failure and society’s epidemic ills.
Physician moral entrepreneurs are likely to see the environment as more dangerous to health than does the layman, and to emphasise the seriousness of the health problem preoccupying them by estimating the cases probably undiagnosed and therefore untreated.
They are disposed to see mental illness where the layman sees nervousness, to see illness where the layman sees variations within the broad range of normality, to see a serious problem where the layman sees only a minor one. They are biased towards the creation of sick roles and press their licence as physicians to manage the newly defined sick within their relevant speciality frameworks.
In brief, the medical profession is more prone to see illness and the need for treatment than it is to see health and normality. This selective perception is both self-confirming and self-sustaining."
END OF ARTICLE
Aropax is known in the UK as Seroxat and in the US and Canada as Paxil so I've inserted [PAXIL/SEROXAT] where Aropax appears.
I've also outlined in bold some of the points re suicidality and some re Relative Risks.
It amazes me how a relative few good (and very busy) expert doctors can come up with more information in their 'own time' than drug regulators (like the MHRA and the FDA) and their 'special investigatory committees' can - even though they have the power to find out the facts from the pharma industry, its THEIR JOB and doing so to protect the public is THEIR RESPONSIBILITY!
Dr Lucire's home page
And this her article titled:
Do SSRIs Cause Suicide
(converted from a PowerPoint presentation)
"Antidepressants form two major groupings: New SSRIs and older TCAs, which I’ll call TricyclicsSSRIs act on Serotonin and have profound effects. They are capable of changing people profoundly and not always for the best. Contrary to popular opinion, there is no scientific evidence that serotonin is abnormal in depression.Having more of it floating around makes for a lot of change.
SSRIs (the Accused) TCAs (the Comparator) Prozac Tryptanol Zoloft Tofranil Aropax Prothiaden Efexor SinequanCipramilLexaproLuvox
Caution:Do not stop taking an antidepressant without medical supervision.Complications occur on starting, stopping and with irregular dosing. Withdrawal can start up to four weeks after stopping the drug and can go on for three months Complications include agitation, mania, psychosis and self harm and suicide and violence and homicide.
The possibility that a drug was causing the effects it was supposed to cure was unthinkable, especially by clinicians.But it is accepted: SSRI-induced akathisia is in the latest Diagnostic and Statistical Manual, the ever expanding list of mental disorders. DSM
How common is it?A 2001: Yale: 8% of patients admitted ‘may suffer’ from SSRI-induced mania or psychosis.Higher levels of prescribing in OZ and including agitation, suicidal thoughts and attempts, its more like 20%.
I will give you Daubert competent science. Science that has passes 6 Daubert Hearings.Scientific (as opposed to opinion) evidence is the only kind of expert evidence admissible in American and Australian courts Scientific evidence that SSRIs cause: Suicidal thinking Suicidal acts Completed suicide.
The 1993 US Supreme Court Decision in Daubert v. Merrell Dow Pharmaceuticals altered the criteria by which scientific testimony is admitted as evidence in court. The unanimous ruling states that the criterion of the scientific status of a theory is that it can be tested, refuted and falsified.Scientific method is based on generating a null hypothesis, a conjecture that something does not exist, and testing it to see if it you can prove the contrary.The unicorn does not exist. The prisoner is not guilty. These are respectively good science and good law Disproving the negative differentiates science from other forms of inquiry William Daubert, et ux., etc., et al., Petitioners v. Merrell Dow Pharmaceuticals, Inc.Supreme Court of the USA, June 28, 1993.
We need to watch two numbers RELATIVE RISK RR SUICIDE RATE /100,000
A Relative Risk, RR, is how many more times SUICIDE and its precursors THINKING OF SUICIDE AND SUICIDAL ATTEMPTS occur in SSRI-TREATED PATIENTS over and above those treated with a Tricyclicor not treated at all.
If a medicine saves some depressed patients from committing suicide, the RR between that medicine and no treatment should be less than 1.Tricyclics generally had an RR of 0.5 against no treatment, in "hospital" depressions, in which suicides were a known risk. Tricyclics halved the number of suicides in a seriously depressed population.
Tricyclics were known to cause suicide by energising the depressed, but RR was still favourable.If the relative risk equals 1.0, the risk in treated individuals is the same as the risk in untreated ones. If the relative risk is more than 1.0, the risk in treated is greater than in untreated.As we are trying to prevent suicide, an RR of 1 would be ominous.
Eli Lilly (Prozac) Pfizer (Zoloft) and GSK (Aropax) proposed in 1999, the cut off point of SIGNIFICANCE, Relative Risk, RR, be 2.0. Ridiculously HIGH by any standard. Corporate chutzpah.
Exposure to asbestos is deemed contributory to cancer if the RR is only 1.2 which is 20% higher. Asbestos was never expected to PREVENT cancer. AN RR OF 2 IS FIVE TIMES THAT.
The evidence for suicide induction can be found in many areas of research1. CLINICAL PSYCHIATRY Observations and mechanisms Challenge-Dechallenge-Rechallenge experiments Studies of NEW suicidal ideation, (Fava)2. SUICIDE EPIDEMIOLOGY SUICIDES BY PRESCRIBED DRUG JICK, UK DSRU DONOVAN POPULATION STUDIES , PRIMARY CARE HEALY AND BOARDMAN3. HEALTHY VOLUNTEER STUDIES 4. RANDOM CONTROL TRIALS (RCTs) The evidence from all these sources is overwhelmingly supports a relative risk of suicide by SSRI users of greater than 2, and sometimes as high as 8 or 10.
CLINICAL PSYCHIATRY 1990 American Journal of Psychiatry. 147(2):207-10, 1990 Feb.Abstract Teicher Glod and Cole. Six developed intense, violent suicidal preoccupation after 2-7 weeks of Prozac which persisted 3 days to 3 months after Prozac was stopped. None had ever experienced a similar state .Drug companies called this ‘anecdotal’ and said "It’s the disease not the drug, doctor" Now scores of such reports, patients treated for anxiety, eating disorders,OCD and menstrual problems and children
CLINICAL PSYCHIATRYTeicher and Cole (1993) delineate 9 "clinical mechanisms" by which SSRIs can induce or exacerbate suicidal tendencies by: (1) energizing depressed patients, (2) paradoxically worsening their depression , (3) inducing akathisia, (4) inducing panic attacks, (5) switching patients to mania or hypomania, (6) causing insomnia or interfering with sleep architecture (esp. with REM sleep), (7) inducing an organic obsessional state, (8) promoting personality disorder with borderline traits, (9) producing EEG or other neurological disturbances.
Those at risk of suicide are agitated,in turmoil, nervous, sleepless, pacing, energized, almost manic, and they reject their obsessive suicidal thoughts as ‘strange’, ‘weird,’‘not me’.This can go on for weeks or can turn into suicide unpredictably in a matter of minutes.Teicher and Cole, 1993 Healy, Langmaak, and Savage, 1999;’
The traditional suicidogenic triumvirate of psychotropic drug reactions are 1) akathisia, (2) emotional blunting, also called psychic numbing "I cannot feel anything, do not care" and/or (3) psychotic decompensation Akathisia is turmoil, feeling numb as if nothing matters, and feeling one is going mad. It can happen over weeks or days, or very very quickly, in a matter of minutes. Teicher and Cole, 1993 Healy, Langmaak, and Savage, 1999;
CLINICAL PSYCHIATRY1991: Suicidal thinking (out of the blue)Fava and Rosenbaum found suicidal thinking developed in patients who had never been suicidal before, more on Prozac than on other drugs. Prozac v TCAs = RR = 2.7Scores of reportsFava, M. & Rosenbaum, J. 1991. Suicide and 3 fluoxetine. Journal of Clinical Psychiatry, 52-5.
CLINICAL PSYCHIATRYSUICIDAL ACTS 2 of 26 depressed patients overdosed in the first 2 weeks when Prozac was increased quickly. 7.6% is an extremely high rate. M. Muijen, et al., A Comparative Clinical Trial of Fluoxetine, Mianserin, and Placebo in Depressed Outpatients, Acta Psychiatrica Scandinavica, Vol. 78 (1988), pgs. 384-390).
CLINICAL PSYCHIATRYChallenge-Dechallenge-Rechallenge CDRThere are many Challenge-Dechallenge-Rechallenge studies. Suicidality starts on drug, clears up when it is stoppedand Reappears on re-exposure, even to another SSRI.
SUICIDE EPIDEMIOLOGY: JICK Against concerns that Britain’s most popular TCA antidepressant, Prothiaden, dangerously toxic in overdose and being labeled as a ‘dirty drug by SSRI mfrs.Jick examined 172,598 persons and 1.2 million scripts for 10 antidepressants, old and new, general practice patients 143 had committed suicide.Jick S, Dean AD, Jick H (1995). Antidepressants and suicide. British Medical Journal 310: 215-218
SUICIDE EPIDEMIOLOGY : JICK Prothiaden turned out to be the safest as only 14% of suicides involved antidepressant overdose. RR of SUICIDE Prozac v all TCAs RR = 6.6 Prozac v Tofranil RR = 1.9 Prozac v Amitriptyline RR = 4.0 Prozac v Prothiaden RR = 2.1 Prozac v Lofepramine RR = 4.04 SSRI overdoses are not fatal. SSRI suicides tend to be violent: hanging, drowning, shooting, jumping, stabbing or cutting, dying on a railway, burning, electrocution, or deliberate road accidents.
SUICIDE EPIDEMIOLOGY: JICK Jick was embarrassed and suggested that ‘selected’ patients may have been given Prozac, which had a high suicide rate attached.
SUICIDE EPIDEMIOLOGY : DRUG SAFETY RESEARCH UNIT UK (50,000 pop.)The DSRU follows up drugs in the community it looked at completed suicides and what medicines they had been prescribed.Suicide rate on SSRIs = 219/100,000.Prozac 244/100,000 Aropax [PAXIL/SEROXAT] 269/100,000 Luvox [FAVERIN] 183/100,000
Boardman and Healy investigated 475,000 over 5 years counting all the mood disorders in all the private practices and suicide rates for these disorders
SUICIDE EPIDEMIOLOGY: Boardman & Healy PRIMARY CARE SUICIDE RATES All mental disorders < 27-67/100,000. Fits in with other primary care mood disorders suicide statistics Holland 30/100,000 Sweden 0/100,000Antedating SSRIs Simon, von Korff 30/100,000 Highest UK rate 68/100,000Boardman AP, Healy D. Madeley suicide risk in primary care primary affective disorders. European Psychiatry. 2001; 16: 400-405.
SUICIDE EPIDEMIOLOGY: DONOVAN again sought to establish the safety of SSRIs against TCAs which were toxic in overdose. Examined 222 COMPLETED SUICIDES, and the medicines they had been taking, and found SSRIs v TCA RR= 2 Donovan S, Kelleher MJ, Lambourn J, Foster R. The occurrence of suicide following the prescription of antidepressant drugs. Arch Suic Res. 1999; 5: 181-192.
SUICIDAL ACTS: DONOVAN At the same time, DONOVAN looked at 2776 acts of DELIBERATE SELF HARM in 1954 persons presenting to emergency and what they were taking Aropax v Tryptanol (TCA) RR = 4.0 Prozac v Tryptanol (TCA) RR = 6.6 Zoloft v Tryptanol (TCA) RR = 4.9 Aropax v Tofranil (TCA) RR = 1.9 All SSRI v Tofranil (TCA) RR = 5.5 Donovan S, Clayton A, Beeharry M, Jones S, Kirk C, Waters K, Gardner D, Faulding J, Madely R. Deliberate self-harm and antidepressant drugs. Investigation of a possible link. Brit J Psychiatry. 2000; 177: 551-556
HEALTHY VOLUNTEERS Healy: 2 of 20 healthy volunteers suicidal on Zoloft.
2 healthy volunteers have suicided: 19 year old Traci Johnston, a healthy volunteer, suicided February 7th 2004 in a trial of Eli Lilly's new Serotonin drug - duloxetine [CYMBALTA/YENTREVE], for incontinence aborting the trial Reported in Sydney Morning Herald Lilly had been doing clinical trials in Australia
Result:You cannot set up a trial to see how many people kill themselves as a consequence of the drug you are testing It would be impossible to get insuranceor ethics approval. Or informed consent? Have to make do with information we have.Emergence of antidepressant suicidality, published in 2000 in Primary Care Psychiatry (Vol. 6, No. 1).
RANDOM CONTROLLED TRIALS (RCTs)SUICIDES AND SUICIDAL ACTS2003, Khan et al. looked atBLIND CLINICAL TRIALS from 1986-90 Presented to the US Federal Drug Administration, to get SSRIs licensed. FOR9 Serotonin ANTIDEPRESSANTS against comparators and placebos.
Kahn found NO DIFFERENCE in suicides and suicidal acts between those on SSRIs or on COMPARATOR DRUGS or PLACEBOS48,277 depressed patients participated in the trials,and 77 committed suicide. That’s a lot. Am J Psychiatry. 2003 Apr;160(4):790-2.
RANDOM CONTROLLED TRIALS SSRIs had failed to demonstrate usefulness in hospital depressions. (We still give as much ECT as we ever did) so ‘hospital patients’ carrying suicide risk were not recruited into these trials.SSRIs were aimed at general practice. ‘Samples of convenience’ patients under stress, with minor disorders, The Valium using population of the 1970sWith suicidal patients filtered out.
In September of 2003, Healy and Whittaker re-evaluated the same, original FDA studies. They published a watershed paper in September 2003. Antidepressants and suicide:risk–benefit conundrums David Healy, MD; Chris Whitaker, MScHealy — Department of Psychological Medicine, University of Wales College of Medicine, Hergest Unit; Whitaker — Department of Informatics, University of Wales Bangor, Bangor, United Kingdom. J Psychiatry Neurosci 2003;28(5):331-7
Whereas Kahn had coded as ‘placebo suicides’ those within 2 weeks of stopping an SSRI Healy and Whittaker recognised these 5 SUICIDES and MANY SUICIDAL ACTS AS ‘SSRI WITHDRAWAL SUICIDES’.
Khan had counted suicides per number of patient years exposed to the drug, PEYs .Healy counted suicides per number of patients treated
Healy argued that the risks of SSRIs resembled the risks of space travel which, mile for mile, was the safest form of transport available. But going up and coming down are the danger periods for both.
But landing and re-entry occurs each time a dose is forgotten, not absorbed, taken with alcohol or if a co-prescribed medicine is added or removed.
Summary: Incidence of Suicides and Suicide Attempts (combined) in Antidepressant Trials From FDA Medical Reviews
FDA TRIALS SUMMARY 26,000 subjects SUICIDE RATES ALL DRUGS SUICIDE = 232/100,000SSRI SUICIDE = 186/100,000 PLACEBO SUICIDE = 64/100,000RELATIVE RISK FDA TRIALSSUICIDE ON SSRI RR = 2.4 (CI 0.6-10.2)SUICIDAL ACT ON SSRIS RR = 2.2 (CI 1.4-3.5)S/ ACTS ON NEW ANTIDEPRESSANTS RR = 4.3 (CI 1.1-17.8)
SUICIDE RATESDRUG SAFETY RESEARCH UNIT SSRI SUICIDE = 212/100,000JICK PROZAC in first 30 days of treatment 274/100,000 PEYsPROZAC 93/100,000
SUICIDE EPIDEMIOLOGY: Boardman & Healy and many othersAntedating SSRIsPRIMARY CARE SUICIDE RATES < 27-68/100,000 MAXIMUM ANY POPULATION STUDY 68/100,000Boardman AP, Healy D. Madeley suicide risk in primary care primary affective disorders. European Psychiatry. 2001; 16: 400-405.
Healy and Whittaker’s conclusion was modest: It is no longer possible to support the null hypothesis that SSRIs do not cause suicide The null hypothesis has been falsified.
Any way you look at available information, clinical settings,emergency rooms, morgues, clinical trials,SSRIs as a general cause of suicide would pass the scientific standard of proof.The BMJ issued warnings on February 5 2004.FDA on March 23Most manufacturers put on Websites on May 3, 2004. Only in USA.
WARNING MAY 3 2004… patients being treated with antidepressants should be observed closely for clinical worsening and suicidality, especially at the beginning of a course of drug therapy, or at the time of dose changes, either increases or decreases.
WARNING MAY 3 2004 Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and non-psychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers
Unlike smallpox, depression has not been disappeared since a cure became availablePotentially fatal complications of any treatment might be acceptable if the treated population were small, dangerously ill, at high riskthe availability of a remedy has increased the diagnosis of depression a thousandfold.and lethal side effects have increased by the same multiplier.
The drug manufacturers promote the medicalization of stresssubsidize psychiatrists, journals, conferences. Encourage moral entrepreneurs of health whotalk about cases undiagnosed, and so untreatedJohn Merson calls this phenomenon ‘epistemic capture’: the control of knowledge by vested interests.
200/100,000 represents 1 death in 500 people treated with SSRIs in primary care.68/100,000 v 200/100,000A least 100 suicides per 100,000 over treatment with other drugs or non treatment.By 2003, over 28 million people had started Prozac since its launch in 1988.
6,664,960 prescriptions for SSRI written 2003 by Australian doctors.Twelve times the annual number studied by Donovan40% of first prescriptions remain unfinished, because of side effects. PBS spends $160 million a year on SSRIs.Cui Bono?
I in 500 too rare for clinicians to see.They need advice from suicide epidemiologists and statisticians.Opinion evidence is not admissible. ‘We are not convinced’ and ad hominem arguments do not get admitted as evidence. 1 in 500 is well above Rogers and Whittaker’s, 1 in 14,000 and demands a duty to warn of a catastrophic side effect.
Someone has that duty.Who will tell the prescribing doctor? The manufacturers have not done so in Austrlalia. The Therapeutic Goods Administration has not issued warnings. The Federal Drug Administration in USA argues that its role is licensing drugs, not protecting the public.Psychiatrists, all clinicians, are ‘not convinced’.
Some more alarming informataion has emerged from David Healy's re evaluation of the clinical trials of antipsychotic drugs presented to the FDA.It concerns commonly prescribed antipsychotic drugsThe regulator, the FDA, just did not notice in the late 1980s that one in 208 or 12 in 2,500 clinical trial subjects committed suicide while Zyprexa was being trialled and only one on placebo and one on a comparator, most likely haloperidol did that.
The subject numbers are so small that relative risk cannot be calculated, but Zyprexa (Olanzepine) trials had the highest rate of suicide in clinical trial history. Suicidal Acts have not been reportedRisperdal was not far behind Zyprexa. The mechanism is thought to be similar,through causing akathisia and doing these drugs synergistically with SSRIs. Doctors have not been warned.
All Truth passes through Three Stages: First, it is Ridiculed... Second, it is Violently Opposed... Third, it is Accepted as being Self-Evident.Arthur Schopenhauer (1778-1860 )
In Friedson’s account, moral entrepreneurs in medicine are commonly part-time practitioners who crusade in health matters. The thrust of their activity is towards political power as they seek to implement measures designed to improve what they see as public health. They give press interviews and try to give testimony in court.
They are often responsible for legislation. They want to place jurisdiction for their concerns in the hands of health professionals rather than leave them with society. Freidson identified lay interest groups, sometimes led by, and always including, prominent physicians, whom he described as ‘the most flamboyant moral entrepreneurs of health, untrammelled by professional dignity, crusading against the menace of a specially chosen disease, impairment or disease-producing agent’
Such moral entrepreneurs, essential players in any moral panic, are ubiquitous. Professional entrepreneurs are creating panics about the consequences of child sexual abuse, others about failing to have professionals attend immediately on persons involved in traumatic events and about depression which had become the greatest scourge of modern society.
They advert to cases of undiagnosed and untreated post-traumatic stress disorder and depression, which medication would surely cure. They attribute to these evils a status of being important causes of personal failure and society’s epidemic ills.
Physician moral entrepreneurs are likely to see the environment as more dangerous to health than does the layman, and to emphasise the seriousness of the health problem preoccupying them by estimating the cases probably undiagnosed and therefore untreated.
They are disposed to see mental illness where the layman sees nervousness, to see illness where the layman sees variations within the broad range of normality, to see a serious problem where the layman sees only a minor one. They are biased towards the creation of sick roles and press their licence as physicians to manage the newly defined sick within their relevant speciality frameworks.
In brief, the medical profession is more prone to see illness and the need for treatment than it is to see health and normality. This selective perception is both self-confirming and self-sustaining."
END OF ARTICLE
Aropax is known in the UK as Seroxat and in the US and Canada as Paxil so I've inserted [PAXIL/SEROXAT] where Aropax appears.
I've also outlined in bold some of the points re suicidality and some re Relative Risks.
It amazes me how a relative few good (and very busy) expert doctors can come up with more information in their 'own time' than drug regulators (like the MHRA and the FDA) and their 'special investigatory committees' can - even though they have the power to find out the facts from the pharma industry, its THEIR JOB and doing so to protect the public is THEIR RESPONSIBILITY!
posted by Small Voice | 9:36 am
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