More threads by David Baxter PhD

David Baxter PhD

Late Founder
Making Sense of the Great Suicide Debate
February 10, 2008

An expression of true love or raw hatred, of purest faith or mortal sin, of courageous loyalty or selfish cowardice: The act of suicide has meant many things to many people through history, from the fifth-century Christian martyrs to the Samurais’ hara-kiri to more recent literary divas, Hemingway, Plath, Sexton.

But now the shadow of suicide has slipped into the corridors of modern medicine as a potential drug side effect, where it is creating a scientific debate as divisive and confounding as any religious clash.

And the shadow is likely to deepen.

After a years-long debate about whether antidepressant drugs like Prozac and Paxil increase the risk of suicide in some people, the Food and Drug Administration in recent days reported that other drugs, including medications used to treat epilepsy, also appear to increase the remote risk of suicide. The agency has been evaluating suicide risk in a variety of medicines, and more such reports — and more headlines — are expected.

Many doctors who treat epilepsy patients said they were bewildered by the recent reports and concerned that regulators were scaring patients away from valuable medications based on limited evidence. On the other side, critics of the agency have charged that the reports were long overdue.

For veterans of the debate over the side effects of drugs, it all had a familiar odor. “Here it comes again,” said Ronald Maris, a professor emeritus at the University of South Carolina School of Medicine and a forensic scientist who works as a paid expert for plaintiffs’ lawyers. “It looks like this is headed down the same road.”

In short, consumers and patients may be in for a Pandora’s box of exasperating, drawn out public debates over suicide risk, if not lurid court cases — with little chance of a clear, satisfying resolution.

The reason is simple: Suicide is an intimate, often impulsive decision that has defied scientific understanding, just as it has confounded easy explanation throughout history, or in literature.

Researchers can count the bodies, all right, and they have confirmed what people already suspected about suicide, that it is associated with depression, alcoholism, and other habits or disorders that leave people miserable.

But the act itself is so rare — 1 in 10,000 — that a series of drug trials cannot pick up enough cases to allow for adequate analysis. A drug trial typically lasts weeks to months and may include, at the high end, little more than a couple of hundred patients. In the case of the epilepsy drugs, the F.D.A. found 4 suicides among some 44,000 people taking the drug in 199 studies, and none among some 28,000 on placebo. Doctors would have to treat about 500 patients before seeing one case of suicidal thinking or behavior that would not have occurred without the drug.

The agency is now requiring that manufacturers in their studies track suicidal symptoms. But drug makers traditionally have had little incentive to do so; on the contrary, in many studies scientists try to screen out suicidal patients and bury any mention of suicide attempts deep in their reports, or with vague language.

To make up for the tiny number of completed suicides, health regulators have used suicide signs, or markers. But these are not well understood, either. One of them is suicidal thinking, or “suicidal ideation.” This is recorded in a study when a patient tells a doctor that he or she is feeling suicidal.

It hardly takes a psychiatrist to point out that the act can’t happen without the idea. But having the idea very rarely leads to the act, as psychiatrists, psychologists and almost anyone who has been a teenager can attest.

Is the person who tells the doctor about the dark thoughts somehow more at risk?

No one knows. “Every psychiatrist with a big practice will have a few suicides, and you’re going to have people who don’t say anything about it — and are very much at risk,” Dr. John Davis, a professor of psychiatry at the University of Illinois at Chicago, said.

Lanny Berman, executive director of the American Association of Suicidology, said in an interview that research suggests that about a quarter of suicides are impulsive: the idea strikes and the person acts quickly. Studies of hospitalized patients have found that many who go on to take their own lives deny to doctors any thoughts of it, he said. “We just don’t know enough about the relationship” between the thoughts and the behavior, Dr. Berman said.

Not to mention that people who are thinking about it more often talk themselves out of the act, also on a sudden whim. As the G. K. Chesterton poem A Ballad of Suicide has it,

But just as all the neighbors - on the wall -
Are drawing a long breath to shout “Hurray!”
The strangest whim has seized me ... After all
I think I will not hang myself today.
Finally, doctors who have spent their lives studying suicide say that it is, almost always, a complex combination of factors — the stars aligning, darkly — that leads to the act.

In his forensic analyses of suicides, Dr. Maris tries to evaluate biological factors, like drug metabolism, as well as family history, sleep habits, personality, and what was happening in the person’s life. Did a spouse threaten to leave? Did a person get fired? Did a best friend just die?

“In that context, then, you have to ask what the drug contributed,” Dr. Maris said. “And often the person is taking more than one medication.”

Perhaps the only thing all parties agree on is that better data is needed.

In a paper in the Journal of the American Medical Association last year, the psychiatrists Dr. Donald Klein of Columbia University and Dr. Charles O’Brien of the University of Pennsylvania argued that the best way to study the risk of rare side effects was to establish large, linked databases of patients, including medical records and prescription histories. Such a system could be created in the United States in a short time, they wrote, but “the possibility has received almost no public discussion or legislative attention.”

And until it does, doctors, regulators and patients alike will have their theories — that the drugs do pose a serious risk; or that the dangers are being exaggerated — and likely see in the limited evidence some confirmation.

Not unlike the tormented souls themselves who are pondering a final exit. In his classic study, The Savage God, the English poet and critic A. Alvarez, a failed suicide himself, wrote that suicide is “a closed world with its own irresistible logic. ... Once a man decides to take his own life he enters a shut-off, impregnable but wholly convincing world where every detail fits and each incidence reinforces his decision.”
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