Suicide Attempts Fall After Depression Treatment Begins

[David Baxter PhD]

Suicide Attempts Fall After Depression Treatment Begins
by Ed Edelson, HealthDay News
Jul 2nd 2007

Suicide attempts dropped among people with depression soon after they started treatment, either with antidepressant drugs or psychotherapy, a study of more than 109,000 patients shows.

The study results come after a controversial 2004 recommendation on antidepressant labeling from the U.S. Food and Drug Administration (FDA). That move slapped a strong "black box" warning on the labeling of drugs called selective serotonin reuptake inhibitors (SSRIs), which include Celexa, Paxil, Prozac and Zoloft.

The warning outlined the potential for an increase in suicidal thoughts among teenagers and young adults prescribed the medications. The warning also urged closer clinical monitoring of these patients.

However, "the FDA warning was based on placebo-controlled trials," noted lead researcher Dr. Greg Simon, a psychiatrist and researcher at Group Health, a Seattle-based nonprofit health care system. "They did not look at suicide attempts, because they were too rare. In the whole group of studies the FDA looked at, there were only two suicide attempts," Simon said.

The current trial, published in the July issue of the American Journal of Psychiatry, does focus on suicide attempts. It finds that pharmaceutical and psychotherapy treatments aimed at fighting depression reduce those attempts.

Simon's study looked at suicide attempts among more than 70,000 people who got an antidepressant prescription from their primary care physicians, almost 7,300 people who got prescriptions from a psychiatrist and more than 54,000 who started psychotherapy for the treatment of depression.

"The pattern of [suicide] attempts over time was the same in all three groups: highest in the month before starting treatment, next highest in the month after starting treatment, and declining thereafter," the report said. "Results were unchanged after eliminating patients receiving overlapping treatment with medication and psychotherapy. Overall incidence of suicide attempts was higher in adolescents and young adults, but the time pattern was the same across all three treatments," the study authors found.

The overall incidence of suicide attempts in the first six months was highest in those taking antidepressant drugs prescribed by a psychiatrist (1,124 attempts per 100,000), lower among those starting psychotherapy (778 per 100,000) and lowest of all among those who were taking antidepressants prescribed by a general practitioner (301 per 100,000).

The bottom line: "Our study indicates there is nothing specific to antidepressant medications that would either make large populations of people with depression start trying to kill themselves or protect them from suicidal thoughts," Simon said.

"Instead, we think that on average, starting any kind of treatment medication, psychotherapy or both, helps most people of any age have fewer symptoms of depression, including thinking about suicide and attempting it," he said.

The new report "is one of a couple showing that prescribing antidepressant medication for people who are depressed has the potential for reducing the number of suicide attempts," said Dr. J. John Mann, chief of the department of neuroscience at the New York Psychiatric Institute, New York City.

Mann co-authored one such report, which relied on U.S. Veterans Administration data. "We found exactly the same thing" as the Simon report, Mann said. "Antidepressant treatment resulted in lower rates of suicide attempts after people went on to treatment."

Such studies "suggest that these medications may be more beneficial than has been thought in the past," Mann said. "If there is a risk in these medications, it clearly is outweighed by the benefits. No treatment is the worst option of all."

Simon also pointed out that the FDA warning reduced use of SSRI drugs for treatment of depression, but it has not appeared to increase doctors' monitoring of young people who are taking the drugs. The standing recommendation for three follow-up visits to the therapist prescribing antidepressant drugs was observed in only 21 percent of cases, the researcher said.

"That is where we are poor in practice," Simon said. "My concern is that the practical impact of the warning was [only in] reduced rates of treatment."

More information
There is more on suicide prevention at the U.S. National Institute of Mental Health.

 

[David Baxter PhD]

Both depression drugs, psychotherapy halve suicide risk within weeks

Suicide attempts peak in the month before treatment starts

In a study of more than 100,000 patients treated for depression, suicide attempts declined during the first month of treatment - whether that treatment consisted of medication, psychotherapy, or both. The findings, published by Group Health researchers in the July American Journal of Psychiatry (AJP), show a similar pattern for populations of adolescents and young adults (up to age 24) as for older adults.

The study sheds new light on the "black box" advisory that the U.S. Food and Drug Administration (FDA) placed in 2004 and has revised since then, said Greg Simon, MD, MPH, the Group Health psychiatrist who led the study. The advisory - which has concerned many patients, families, and care providers - warns that suicidal behavior may emerge soon after people younger than 25 start treatment with newer antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). It was spurred by randomized placebo-controlled trials showing that starting to take an SSRI can make thoughts of suicide more common among some teens and young adults.

However, none of the trials looked at the actual rate of suicide attempts, "because they were too rare. In the whole group of studies the FDA looked at, there were only two suicide attempts," Simon said.

Dr. Simon's study is the first published research to compare the risk of suicide attempts before and after the start of treatment with not only antidepressants but also psychotherapy. It is based on computerized medical and pharmacy records for more than 109,000 patients who started treatment for depression at Group Health from 1996 to 2005.

In the study, suicide attempts were about twice as common among patients up to age 24 as among older adults. However, the time pattern was the same for both age groups, regardless of the type of treatment they received: Suicide attempts were most likely during the month before treatment started, falling by at least 50 percent in the month after treatment began, with steady declines thereafter.

At all time points - up to three months before and six months after starting treatment - patients who received their antidepressant prescription from a psychiatrist tended to be most likely to attempt suicide. Those who received it from their primary care doctor were least likely to attempt suicide, with levels in between for those who got individual psychotherapy from a therapist other than a psychiatrist. "That's not because seeing a psychiatrist makes you want to kill yourself," said Dr. Simon. Rather, he suggested, these results reflect the fact that people with severe depression, who tend to be more suicidal, are more likely to be referred to psychiatrists, while those with milder depression stick with their primary doctors.

"Our study indicates that there's nothing specific to antidepressant medications that would either make large populations of people with depression start trying to kill themselves - or protect them from suicidal thoughts," said Dr. Simon. "Instead, we think that, on average, starting any type of treatment - medication, psychotherapy, or both - helps most people of any age have fewer symptoms of depression, including thinking about suicide and attempting it." That said, he likened population-based studies-both observational studies such as this one and randomized controlled trials of medications-to "circumstantial evidence" about what happens to individual patients.

Like other psychiatrists, Dr. Simon has seen a few depressed patients start having suicidal thoughts while taking antidepressant medication despite never having thought about suicide before then. He hypothesizes that subgroups of people may be vulnerable to becoming more agitated or suicidal after taking these drugs. "We hope to learn how to identify these people in advance," he said.

Dr. Simon published an earlier paper showing that the risk of suicide attempts decreased in the weeks after patients started taking antidepressant medication. His new study strengthens his earlier conclusion that for populations of people, even teens and young adults, suicide attempts tend to be rarer right after starting antidepressant medication than beforehand. He echoed the FDA's recommendations that doctors regularly monitor their patients during treatment with antidepressants to ensure that they are receiving the right medication at a dose that helps them feel better. "If people feel agitated or suicidal, they should seek help from a doctor or therapist," he added.

Commentating on the research, Dr. J. John Mann, chief of the department of neuroscience at the New York Psychiatric Institute said, "[The study] is one of a couple showing that prescribing antidepressant medication for people who are depressed has the potential for reducing the number of suicide attempts." Mann is a coauthor of a second study in the current issue of the American Journal of Psychiatry which looked into the effects of SSRI antidepressants on suicide rates in young adults. "We found exactly the same thing," he said. "Antidepressant treatment resulted in lower rates of suicide attempts after people went on to treatment."

The research was funded by the National Institute of Mental Health.

Source: Simon GE, Savarino J. Suicide Attempts Among Patients Starting Depression Treatment With Medications or Psychotherapy. Am J Psychiatry 2007 Jul;164:1029-34 [Abstract]