Monday 18 December 2017

Mind and meaning: Antidepressants work

Photo: Thinkstock
Photo: Thinkstock

Patricia Casey

I have written on many occasions about the over use of medication in psychiatry, particularly for those with "depression". This stems from the fact that "depression" is such a broad church. It is an emotional state that occurs in everybody - the word is used interchangeably with "sadness". It is a symptom that features in many psychiatric illnesses and it is an illness. The fairly crude description of the illness in modern textbooks lacks the nuance to distinguish this from normal sadness in many cases. Yet, every doctor knows that when antidepressants are correctly used in depressive illness, their impact is remarkable and I make no apology for prescribing them in these circumstances.

In 2004 the FDA mandated a "black box warning" in respect of antidepressants. This is the highest level of warning that the Food and Drugs Administration (FDA), the body that regulates the licensing and prescribing of medications in the United States, issues in respect of a product. The risk of suicide, associated with antidepressant use, especially in children and young adults was the determining factor.

Now, 11 years on, there is evidence that not only has antidepressant prescribing for the treatment of depression reduced but suicide attempts and suicide itself have increased. A sobering study was published in the American Journal of Psychiatry in 2007 dealing with youth suicide in America. It showed that the suicide rate among 0- to 19-year-olds rose by 14pc in the year after the warning was issued having declined by 28.5pc in the 13 years prior to that. Similar trends were observed in the Netherlands where a 49pc increase in suicide was documented since the "black box" warning.

The author of the study, Robert Gibbons, a biostatistician from the University of Chicago, comments that prescriptions of antidepressants fell by 22pc in both countries since the 2004 warnings and he attributes the spiralling suicide rates as an unintended consequence of this reduction.

At the same time a report from the Centre for Disease Control in the United States found that among 10- to 19-year-old girls, the suicide rate jumped by 76pc in 2004 while in boys it increased also although less dramatically. Moreover, shooting was replaced by hanging as the most common method. There have recently been calls to remove the warning entirely in light of the substantial evidence that it may deter people from seeking treatment for depression and doctors from prescribing antidepressants. Writing in the prestigious New England Journal of Medicine, Professor Richard Freidman of Cornell University, New York, has called for a discussion on this within the psychiatric profession.

A study published in the June issue of the Irish Journal of Psychological Medicine authored by Dr J Kielty and colleagues from the Department of Psychiatry, NUI Galway, examined the characteristics of those dying by suicide in the West of Ireland. In light of the controversy about the black box warning this study caught my eye. It examined, among other things, the post-mortem results of 153 who took their own lives and established that 58 had attended the mental health services. Of this group, almost half (44pc) had depressive illness, followed by alcohol dependence or misuse (35pc). The remainder comprised diagnoses such as schizophrenia, bipolar disorder, anxiety disorders and so on. 65pc had made a previous suicide attempt and 25pc had self-harmed without intent to end life.

For me the most telling findings were the toxicology assessments. These showed that, among those prescribed antidepressants, the drug was not identified on screening in over two-thirds of those assessed. Also, while schizophrenia was a diagnosis in five people, antipsychotic medication was found in only one person. These results suggest that large numbers of people who should have been taking appropriately prescribed medication were clearly not doing so. Whether the medications were discontinued by the people themselves or by a health professional outside the psychiatric services is a question that they study was unable to answer.

In light of the antipathy to medication for the treatment of mental illness, and in particular to antidepressants, it is reasonable to question whether these cultural attitudes influenced the decision to discontinue treatment among the individuals evaluated in this study. If this could be tested by further research it would make an important contribution to the black box debate. Is non-treatment adherence and ultimately suicide an unintended consequence of the warning? This question cries out for an answer as life itself is at stake.

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