“IT’S NOT quite being alive, but still having to go through all the crappy parts of being alive,” 22-year old Ian Hanley told Time magazine. In the six years since the day in 10th grade when he “lost all desire to get out of bed in the morning,” Hanley tried half a dozen antidepressants as well as combinations of those drugs.
As suicide numbers rise, notably in the 10-34 age group (14,000 in a recent single year, and up by about 50% in adolescents between 2003 and 2016), questions remain about the role antidepressants play. In 2003, these led to a Black Box warning for children about Prozac and other SSRIs (selective serotonin reuptake inhibitor), which was extended in 2007 to include young adults.
Blaming any individual’s suicide on antidepressants is a thorny problem, especially when depression is the leading cause of suicide in young people and these drugs might offer the best hope of combating it. Also, while some studies have found that patients taking antidepressants are more likely to have suicidal thoughts and to commit suicide; others have found no relationship.
A Complex Story
The picture grows more complicated because recovery from severe depression, with or without antidepressants, can follow a devastating natural trajectory. As a patient becomes less depressed, they may still feel miserable enough to believe that family and friends would be better off without them, but without the paralysis of depression, they have enough energy to act on that belief to successfully kill themselves.
In one review of 70 trials of adult volunteers with complaints other than depression, taking antidepressants doubled the occurrence of events defined by the FDA as “possible precursors to suicide and violence.” Middle-aged women taking Cymbalta for stress urinary incontinence had four to five times more of these events than those taking a placebo.
No clear relationship between suicide and antidepressant use in adults was the 2012 “summary of current evidence” published by Indian psychiatrists in Mens Sana. In children and adolescents, on the other hand, the study found an increased risk of suicidal thoughts and attempts but not of completed suicides. It concluded by advising physicians prescribing these drugs to follow their patients very closely.
Another complication is that most research separates subjects by age group, but there is little agreement about when an adolescent becomes an adult. “Late adolescence,” according to several definitions, can last into the 20s.
Guns and Suicide Attempts
And then there are factors, such as having a gun on hand or being able to easily purchase one, that are linked to completed suicides. Over the past decade, the rate of suicide by firearm increased by 19%. Although guns are involved in fewer than 6% of suicide attempts, they are responsible for more than half of deaths by suicide.
Among antidepressants studied, three (trazadone, mirtazapine and venlafaxine) are more often associated with a higher risk of suicide and self-harm attempts, compared to SSRI drugs, such as Prozac. In two UK studies of 238,000 and 300,000 adults respectively, the former found that patients on these three drugs were more likely to commit suicide than those taking SSRIs; the latter found “no meaningful difference in risk for suicide” between the two groups.
The three drugs, however, are often prescribed only after SSRIs haven’t helped. That suggests that these patients may have more intractable depression or have become more depressed during repeated, failed trials of other drugs, and thus more likely to consider suicide.
The Jitters and SSRIs
For SSRIs, the debilitating side effects are most directly linked to suicide. Five days before killing himself, Stewart Dolan had started taking paroxetine, the generic form of the SSRI Paxil, which caused akathisia —acute physical and psychological agitation that sufferers have compared to “jumping out of their skin.”
One review of more than 100 studies of SSRIs found the rate of the “jitteriness/anxiety syndrome” ranged from 4 to 65% among patients who began treatment with these drugs. “Akathisia symptoms so closely resemble symptoms of anxiety and depression that it may be hard for a doctor to distinguish between the underlying illness and what could be a side effect of the drug used to treat it,” UCSF psychiatry professor Joanna Gedzior told the New York Times.
But in the 10 years following the FDA’s highly publicized warnings about SSRIs, the result has been less access to mental health services and a significant reduction in the diagnosis of major depressive disorder in young adults. For adolescent patients, the rate of suicide increased by 50%, while the number of those diagnosed with major depressive disorder decreased by 40%.
Increased Suicide Rates/Fewer Diagnoses
These changes — increased rates of suicide with decreases in diagnoses — occurred at the same time as a 24% and 31% reduction in antidepressant use respectively among adolescents and young adults; as well as comparable increases in “poisonings” from drugs like Valium, often used by young girls in suicide attempts.
By 2018, “suicides and overdoses are, by any objective measure, flat-out boiling,” wrote Zachary Siegel in the New York Times. “Researchers believe…they’re to blame for the nation’s life expectancy actually dropping over the past two years.”
Meanwhile, recent advances in depression research point to different categories of the condition, with each suited to a better tailored treatment. In addition to antidepressants, psychotherapy is increasingly supplemented with advice on exercise and diet as well with acupuncture, yoga and even psychedelics.
Over the past two years, Facebook has attempted to reduce this complex issue to an algorithm that scans posts for risk of depression. For individuals deemed high-risk, FB connects them to friends, sends contact information for help lines, and in 2018 made calls to thousands of local police stations worldwide. However, experts question the algorithm as well as the safety and effectiveness of what may constitute the unlicensed practice of medicine.
New drugs useful against depression include the club drug ketamine, which provided the best relief for Ian Hanley and has been particularly effective in ending suicidal thoughts. Cristina Cusin, head of the ketamine clinic at Massachusetts General Hospital, told Time, “We have patients saying I’m exactly as depressed as I was before. I just don’t want to kill myself anymore.”
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news we can use.