More Teen Suicides Due to Less Medication?

According to CDC statistics, teen suicides rose from 2.2 per 100,000 to 2.6 per 100,000 in 2004, an 18% increase. This was the first increase seen in more than a decade:

http://www.medpagetoday.com/tbprint.cfm?tbid=5005&topicid=138

The article reporting this finding (which had originally appeared in the journal Pediatrics) quoted several experts claiming that a likely cause of this rise was the new black box warning that the FDA required to be placed on SSRI antidepressants (selective serotonin reuptake inhibitors), warning of the increased risk of suicidal behavior in children and teens.

In HOOKED, I reviewed some of the evidence on how the pharmaceutical industry tried its best to hide and to deny this risk, which is a small but real concern. (See post below on the BBC program "Panorama" from last month which looked at this story.)

There has been a standard response from many child psychiatrists, most often those in bed with the industry--that it's terrible to impugn the SSRI drugs, because it will prompt physicians to stop prescribing them for teens, which will lead to untreated and worsening depression among teens, which will cause many more suicides than would ever be the case had SSRIs been widely used. (This response came only after the first industry ploy failed--that kids who engaged in suicidal behavior did so not because of the drug, but due to the underlying depression. That has been shown to be false since non-depressed teens given SSRIs have been shown to display the same sort of behavior.)

So when I saw psychiatrists claiming that this increase in suicide is due to the mean old FDA beating up the poor drug companies, I naturally wondered about the money trail.

Two major authorities are cited in the MedPage article: Dr. Charles Nemeroff of Emery University, and Dr. David Fassler, affiliated with the University of Vermont. Dr. Nemeroff is probably Exhibit A for unrepentent conflict of interest in high places in American medicine. He was exposed last year in the Wall Street Journal after he was forced to resign as editor of a psychiatric journal, due to the journal publishing a paper that he wrote advocating an implanted electric device for treating depression, without disclosing that Nemeroff was a shareholder in the company that makes the device. That led to a maudlin letter to the editor from 40-odd psychiatrists, all protesting that their colleague was a person of the highest integrity and how dare the WSJ impugn his honor.

Dr. Fassler has published much less in scholarly journals lately and so I was unable to see if he has direct financial ties to drug companies. He is a member of the board of Mental Health America. This is a legitimate advocacy organization, with numerous local chapters, which is supported in part by the MacArthur Foundation. But it also boasts among its donors most of the major drug companies, to the tune of $500K to $1M each.

So: did decreased use of SSRIs lead to this increase in teen suicide? Well, first one would like to know if there are any data that fewer SSRIs were in fact prescribed. Studies in the past have shown that physicians are actually pretty good at ignoring black box warnings. Second, to make the claim plausible, one would need to believe that the SSRI drugs are really very effective in treating depression in teens. But the available studies in fact show either no effect or very little effect. The relatively poor performance of SSRI drugs generally, not to mention their risks, is one of the better-kept secrets in drug industry marketing.

MedPage, to its credit, indicated skepticism as to whether the black-box-warning claim was the true reason for the rise in suicides.

What is perhaps saddest about this dispute is that it probably never had to arise at all. I am not a child psychiatrist or an expert in the use of SSRIs. But as best as I can understand, the behavioral syndrome that is related to SSRIs, and that prompts the suicidal or occasionally homicidal behavior, is a very specific syndrome called akithisia. It typically occurs in the first few weeks of starting therapy with an SSRI. Most patients have oppressive, intrustive thoughts of harming themselves or others, and had they immediately stopped taking the drug when those thoughts occurred, the harm would probably have been prevented in almost all cases.

Now, suppose the drug companies had been interested in science and patient care, instead of marketing and sales. As soon as this risk became known, it might have been widely publicized. Doctors could have been told by the ubiquitous drug sales reps: Watch your patients like a hawk for the first few weeks of treatment for this specific syndrome. Make sure that they and their family members know to stop the drug right away if it occurs. If after those first few weeks you haven't seen this--and thankfully it is rare--you are probably home free. This warning would have reduced the risk of anyone being harmed by this side effect by perhaps 90% at least, while still allowing physicians to prescribe SSRIs widely (assuming that they really work--see above). But no, the companies had to let their marketing concerns override quality medical care.