By Steven Daviss, MD
[Fall 2007; Vol. 34, No. 1; Pg 5, 11]
In
the last column, "What's Inside the Black Box," I reviewed the FDA
hearings on SSRI antidepressants, and the labeling changes which emphasize not
only potential increased risk of suicide in younger people, but also decreased
risk in older people, and that there is a risk of suicide if depression is not
treated.
I
was going to move on to a different topic but a series of articles were
published in the July 2007 issue of the American Journal of Psychiatry, which
adds so much more data to this discussion that I just couldn't let it go.
Posner
et al. (1) published the Columbia Classification Algorithm of Suicide Assessment
(C-CASA). This algorithm is an
attempt to better categorize behaviors in drug trials that have previously been
ambiguously reported. Their Table 2 is particularly worth reviewing.
This table uses anchor behaviors to help define the following terms:
"suicidal ideation," "preparatory acts toward imminent
suicidal behavior," and "suicide attempt." For example,
"suicide attempt" is defined as
The
authors also include the following examples:
'1)
After a fight with her friends at school, in which they discontinued speaking
with her, the patient ingested approximately 16 aspirin and eight other pills of
different types on the school grounds. She said that she deserved to die,
which was why she swallowed the pills.
2) The patient used a razor blade to lacerate his wrists, his
antecubital fossae, and his back bilaterally. He told his therapist that
the “the main objective was to stop feeling like that,” and he knew
that he could die but didn’t care. According to the patient, he also
ingested a bottle of rubbing alcohol because in his health class he heard
“that the medulla will get more suppressed that way,” thereby increasing the
chances that he would be “successful” and die.'
Using
this method, their re-analysis of FDA data indicates a substantial reduction of
"suicide attempts" (n=33) in this pediatric database for patients on
SSRI’s compared with drug company ratings (n=78).
Simon
& Savarino (2) looked at one health plan's half-million members to identify
about 130,000 claims which mark the initiation of either an antidepressant
prescription or of psychotherapy. They compared these with inpatient and
outpatient claims which identify a suicide attempt within 3 months before or 6
months after treatment initiation. They found that the suicide attempt
rate was highest in the month BEFORE treatment initiation. If
antidepressants truly triggered suicide attempts, a high rate might be expected
in the month AFTER treatment initiation. Additionally, the pattern of
attempts before and after medication initiation was similar to the pattern seen
with psychotherapy initiation. In an accompanying editorial, David Brent
notes: "it is much more likely that suicidal behavior leads to treatment
than that treatment leads to suicidal behavior."
Finally,
Gibbons et al. (3) analyzed V.A. data from 226,000 veterans with an initial
depressive disorder diagnosis, to examine the relationship between suicide
attempts and antidepressant treatment. Given the new black box warnings
about treatment of people age 18-25, they also looked for any evidence of
age-related effects. The suicide rate was higher in depressed veterans who
were not treated with antidepressants than in those who were treated. Like
the above study, suicide rates were higher prior to treatment initiation than
after. These same findings were present in the age 18-25 group.
These
studies have practical significance in day-to-day practice. The media
attention to these issues has a lot of patients and families asking pointed
questions about the risks of pharmacologic treatment of depression.
Familiarity with these studies, especially the last two, will help you
answer some of your patient’s and their loved ones’ questions. In
fact, Figure 1 in the Simon & Savarino article is particularly helpful.
This figure shows the month-by-month risk of suicide attempt before and
after treatment initiation and should be copied and kept handy. I can
email you a copy if you'd like one (sdaviss@comcast.net).
Next
time, I will focus on what we've learned about depression from the STAR*D study.
_________________
Footnotes:
(1) Posner K, et al., Columbia Classification Algorithm of Suicide Assessment
(C-CASA): Classification of suicidal events in the FDA's pediatric suicidal risk
analysis of antidepressants. Am J Psychiatry 2007; 164:1035.
(2) Simon GE & Savarino J, Suicide attempts among patients starting
depression treatment with medications or psychotherapy. Ibid p1029.
(3) Gibbons RD, et al., Relationship between antidepressants and suicide
attempts: An analysis of the Veterans Health Administration data sets. Ibid
p1044.