Black box warning labels DECREASE suicide

No Significant increase since HUGE REDUCTION in SSRI Use!

 Recently people have been reporting that SINCE the anti-depressant medications have obtained a Black Box Warning Label, indicating they can CAUSE people to feel suicidal, there has been a significant reduction in the use of these drugs, there has been a 16-18% increase in suicides…due to not taking the medications.  THIS IS SIMPLY FALSE AND MISLEADING.

 While one obvious rebuttal for this antidepressant/suicide story is that correlation does not equal causation -- and researcher Dr. David Antonuccio, PhD makes a good point about neglecting the increase in anti-psychotics for kids (i.e. as well as  many other potential variables) --there is an even MORE GLARING REASON that  Newsweek and other media should be ashamed of itself for suggesting this idea.  Read Below.
         
Only wishful thinking on the part of antidepressant manufacturers leads to a conclusion that the drop in SSRI prescriptions for 5-18 year old in 2004 has resulted in increased suicide for that age group. The researcher who told Newsweek that reduced antidepressant prescribing has led to more suicides in kids is on the advisory board of Eli Lilly (manufacturers of Prozac).  If one examines suicide rates for the entire period from 1999 to 2003, when antidepressant use for this age group was high, one sees that 2004 suicide rates are unremarkable.  According to official CDC statistics, the rate of suicide for CDC's 5-14 age group in 2004 is exactly the same rate as in both 2001 and 2000.  Similarly, the suicide rate for CDC's 15-24 age group in 2004 is actually slightly lower than the 2000 rate. Should there actually ever be a substantive increase in suicide rates, history tells us the likely source will not be a lack of psychiatric treatment but rather social or economic upheavals.

Sources:   If you and Newsweek would like to check out the actual CDC suicide statistics, I have the CDC links and tables that make it clear that suicide rates have not increased after decreased antidepressant prescriptions for 5-18 year-olds.

http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_13.pdf
CDC's National Vital Statistics Report Deaths: Final Data 2003 (which includes data from 1999-2003)

http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_19.pdf
CDC's National Vital Statistics Report: Deaths Preliminary Data 2004

Deaths per 100,000
Intentional self-harm
(suicide)             5-14 years        
2004                       0.7                               
2003                       0.6                   
2002                        0.6                 
2001                        0.7                          
2000                        0.7                   
1999                        0.6                  

Intentional self-harm
(suicide)             15-24 years
2004                       10.1            
2003                         9.7
2002                         9.9
2001                         9.9         
2000                       10.2
1999                       10.1
Intentional self-harm
(suicide)             All Ages       
2004                    10.8                      
2003                    10.8             
2002                    11.0             
2001                    10.8              
2000                    10.4             
1999                    10.5             

"Pharmacoepidemiological studies examining the relationship between trends in sales or prescription fills of SSRIs have consistently shown a relationship between increases in SSRI prescription rates and declines in adolescent suicide rates (9, 35–37). On the basis of those studies, one might expect that the adolescent suicide rate would begin increasing in the wake of the FDA advisory after a decade of steady decline. {p. 890}"

The Newsweek article stated that prescriptions for pediatric depression (ages 5 - 18) dropped more than 50% between 2003 and 2005 -- a 2-year period. This is also not what the article in Am J. Psychiatry stated. It stated that prescription rates for pediatric depression had been steadily rising since 1998, and that after the October 2003 black box warning prescription rates in October 2005 were 58% lower than they would have been had they continued to rise between October 2003 and October 2005 at the same average rate at which they had risen between October 1998 and October 2003. Using their figures, the actual decline in prescription rates for SSRIs for pediatric depression between October 2003 and October 2005 was 45.5%.

Then the article states that "in a parallel development, the number of teen suicides jumped a record 18% between 2003 and 2004." It mentioned no source. It did mention that the CDC will release suicide figures for 2005 in December of this year. This leads me to believe that the Newsweek article used CDC above.

If they used the CDC data for the ages 5 - 14, using only one significant figure (we could use more than one) the increase between 2003 and 2004 is 0.7 / 0.6 = 16.67%.

In the 15 - 24 "teenager" age  group the increase between 2003 and 2004 is 10.1 / 9.7 = 4.1%.

I would expect to find more teenagers in this group than in the former, and would certainly expect a higher suicide rate in the latter group.When the two age groups are aggregated into one (5 - 24), there was no change, the rate remained 10.8 per 100000.  In this case a reversal from increases in suicide rates over time to no significant rate change over time. It isn't really a paradox. It is just the result of combining groups of different sizes and comparing aggregates with the separate groups. It looks as someone picked the group that best fit what they wanted and ignored the aggregate data. When discussing teen suicides I think that the 5 - 14 group is the least significant of the three.

Now this "18 % increase in teen suicides from 2003 to 2004" is being broadcasted all over the place as if it is an actual fact.

Tony Dokoupil’s Trouble in a ‘Black Box’ (July 16 article) importantly addresses the risks and benefits of prescribing antidepressants to children. However, the referenced study is far from “compelling” evidence for removing the FDA Black Box warning and such an interpretation of its findings is misleading.

 An inspection of this Eli Lily funded study reveals that the precipitous drop in SSRI prescriptions did not occur, as reported, from 2003 to 2005 but rather from February to October of 2005 (over 85% of the drop in the last 6 months of the reported time). The so-called “parallel development” of increased suicides occurred between 2003 and 2004—and therefore had no relationship to the drop in prescription rates reported in this study. Given that the decrease in prescription rates and increase in suicides occurred in different time periods, it begs the question of how such unsubstantiated statements could be made by the experts cited in the a rticle.

Only 3 of 15 clinical trials have shown antidepressants to be superior to a sugar pill on primary measures. Children and parents in those 15 studies reported no advantage of antidepressants over a sugar pill.

Data from the FDA and its British counterpart demonstrate that children and adolescents taking antidepressants are twice as likely to experience suicide-related events. Given the meager results and increased risk for suicide-related events (as well as other serious adverse events), antidepressants are not a good choice for youth struggling with depression—a conclusion reached after an extensive risk/benefit analysis conducted by the American Psychological Association’s Work Group on Psychotropic Medication (e.g first choice).

Given that depression tends to remit over time, and so suicidality, do these studies really prove anything other than that any possible increase in suicidality caused by the medications is insufficient to overwhelm the natural average decrease in suicidality expected to be seen in any depressed population over time?