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July 1, 2007
Suicide attempts decline after depression treatment
Group Health study sheds new light on FDA warning for antidepressants
Seattle—In a study of more than 100,000 patients treated for
depression, suicide attempts declined during the first month of
treatment—whether that treatment consisted of medication, psychotherapy, or
both. The findings, published by Group Health researchers in the July
American Journal of Psychiatry, show a similar pattern for populations
of adolescents and young adults (up to age 24) as for older adults.
The study sheds new light on the “black box” advisory that the U.S. Food
and Drug Administration (FDA) placed in 2004 and has revised since then,
said Greg Simon, MD, MPH, the Group Health
psychiatrist who led the study. The advisory—which has concerned many
patients, families, and care providers—warns that suicidal behavior may
emerge soon after people younger than 25 start treatment with newer
antidepressant medications called selective serotonin reuptake inhibitors
(SSRIs). It was spurred by randomized placebo-controlled trials showing that
starting to take an SSRI can make thoughts of suicide more common among some
teens and young adults.
Dr. Simon’s study is the first published research to compare the risk of
suicide attempts before and after the start of treatment with not only
antidepressants but also psychotherapy. It is based on computerized medical
and pharmacy records for more than 109,000 patients who started treatment
for depression at Group Health from 1996 to 2005.
In the study, suicide attempts were about twice as common among patients
up to age 24 as among older adults. However, the time pattern was the same
for both age groups, regardless of the type of treatment they received:
Suicide attempts were most likely during the month before treatment started,
falling by at least 50 percent in the month after treatment began, with
steady declines thereafter.
At all time points—up to three months before and six months after
starting treatment—patients who received their antidepressant prescription
from a psychiatrist tended to be most likely to attempt suicide. Those who
received it from their primary care doctor were least likely to attempt
suicide, with levels in between for those who got individual psychotherapy
from a therapist other than a psychiatrist. “That’s not because seeing a
psychiatrist makes you want to kill yourself,” said Dr. Simon. Rather, he
suggested, these results reflect the fact that people with severe
depression, who tend to be more suicidal, are more likely to be referred to
psychiatrists, while those with milder depression stick with their primary
doctors.
“Our study indicates that there’s nothing specific to antidepressant
medications that would either make large populations of people with
depression start trying to kill themselves—or protect them from suicidal
thoughts,” said Dr. Simon. “Instead, we think that, on average, starting any
type of treatment—medication, psychotherapy, or both—helps most people of
any age have fewer symptoms of depression, including thinking about suicide
and attempting it.” That said, he likened population-based studies—both
observational studies such as this one and randomized controlled trials of
medications—to “circumstantial evidence” about what happens to individual
patients.
Like other psychiatrists, Dr. Simon has seen a few depressed patients
start having suicidal thoughts while taking antidepressant medication
despite never having thought about suicide before then. He hypothesizes that
subgroups of people may be vulnerable to becoming more agitated or suicidal
after taking these drugs. “We hope to learn how to identify these people in
advance,” he said.
Dr. Simon published an earlier
paper showing that the risk of suicide
attempts decreased in the weeks after patients started taking antidepressant
medication. His new study strengthens his earlier conclusion that for
populations of people, even teens and young adults, suicide attempts tend to
be rarer right after starting antidepressant medication than beforehand. He
echoed the FDA’s recommendations that doctors
regularly monitor their patients during
treatment with antidepressants to ensure that they are receiving the right
medication at a dose that helps them feel better. “If people feel agitated
or suicidal, they should seek help from a doctor or therapist,” he added.
The National Institute of Mental Health funded the study, whose other
author is James Savarino, PhD, a programmer analyst at Group Health Center
for Health Studies.
About Group Health Center for Health Studies
Founded in 1947, Group Health is a Seattle-based, consumer-governed,
nonprofit health care system that coordinates care and coverage. Group
Health Center for Health Studies conducts research related to prevention,
diagnosis, and treatment of major health problems. It is funded primarily
through government and private research grants.
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