2004 Suicide Data: Sound And Fury And Perspective

Most of you already know that the CDC released data yesterday showing a rise in the teen suicide rate in the US in 2004. Of particular concern was an increase in suicides among girls aged 10 to 14 years old. The media went nuts over this information and allowed several alleged experts in the psych world to link the rise to the 2004 black box warning which the FDA required pharma companies add to anti-depressants specifically for children and teens up to 15-years-old due to many documented cases of suicides and suicidality among kids who'd been on anti-depressants.

The move by the FDA was very controversial at the time and represented something of a compromise as there were some people who wanted to warnings applied to adults as well. There are of course plenty of documented cases of suicides and suicidality among adults on anti-depressants. (I would be one of those cases.) There are also many documented cases of people who've benefitted from anti-depressants (I would also be one of those cases. I have natural biases in both directions on this issue), just as there are many documented cases of researchers and advocacy groups who've taken money from companies making anti-depressants and then gone on to say glowing things about said drugs.

My point is that there is a boatload of conflicting evidence about whether anti-depressants have ever induced suicide in patients or whether they are a super-duper anti-suicide technology. Many researchers continue to talk as if SSRIs and the like are the Rosetta Stone to the soul. They are delusional. Just as delusional are those who claim that the black box warning is to blame for the increase in suicides in 2004. Drug Wonks had a howler of a post on this yesterday.

Guess what? The 2004 black box warning was issued on October 15, 2004. At worst, the warning could only affect about 10 weeks of suicides. Which sort of shoots down the anti-black boxers out there. And makes me wonder if there aren't a few media organizations out there who ought to be running a correction or clarification.

But I want to talk some more about 2004's suicide data because I have a special relationship with suicide that year, and because I think the media and the CDC are missing the big story on suicide. Unfortunately, I cannot speak to the suicide situation in other countries, principally because I am not as conversant in the evidence. But I think the same questions of anti-depressant-induced suicidality pertain elsewhere.

Oh, yes, something else about the release of the 2004 data and the press coverage of the ceaseless divide over anti-depressants and suicide. From Slate:

"Traci Johnson's body was discovered on Feb. 7, 2004, hanging by a scarf from a shower rod in an Indianapolis laboratory run by the drug company Eli Lilly. The 19-year-old college student had been serving as a test subject in a clinical trial of the experimental antidepressant duloxetine. Investigators from the Food and Drug Administration rushed to Indianapolis to determine whether the experimental drug was related to her death. The probe was inconclusive.

"This left researchers in a quandary: Was the drug safe or not? Could duloxetine trigger suicide, as some experts suggested? Or was Johnson's death an "isolated tragedy," as Eli Lilly claimed?"

She was taking Cymbalta in a trial of the drug for stress urinary incontinence, not depression. There was not one mention of Johnson in any of yesterday's press coverage, and as far as I know her name was not mentioned by anyone at the CDC despite the fact that she was a suicide in 2004 in exactly the age cohort driving the CDC's press release who killed herself by the precise method over which the CDC is properly concerned about an increase amongst youngsters--hanging.

Traci is the very tragic poster child for the situation. How did the media miss that? Her story is known.

Look, the only controversy isn't about whether or not anyone has had a suicide induced by anti-depressants. The controversy is about what do you ask and what do you tell.

But back to 2004.

CYNTHIA DOYON

In August 2003, a much-beloved DJ at KUOW-FM, Seattle's NPR station, killed herself on the University of Washington campus. About a week later, I began doing what reporting I could on what happened because it struck me that it was a good way to write about the unending problem of suicide in America. I was stonewalled by her colleagues and friends for almost two months before people began talking. What developed was a very sad picture, of course--the aloof, depressed loner with a hand gun.

Along the way, I began looking at national and local suicide statistics going back into the 1950s. What struck me was how little the rate of suicide had changed in the years since the advent of the Prozac revolution. From what I could figure at the time, the rate had decreased by about 10 percent, depending on what years you used as endpoints, and given that we were pouring $20 billion a year or so into anti-depressants in the US, it struck me that we had a technology that wasn't working as advertised. I interviewed many experts in the field including Kay Redfield Jamison about suicide and the anti-depressant/suicide disconnect. After a time, I determined they were clueless and had little more than stock answers to offer for why suicide continued to rage in our culture.

I went to my editors and asked them to let me write about Doyon and wrap my own story about depression, bipolar disorder and meds around her story. They agreed. I wound up writing a very angry article that ran in January 2004. In it, I attacked the media--especially the New York Times--for practically ignoring the problem of suicide in American culture except where teens were involved. Statistically, teens (classed as 15 to 24 year olds in national data for some reason) are not the big driver of suicide rates in America. About 4,500 of 32,000 suicides each year are by teens--making them about 17 percent of the problem--and you could see that even if you could eliminate 20 percent of teen suicides, or about 1,000 suicides, it would barely touch the overall national rate (this holds true for the 2004 data as well). I couldn't understand why the media and mental health advocates spent so much time on teens--as they were at the time--to the exclusion of every one else. Except of course they are kids and anything affecting kids is always something editors and news directors and policy makers want to jump on. I suppose their impulses are noble enough.

I had no idea what kind of response the article would get and what fallout there would be for me personally since it was one of those naked first-person pieces you write once in a career. In the end, my paper ended up getting over 1,000 emails about the article and I stopped counting at 400 phone calls. The next week, I went on KUOW to talk about Doyon and suicide. (For those of you amused by such things, an archived version of the interview is here.)

In the article, I took a few swings at meds, calling them "neutron bombs." Several readers wrote to tell me that I would kill people by saying such things, even though I had gone nowhere near the anti-depressant-induced suicide issue. No one had any idea if Doyon had ever been diagnosed with depression or if she took meds. I also heard from a few readers who were actively suicidal and in each case was able to talk them out of the bad place they were headed to. But there was one man I couldn't reach.

THE END OF PHILIP DAWDY

One afternoon in May 2004, my work phone rang. On the other end was a cop identifying himself as a detective with the New Jersey State Police. "Are you Philip Dawdy?" he asked.

"Yes."

"Philip Dawdy the writer?"

"Yes. What's this about?" Being in Seattle, I didn't get too many calls from Jersey cops.

The detective proceeded to tell me that a young man named Philip Dawdy who lived in Toms River, NJ had gone missing and could be a possible suicide. He wanted to know if I'd heard from him or if I knew him. At the time, I only knew of three Philip Dawdys in the entire country.

"No. Why would I?"

"Well, we searched his residence and found your article on his computer. If he calls, will you let us know?" He gave me his number.

I was in quite a bit of shock. Toms River is about 30 miles from where I went to high school and the odder coincidence of someone with my same name--my last name is rare enough, but first and last?-- reading my work and possibly going off and doing something regrettable was a bit much to handle. Even though the article is pretty strongly life-affirming in its angry, rambling manner. I spent the next two days near my phone at work and checked my email from home constantly. I hoped Phil, as he was called, would contact me on some impulse and that hopefully I could talk him back to Earth.

But he never did contact me. Soon, I heard from the family's priest that Phil's body had been found in a field in Eastern Pennsylvania. I don't know much about Phil or what was driving him--whether he was depressed and taking meds or not taking meds or whether he was responding to some kind of life crisis. I still don't know. I just hope he's at peace. And that the wounds have healed as much as they can for his family and friends.

WHITE MEN DON'T COUNT

As I noted above, teen suicides--tragic as hell and heartbreaking, of course--get the big attention in our culture while not being much of a driver of the suicide rate which in 2004 stood at 10.9 per 100,000 people. Suicide is the 11th leading cause of death in the US. The federal department of Health And Human Services has a goal of halving the suicide rate by 2010. The goal was set in 1999 when the suicide rate was about 10.5 per 100,000. So we are clearly getting nowhere in a hurry.

When I was reporting the Doyon article in 2003, I interviewed numerous public health officials, mental health experts and suicide prevention groups. When I asked them how I should be writing about suicide, they almost all stressed that I should be writing about teens and "disadvantaged groups," as one put it, where disproportionality loomed. What groups were these? "Native Americans," one interviewee told me. I almost fell out of my chair. I knew that the rate of suicide among Native Americans was very high--on the order of twice the national average, if I recall--but again we were talking about a group that comprised about 200 suicides a year. I didn't think those lives weren't important. But again it was a problem of if you wanted to cut suicides in half, wouldn't you be going where the action was? If you were in the media, wouldn't you be covering the astounding body count among men--and, to be very pointed about this, white men?

At the time, men made up about 75 percent to 80 percent of all suicides. White males comprised about 67 percent of all suicides. In 2004, according to the CDC's data, the numbers are:

Total suicides: 32,439 Rate 10.9 per 100,000
Men: 25,566 Rate: 17.7 per 100,000 or 79 percent of all suicides in 2004.
Women: 6,873 Rate: 4.6 per 100,000 or 21 percent of all suicides in 2004.
White Men: 21,214 Rate: 21.6 per 100,000 or 65 percent of all suicides in 2004.

White males make up about 30 percent of the US population. Talk about your disproportionality. So why is it that the CDC and the media are choosing to focus on teen suicide, once again, as the big problem? Beats the hell out of me. I simply know that if the problem of teen suicide is big news, then white male suicide is even bigger. But too big for news coverage and emphasis by public health officials? Please.

Why is it that men like Phil Dawdy, who killed himself in 2004, get very little attention? Is it because public health officials are so desperately politically correct that they won't dare point to white men as the problem here because white men are allegedly the oppressors in our society? Or are they just stupid while working on the public's dime? Do reporters who read the CDC's press releases even bother to go read the full report and see what's going on?

BLACK BOX HATERS: BE CAREFUL WHAT YOU WISH FOR

I hope no one understands what I've written above as some kind of twisted teen hatred. It's not. Speaking of teens, the CDC reported:

"In absolute numbers, from 2003 to 2004, suicides increased from 56 to 94 among females aged 10--14 years, from 265 to 355 among females aged 15--19 years, and from 1,222 to 1,345 among males aged 15--19 years."

It was suicides among these groups that drove yesterday's news. Let's assume for a moment that the 2003 numbers were "normal." Taking the 2003 and 2004 numbers for the groups together, you'd see an increase of 251 deaths. There is no indication from the CDC whether or not those 251 teens were diagnosed with a mental illness, and there is no information as to whether or not they were taking meds. Yet the assumption among critics of the FDA's black box warnings are that somehow these 251 people were denied access to meds because of the warnings.

Let's assume for a minute that all 251 had been diagnosed with depression and were receiving anti-depressants--in other words the black box would have no impact even if it were in effect for all of 2004. Let's further assume that these anti-depressants performed on these obviously very depressed people along the lines of what we know about anti-depressant performance in the real world. About 30 percent of them saw very good results (84 lives saved), about 20 percent saw mixed results (50 people among whom half would commit suicide and half would live for a net of 25 lives saved) and a full 50 percent who'd see very little effect (no lives saved). A total of 109 lives would be saved from these groups.

I know that's a very back of the envelope calculation, but basically yesterday's hubub in the media was about 109 lives, if you want to be very persnickety with where the CDC spent its public relations dollars. Out of 32,000-plus suicides, that's just not very impressive. And makes me wonder if the black box argument is even worth having.

In addition, who's to say that these same youngsters were not all recent bipolar disorder diagnoses who were maybe taking a mood stabilizer plus an antipsychotic plus an anti-depressant? No one is to say, of course, because we just don't have data on that level right now. But let's assume that these were all people who were on Zyprexa, Risperdal or Seroquel (and I bet some were). Would the black box haters then come out against the black box warning for diabetes and hyperglycemia, etc. on atypical antipsychotics because it was scaring bipolar teens--among whom we know there has been a massive explosion in diagnoses of bipolar disorder in recent years, perhaps even replacing some diagnoses of depression--away from medication? What proof do the black box haters have that everyone who commits suicide should be diagnosed with depression and be taking an anti-depressant, when a good number of these youngsters could just as easily be bipolar?

Maybe we'll find out. The CDC did say in one article I read that it intended to look very closely at these age groups. I hope they do. Right down to the level of what diagnoses these poor people did or did not have and to what meds they were or were not taking. Hopefully, they'll make the results public as well.

Then, we'll see if they can summon the nerve to talk about white men.

Posted by Philip Dawdy at September 7, 2007 01:42 AM
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