November 20, 2007

Is America Using Suicide As A Scare Tactic?

Recently, I've had a few exchanges with new readers who feel that my criticism of the mental health paradigm in this country is somehow designed to scare people off their meds, or to scare them away from ever taking meds. My usual objection to such silly assumptions (I've had these exchanges before) is that I believe in a free market of ideas and believe fiercely in patients having complete and unfettered access to legitimate information and opinions, so they can make their own darn choices about their health care. It's their bodies and their minds and they deserve accurate information instead of rhetoric based upon distorted statistics.

Besides, as a I pointed out to one reader, isn't it possible that one of the totems of mental health care--the argument you can't argue with that you will kill yourself if you are not treated, a line repeated by everyone from pharma marketers to the doc in the neighborhood clinic--could be designed to scare people into taking meds that have very unpredictable outcomes and to scare them into a panic about their fates each time they feel poorly? That reader never answered me, and has likely written me off as a kook (fair enough), but I think I was onto something.

Almost any mental health resource will offer the argument that 10 percent to 20 percent of people with depression, schizophrenia or bipolar disorder will commit suicide. But when you look at the numbers, that doesn't exactly pencil out very neatly.

Consider:

2 million with schizophrenia (1 percent prevalence amogn US adults)
7 million with bipolar disorder (2.2 percent prevalence)
20 million with depression (10 percent prevalence)

Rounding up, that works out to 30 million people at a 10 percent to 20 percent chance of killing themselves. Obviously, I know some researchers estimate depression and bipolar disorder in America at even higher prevalences.

If 20 percent of these folks will kill themselves at some point in their existence, that's 6 million people. We know already that suicides in America average about 30,000 people a year and has for several years, give or take. For 6 million people to kill themselves at a rate of 30,000 people a year--and that's assuming that all 30,000 suicides are a result of schizophrenia, bipolar disorder and depression, and I don't buy that assumption 100 percent--it would take 200 years for that to transpire (this doesn't allow for population growth). If the 10 percent number is used, it would take 100 years.

Clearly, both suicide risk assertions don't measure up. You'll never, ever hear that talk from anyone in the mental health establishment however--possibly because they believe these numbers or because they are religious sorts to begin with.

But something is clearly wrong with these numbers and the kind of marketing through fear used by researchers, advocacy groups, pharma companies and so on. I'm not asserting that suicide is not a problem--it's a problem and a half and I've written about it extensively--but I've grown very weary of the mental health establishment in this country using these numbers to literally scare people onto their meds.

My own casual guesstimate is that suicide rates among the mentally ill likely hover around 5 percent to 7 percent. That's still a sizable problem--one I would like to see solved--but it's not a problem that's going to go away by using false numbers, bad logic and leaning on weak technology (ie, anti-depressants). Because that's just really scary.

Anyway, I'm not throwing this out there as an absolute, but in order to generate some thoughts among readers. Think away in comments.

Yes, I thought I'd do no more posts for today, but this one sort of had to be written.

Posted by Philip Dawdy at November 20, 2007 03:54 AM
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Comments

Where did you come up with the "30,000 suicides per year" figure?

Posted by: Jon S. at November 20, 2007 04:34 AM

I wonder if your five-to-seven per cent suicide rate among people with bipolar and schizophrenia includes iatrogenically caused suicide by drug reaction? I know the difference, having watched my son have 100% illness-related suicidality as a person with bipolar, and my daughter, who had drug-induced suicidality triggered by both Lexapro and Lamictal - with results lingering for months. We know there at least WERE a goodly number of SSRI suicides as the law firms have been kept busy, and some number of the same with the atypicals. I wonder how these numbers parse out...50% from the illness, 50% from the drugs?

Posted by: Sprrpwgi; at November 20, 2007 05:48 AM

I agree they scare us onto meds, and I think I'd sooner buy the 5-7% but the statistic I'm most curious about is attempted suicides. I know that's harder, almost impossible to track. The 30,000 a year if attempts were included would jump significantly I suspect. Triple perhaps or more? I mean I know a fair amount that weren't successful. Cough cough. That percentage might be more of a number that would scare people onto meds or to stay on them. I know I'm scared to come off my meds due to suicidal ideation that still persists off and on while on medications, but now it's manageable. The lithium has what like a 9 times reduction of chance of suicide?

Posted by: Nathaniel at November 20, 2007 06:01 AM

Your guesstimate is pretty good. Here are data for suicide in patients with depression. The old number one still sees thrown around of 15% lifetime suicide risk is no longer accepted.

________________________________________
Citation 1. Unique Identifier 11097952

Authors Bostwick JM. Pankratz VS.

Institution Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA. bostwick.john@mayo.edu

Title Affective disorders and suicide risk: a reexamination.[see comment].

Comments
Comment in: Am J Psychiatry. 2001 Nov;158(11):1934-5; PMID: 11691715, Comment in: Am J Psychiatry. 2001 Nov;158(11):1934; author reply 1935; PMID: 11691716

Source American Journal of Psychiatry. 157(12):1925-32, 2000 Dec.

Abstract
OBJECTIVE: In 1970, Guze and Robins published a meta-analysis of suicide in patients with affective illness that inferred a lifetime risk of 15%. Since then, this figure has been generalized to all depressive disorders and cited uncritically in many papers and textbooks. The authors argue for an alternative estimate of suicide risk and question the generalizability of the Guze and Robins estimate. METHOD: The authors sorted studies obtained through a literature search that included data pertaining to suicide occurrence in affective illness into one of three groups: outpatients, inpatients, or suicidal inpatients. Suicide risks were calculated meta-analytically for these three groups, as well as for two previously published collections. RESULTS: There was a hierarchy in suicide risk among patients with affective disorders. The estimate of the lifetime prevalence of suicide in those ever hospitalized for suicidality was 8.6%. For affective disorder patients hospitalized without specification of suicidality, the lifetime risk of suicide was 4.0%. The lifetime suicide prevalence for mixed inpatient/outpatient populations was 2.2%, and for the nonaffectively ill population, it was less than 0.5%. CONCLUSIONS: The percentage of subjects dead due to suicide (case fatality prevalence) is a more appropriate estimate of suicide risk than the percentage of the dead who died by suicide (proportionate mortality prevalence). More important, it is well established that patients with affective disorders suffer a higher risk of suicide relative to the general population. However, no risk factor, including classification of diagnostic subtype, has been reliably shown to predict suicide. This article demonstrates a hierarchy of risk based on the intensity of the treatment setting. Given that patients with a hospitalization history, particularly when suicidal, have a much elevated suicide prevalence over both psychiatric outpatients and nonpatients, the clinical decision to hospitalize in and of itself appears to be a useful indicator of increased suicide risk.

________________________________________

Posted by: Bernard Carroll at November 20, 2007 06:21 AM

that comes from the cdc/natl ctr for health stats.

Posted by: Philip Dawdy at November 20, 2007 09:46 AM

You need to weigh suicides or attempted suicides while on meds against the self-damaging behavior (not necessary physical self-damage) that occurs with the subjects who are not meds but who ought to be. I define self-damaging behavior broadly to include bad judgment, failure to appreciate harm to oneself, etc.

Posted by: Red Rover at November 20, 2007 03:14 PM

Red Rover, I really don't think we can consider "bad judgement" to be a symptom of mental illness. Ditto "failure to appreciate harm." What about the smokers? Kentucky Fried Chicken diners? Gamblers? Fat people? People who drive too fast? Don't wear seatbelts? This is Big Pharma's wet dream: 100% of the population being diagnosable.

Posted by: Francesca Allan at November 22, 2007 08:12 AM
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