Declining Anti-Depressant Use In UK Youth Has No Impact On Suicide

That is the conclusion of this paper in the BMJ, which has surprisingly received little press notice. It's accompanied by a paper on suicide among youths in the UK and an editorial by Greg Simon, a psychiatrist with Group Health Cooperative, a large HMO in Seattle.

The main paper essentially shoots down the assertions of last fall's infamous Gibbons paper, which tried to link a slight uptick in suicides in 2004 to warnings issued that year concerning suicidality and anti-depressant use. While there are a lot of apples and oranges between the British study and the Gibbons paper (which looked at the US and the Netherlands) because of cultural factors and differing time lines, the lack of a relationship between anti-depressant use and suicide rates is still an important fact and one that should be both interpreted carefully and also give anyone who cares about these issues, regardless of where they sit on anti-depressant issues, much to think about.

For my part, I've been wondering aloud here over the last year or so about the fact that anti-depressants just don't seem to be the anti-suicide technology that some make them out to be. I say this independently of what we know about these drugs' role as proximate causes of suicide and suicidality, where I think the evidence is mixed depending on whether you look at clinical trials, population-based studies or anecdotal accounts.

I think the more important issue is how suicide rates have changed versus how anti-depressant use has changed over time. The rhetoric of the last two decades has been that a rise in anti-depressant use would lead to a decrease in the rate of suicide. In the UK, it seems pretty clear at this point that suicide rates and rates of anti-depressant use are essentially independent events. One is not driving the other, at least among youths. Anti-depressant use goes down and so do suicides, at least in the study above.

As the authors put it:

"We found no evidence of a temporal association between trends in antidepressant prescribing and deaths from suicide or hospital admission for self-harm in young people despite a halving in levels of prescribing after the Medicines and Healthcare products Regulatory Agency's regulatory interventions in 2003."

Those interventions included banning the use of Paxil (Seroxat) in anyone under 18 and, later, of advising doctors that the risk/benefit ratio of SSRI anti-dpressants wasn't good for youths. The lone exception was made for the drug Prozac.

What this study tells me is that asking how anti-depressant use influences suicide isn't asking the right question. We should be asking if we are treating depression at all and how we are treating it. I point this out because just after the time period in the above British paper, the NHS began leaning much harder on things like exercise, diet and psychology than on anti-depressants. I know that that paradigm shift is still essentially just under way in the UK and that loads of patients are not being given proper psychological services, but Britain is light years ahead of the US in this respect. What's more, the paper doesn't attempt to account for psychological treatment or other methods of treating depression that may well have been employed with British youths in the period under examination.

But it's clear that some other dynamic may have been at work. The drop is suicides among the 12 to 17 age group was dramatic--a reduction of suicides in that age group from 80 in 1993 to 48 in 2005. I'd kind of like to know what was going on with British youth over this time period and how their depression was being treated, especially in 2004 and 2005, when the shift away from anti-depressants seems to have begun. I don't think the cultural differences between the US and the UK are so great that there isn't something to be gleaned here.

In this country, we are seeing evidence that during a time period in which the overall suicide rate--and here I am talking adults, teens and kids--has stayed relatively stable, allowing for small year to year variation, anti-depressant use has increased. I know there was a drop off in 2005, but I also have seen figures showing about a 10 percent increase in anti-depressant scrips from 2000 to 2006, when 227 million scrips were written. We don't have 2005 or 2006 suicide data, but it won't be wildly different from the previous few years, I suspect.

What we know already is that preliminary 2005 suicide data shows a slight drop in the suicide rate in the US that year, the same year that anti-depressant Rxs dipped in this country. How that fits in with the 2000 to 2006 prescribing trend remains to be seen and you can bet some researchers are looking into this.

For those of you who suspect anti-depressants of inducing suicides, I'm not sure this study speaks to that issue--this is population-based data, not more narrowly focused clinical trials data.

All in all, an interesting study that surely points to something odd being at work here. What do you all think?