Wow. Well said "Papa" Dawdy.

Therein lies the difference- Goodwin is the old man, McManamy is the old waiter- and you, you are the young waiter. The old waiter realizes he will have the same fate as the old man.

Joyce said of the story-Hemingway has reduced the veil between literature and life, which is what every writer strives to do. Have you read 'A Clean Well-Lighted Place'?...It is masterly. Indeed, it is one of the best short stories ever written..."

Mr. Dawdy, you have written a masterpiece, worthy of Hemingway, who's title this piece evokes, or Carver who your site is named from. And Mr. McManamy- he is no Hemingway, or Carver, though he longs to be. I feel sorry for him.

Okay, so I finally listened to the "Prozac Nation: Revisited" broadcast. I listened to Dr. Goodwin's interview with Dr. Leuchter in which they discuss the relationship between suicidality and antidepressants.

Man, was this conversation misconstrued!

Their main points were as follows:

1. The media sensationalizes the use of antidepressants in disturbed individuals who commit violent crimes while minimizing other factors that are probably more important, such as traumatic childhoods, and disturbed thoughts and behaviour preceding medication use.

2. The term "suicidality" used in the FDA studies is inadequate, because it conflates suicidal ideation and gestures with completed suicides, of which there were none in the FDA studies. Dr. Goodwin stated that a better term should be invented to describe the arousal, agitation and disturbed behaviour of those who have paradoxical reactions on antidepressants, especially given the fact that there were no completed suicides in those studies.

Also, he mentioned a large prospective study where there was a negative correlation between suicidal ideation and completed suicides, because those who seriously want to kill themselves will not tell anyone to prevent their plan from being thwarted. He stated that those who express suicidal ideation should be taken seriously as an expression of distress, but he denied that they were at increased risk of dying.

Dr. Leuchter stated that studies have shown that just having suicidal ideation is not correlated with completed suicides, but having suicidal ideation, plus severe anxiety and insomnia, in the context of a depression, then that is a risk factor for completed suicides, and those people “need to be monitored most closely”.

3. They explicitly mentioned at around 8:10 that in some vulnerable individuals they could have a “paradoxical reaction” to the antidepressants, but that these situations are rare and that they have more to do with the unusual wiring of their brain rather than the medication. Dr. Leuchter agreed that there are “unpredictable reactions” that can occur especially in adolescents and young adults under the age of 25, mainly due to an undeveloped frontal lobe. He then said that these reactions “are extremely rare, but they do occur”. This is actually what the literature says.

4. Dr. Goodwin and Dr. Leuchter explicitly stated that for mild to moderate forms of depression, medications and psychotherapy are equivalent, but that for severe forms of depression, medications are essential, and that the best outcomes actually have medications and psychotherapy to reduce relapse rates.

5. They did describe epidemiological data that showed that as antidepressant prescriptions have gone down, completed suicides have gone up. This is probably the most debatable part of their presentation, as the evidence here seems pretty weak and inconclusive.

I have not listened to the rest of the broadcast, but the first third of it appears quite appropriate to me. They did not deny the signficant risks of antidepressants, but stated that they are rare and should be monitored for, which I think is appropriate.

I think that much of the controversy, as pointed out by Dr. Goodwin, is due to the term "suicidality" that includes both suicidal thoughts and gestures, and completed suicides, and that when they say there is no evidence of a link between antidepressants and suicide, they are describing completed suicides, but they certainly do not deny a moderate increase in suicidal thinking in those under the age of 25, which is what the latest meta-analyses have shown.

Philip:

A question:

Isn't Lamictal ON-LABEL for bipolar, type I? Albeit for chronic ("maintenance") bipolar disorder rather than acute episodes.

Because Glaxo sure advertises it that way; and I remember a lot of publicity for Lamictal being FDA-approved for bipolar I ...

My dog is named after Hemingway. As for McManamy, I got into it on his blog once about the bipolar child - imagine that! It was after Katie Couric did a story on Rebecca Riley. There seem to be three popular perspectives on bipolar disorder, the folks like McManamy and Jamison who cling to the idea that bipolar disorder is a real medical disease and that people who have it are superior, more human than others, touched with fire, you get it, then there's folks like Torrey, and probably Goodwin given his undisputed eugenics background that argue that bipolar disorder is a genetic defect and thus people who have it are so dangerous to society, so much less than human, that their rights don't matter, they must be at the very least medicated and often confined against their will. Then there's the middle ground where reasonable people understand that life can be horribly painful and confusing and that people who feel and experience pain and confusion should be treated with dignity, sympathy and compassion as we are all human.

Meanwhile, I just love this quote:"suicidality," which they felt embraced a range of behaviors far too wide to show a credible link. Dr Goodwin was in favor of a less-loaded term."

I'd love to hear about the "range of behaviors." From the context I'd assume none of them involved being cured, or as they say clinically significant decrease in symptoms and all were on the self harm side of the spectrum. Just imagine a doctor reasoning that it's okay to give someone a pill that will make suicide more likely and rationalizing that it's okay because the suicidality information will make the patient scared to take the pill. Then the patient commits suicide and the doctor blames it on the disease, convenient excuse.

It's like treating diabetes with sugar pills, Goodwin deserves prison and McManamy is sad as he really seems to believe his own party line.

Sally:

First, I think that what Dr. Goodwin meant was that there is a diffence between:

(1) Suicidal thoughts.
(2) Suicidal gestures.
(3) Completed suicides.

All three are concerning, but it is misrepresentation to say that (1) and (2) are equivalent to (3), because they are not. People express suicidal thinking for a variety of reasons, not always to communicate a genuine intention to die. Also, people engage in suicidal gestures, e.g. cutting, for a variety of reasons, not always with an intention to die. Even completed suicides sometimes occur accidentally where someone is attempting to arrange a cry for help, but ends up going too far.

The point is that it is a muddy area that requires some clear conceptual distinctions, because otherwise conclusions will be muddled and unhelpful.

Second, I am not too sure what you were trying to say at the end of your post. No doctor would give someone a medication that WILL make suicide more likely, but I think that many physicians would say that they would prescribe a medication that COULD increase suicidal thinking in a minority of cases, if there was a demonstrable benefit to taking the medication in other areas. Steroids could result in suicidal thinking, but we would not stop using them in asthma patients, autoimmune patients, and so on, becuase the benefits outweigh the risks.

Dguller,

I know that steroids can result in suicidal thinking because a doctor told me. I assume that someone who is unhappy and taking steroids is monitored for mood, and I bet more closely than someone who gets psych drugs from a psychiatrist for various reasons.

In my understanding a suicidal gesture is an attempt to commit suicide, maybe insincere, but still an action towards suicide. I can't help but think that giving a drug that may increase suicidal thinking, i.e. may make you wish you were dead, to someone who is already so unhappy that don't want to live increases the risk of suicide, and a drug that makes you attempt suicide or set up a situation where it looks that suicide is likely to get attention increases the likelihood of suicide, unless you are arguing that completed suicide is a spontaneous event that the deceased never thinks of before doing. In the unlikely event that is your argument, I'd really have to wonder about the source of your data.

What if the black box warning said "may may you wish to end your own life, may make you pretend to attempt suicide to get attention from others." Exactly what sort of marketing tool would that be?

Sally:

You make fair points about suicide, but I think you still miss much of the range of suicidal ideation, gestures and completed termination. However, that is not especially relevant to your point.

You argue that giving individuals who are already severely depressed and suicidal medications that have a risk of worsening their suicidal tendencies is foolish, to say the least. You would be correct, if that was all the medications did.

However, you leave out the other features of those medications, including increase in energy and motivation, improvement in mood, sleep, appetite and concentration, all of which are important markers for the relief of depression. When you factor those other components into the equation, the situation does not appear quite so ridiculous, I think.

Furthermore, I doubt if the increase in suicidal tendencies occurs in a vacuum in individuals on antidepressants. From what I understand, it is the end result of other mental status changes, including induction of a mixed state, akathasia, electrolyte changes due to SIADH, and so on, in a minority of vulnerable patients. All of those conditions create extreme psychological distress, which is what drives those subjects to have suicidal ideation, even when none existed before.

In those depressed and suicidal individuals on antidepressants who find relief in their mood and neurovegetative symptoms, and do not experience the adverse mental status changes mentioned above, then it appears quite clear that their suicidal tendencies would likely reduce. Fortunately, those paradoxical effects of antidepressants are not very common, even in those under the age of 25, but they should still be monitored and patients should be warned for their own protection.

Dguller,

Interesting response. Sorry for taking it out of order. I give, what are electrolyte changes due to SIADH? What is SIADH? I'm thinking that SSRI's drive people who already have suicidal ideation to kill themselves and that surely for a diagnosis of depression you have to have suicidal ideation, though maybe the criteria for depression really are as broad this days as the DTC ads would have us believe, which means any woman who doesn't wear lipstick or in the face of all that is good and decent goes to the grocery store in a sweat shirt, is clinically depressed.

Regarding suicide and ssri's, you write: "However, you leave out the other features of those medications, including increase in energy and motivation, improvement in mood, sleep, appetite and concentration, all of which are important markers for the relief of depression."

My theory is that when someone is suicidal, it's for a reason, relationship, family, financial, at least with the suicides I've known. Look at the news stories about people who commit suicide because of home foreclosure, unemployment, etc. For people like this, curing what you call depression may cause suicide.

In other words, if you've made a plan to commit suicide and you're really down you're no more likely to follow through with it than you are with the plan to wash your dishes but the ssri's make you feel more energetic and hungrier, i.e. better able to accomplish your goal be it curing cancer or killing yourself. Being more energetic is not the same as being less depressed but is similar to akathasia, nor is increased appetite.

In fact it's amazing that, with the exception of SIADH which I'm unfamiliar with, the causes of suicide you suspect listed below are virtually a list of the expected side effects of ssri's.

"From what I understand, it is the end result of other mental status changes, including induction of a mixed state, akathasia, electrolyte changes due to SIADH, and so on, in a minority of vulnerable patients. All of those conditions create extreme psychological distress, which is what drives those subjects to have suicidal ideation, even when none existed before."

Sally:

First, SIADH is the syndrome of inappropriate anti-diuretic hormone (ADH), which causes water retention, which dilutes electrolyte levels, especially sodium. Low sodium concentration can cause mental status and personality changes. SSRI's are known to cause SIADH in some individuals.

Second, one does not have to be suicidal to be diagnosed with depression, at least not according to the DSM-IV.

Third, you are correct that there are a variety of stressors that lead to depression and suicidal ideation. However, it is not the stressors themselves, but rather their impact on the individual's cognitive, emotional and behavioural function. For example, some people respond to losses with indifference, and other respond with severe depression. So, it stands to reason that part of helping people out of depression is improving the cognitive, emotional and behavioural sign and symptoms of depression, which medications are helpful for, in addition to teaching coping skills to deal with the stressors.

Fourth, you are correct that one of the possible underlying mechanisms of increased suicides with SSRI's is that some people get their energy back before their other depressive symptoms return. This does not appear to happen often, and with proper monitoring can likely be avoided.

Fifth, you shouldn't be amazed that the list of underlying mechanisms that I listed could be found on the side effect list of SSRI's. That's exactly what I was saying in the first place.

Dguller, said, "Fourth, you are correct that one of the possible underlying mechanisms of increased suicides with SSRI's is that some people get their energy back before their other depressive symptoms return."

Is it that they get their energy back or is it that they have increased agitated energy? I have heard mental health professionals claim what you've said, but I haven't seen data to back it up. I had a prof say that "people are feeling better so now they have the energy to act on their suicidal thoughts." Say what? I'm feeling so much better, I think I'll go commit suicide now?

It doesn't make sense to me that if someone is feeling so much more energetic they would suddenly commit suicide - unless the energy they're feeling is agitated energy.

Lisa:

Both can happen. Normal energy levels can be dangerous if someone has a depressed mood and suicidal thoughts. Extreme agitation can be dangerous whether one is depressed or not, because it is very dysphoric and uncomfortable.