Antidepressant Drugs and Suicide Rates

In 2010, Acta Psychiatrica Scandinavica published a study by Göran Isacsson et al.  The paper was titled Antidepressant medication prevents suicide in depression.  Here’s the conclusion:

“The finding that in-patient care for depression did not increase the probability of the detection of antidepressants in suicides is difficult to explain other than by the assumption that a substantial number of depressed individuals were saved from suicide by postdischarge treatment with antidepressant medication.”

It’s a complicated article, with some tenuous logic, but note in particular the contrast between the fairly cautious wording in the conclusion, and the bold, even brazen, assertion in the title.

But, in any event, it’s all moot, because the article was retracted by the authors and by Acta Psychiatrica Scandinavica about sixteen months after publication.  The retraction had been requested by the authors because of “…unintentional errors in the analysis of the data…”

The research in question was conducted in Sweden.  Dr. Isacsson works at the Division of Psychiatry in the Karolinska Institutet, Stockholm.  He has been writing since at least 1994 on the putative efficacy of antidepressants in the prevention of suicide.

The 2012 retraction notice did not attract as much attention as the original article, but it did stimulate a measure of discussion.  Mickey Nardo wrote posts on the subject, here, here and here.  Bob Fiddaman wrote a post here, and Ivan Oransky of Retraction Watch wrote on the matter here.  Ivan reported that he had contacted Dr. Isacsson and Acta Psychiatrica Scandinavica for more information, and received the following reply from Dr. Isacsson:

“We discovered lately that there was a coding error regarding diagnoses in the database we utilized for the 2010 paper. When corrected, antidepressants were detected in depressed suicides as often as could be expected and not less than expected which was the crucial finding in the paper. This means that no conclusion can be drawn from the study regarding antidepressants’ effects on suicide risk in any direction.

The database has not been used for other studies so no other papers are affected.”

Jan Larsson, a Swedish journalist, wrote an interesting article on the matter.  Here’s an extended quote: 

“Isacsson’s findings from 2010 were widely published in Swedish newspapers, with headlines like  ‘Antidepressants prevent suicide’ (Dagens Nyheter), where it was said: ‘He [Isacsson] means that many become provoked to hear that depression is a deadly disease and that suicides can be prevented with medicines’. And, said Isacsson: ‘Therefore, it is important to show that antidepressants actually prevent suicide.’

In June 2012 I made an FOI request to Karolinska Institutet (where Isacsson is working) to get the corrected figures in this research project. I specifically wanted to get the document containing the correct percentage of antidepressants for those ‘who committed suicide and who had previously been treated at a psychiatric clinic for depression’ (the earlier mentioned group of 1077 persons).

The answer from Karolinska Institutet: This is confidential information, no data can be released.

It took a five month legal process to get access to the correct data. During this whole process Karolinska Institutet claimed that all the data in this research project were confidential.

In a final statement to the court, after having to answer specific questions, Karolinska Institutet stated that the correct figures did not exist at the time of the FOI-request – remember that they were said to be confidential at the time – but that the correct figures now had been produced.

Karolinska Institutet stated to the court: ‘that information has now been produced … The result shows that ‘the correct percentage’ is 56, meaning that of the persons who had been treated for depression in psychiatric care in the last five years before suicide, 56% had antidepressants in their blood when they committed suicide.’

So finally we got to know that the 15.2% in actual fact was 56% – an increase of 268% (from 164 persons to 603).

We had a seven pages long scientific article, with great impact in media, where doctors and the public got the message that antidepressants protect against suicide – an article built on Isacsson’s faulty finding that only 15.2% in the group had antidepressants in their blood when they committed suicide. And so the correct data, which completely defeated Isacsson’s speculations and conclusions in the original article, ‘published’ in a short statement to the court in Stockholm, where no doctor, no patient and no other researcher could find it.”

So, Dr. Isacsson et al’s original finding of 15.2% was a very large error indeed.  As I mentioned earlier, the logic underlying the study is tenuous, but Table 1 from the study will provide some insight into the authors’ thinking.

Isacsson Table 1

The controls (34,165) are people who did not commit suicide.  These are individuals who died from accidental and natural deaths.  Antidepressants were detected in 6.5% of these individuals post-mortem.

The suicides (18,922) represent all Swedish suicides from 1992 to 2003.  Antidepressants were detected in 22.4% of these people post-mortem.

Then the authors broke the numbers down further.  They note that 11,226 of the suicides had no psychiatric hospitalization in the 5 years prior to their deaths.  Of these individuals, 14.8% had antidepressants detected post-mortem.  The remaining 7,696 suicides, who had been in a psychiatric hospital in the preceding 5 years, had an antidepressant detection rate of 33.6%.

And this is where it gets complicated.  The researchers broke the hospitalized numbers down further, into:

  • Those hospitalized for depression only                              15.2%
  • Those hospitalized for other problems                               37.3%
  • Those hospitalized for depression plus other problems    33.2%

Their argument was that the first group (depression only) would be expected to have about the same, or an even higher, level of detected antidepressants as the other groups.  But, contrary to expectations, they found that they had the lowest level – about the same, in fact, as the group who had not been hospitalized in the previous five years.

So, they reason that large numbers of the hospitalized-for-depression-only group, most of whom presumably had antidepressants in their blood stream, had “been saved from committing suicide by antidepressant treatment.”

But as mentioned earlier, there was an error in the data, and the correct number was 56%.

Now all of this is well-known, but there is an aspect of the matter that has not, to my knowledge, been addressed previously.  Let’s go back to Dr. Isacsson’s letter to Retraction Watch.

“We discovered lately that there was a coding error regarding diagnoses in the database we utilized for the 2010 paper. When corrected, antidepressants were detected in depressed suicides as often as could be expected and not less than expected which was the crucial finding in the paper. This means that no conclusion can be drawn from the study regarding antidepressants’ effects on suicide risk in any direction.

The database has not been used for other studies so no other papers are affected.”

Dr. Isacsson is saying that antidepressants were detected in the depression-only suicides “as often as could be expected and not less than expected.”

Strictly speaking this is true.  56% is not less than 15%.  But the statement is also deceptive, in that 56% is a great deal more than 15%.  The difference in the study in question is 439 people.

Dr. Isacsson issued the above statement on March 19, 2012.  At that time, neither he nor Karolinska Institutet had released the 56% figure (on the patently spurious grounds of confidentiality).  It took several more months of legal process before the 56% figure was produced.  So at the time that Dr. Isacsson wrote  “…not less than expected…”, he probably did not anticipate that the true figure would ever be released.

But the plot thickens even further:

“This means that no conclusion can be drawn from the study regarding antidepressants’ effects on suicide risk in any direction.” [Emphasis added]

If a particularly low number (15%) warrants the conclusion in the article’s title (“Antidepressants medication prevents suicide in depression”), wouldn’t it be reasonable to infer that a particularly high number (56%) might warrant the opposite conclusion?  This is particularly so in that the increase from 15% to 56% can only have come at the expense of one or other of the remaining categories, which would make the discrepancy even larger.

I’m perfectly willing to accept that the original analysis was a genuine error.  But at the time of the retraction and the letter to Retraction Watch, Dr. Isacsson must have known that the true figure was 56%, and the question needs to be asked:  Why did he not release the 56% figure voluntarily at the time of discovery?  In addition, it is difficult to avoid the conclusion that his letter to Ivan Oransky was deliberately deceptive.  Mickey Nardo puts the matter well:

“It would be easy to drift into a debate about the relationship between suicide and antidepressants and miss the point here, which is that medical opinion should follow science, not the other way around. It’s clear that Göran Isacsson is of the opinion that antidepressants should be given to decrease the incidence of suicide – he has an absolute right to express that opinion. But when Isacsson offers as proof of his opinion a published study of the Swedish public records, and it turns out that his data either is wrong, not to be found, or never existed in the first place, we have to conclude that Göran Isacsson is an ideologue and has no place in the psychiatric literature.”

At the time of writing the article in question, Dr. Isacsson had financial ties to Lundbeck, Eli Lilly, and GSK.

INCIDENTALLY

Dr. Isacsson not only continues to promote the notion that wider use of antidepressant drugs will prevent suicides, but he also calls routinely for the removal of the FDA’s black box warning on this matter (e.g.  here).

In June 2010, the British Journal of Psychiatry published a debate on the topic:  The increased use of antidepressants has contributed to the worldwide reduction in suicide rates.  Arguing for the notion were Dr. Isacsson and Charles L. Rich, MD, Professor Emeritus of Psychiatry, University of South Alabama; arguing against were Jon Jureidini, MD, child psychiatrist at the Women’s and Children’s Hospital, Adelaide, and Melissa Raven, PhD, Research Fellow at Flinders University. Adelaide.

The debate effectively discredits Dr. Isacsson’s position, and is well worth reading.

  • Brett Deacon

    Phil, thank you for this characteristically informative and important post. The article you discuss is a good example of the well-documeted and problematic phenomenon of highly publicized studies receiving little attention when not replicated, or worse, retracted. But this study goes beyond the usual problem because the author appears to have an agenda, and the failure to publicize the retraction has important public health implications. For me, the most telling section of you post was this: “At the time of writing the article in question, Dr. Isacsson had financial ties to Lundbeck, Eli Lilly, and GSK.” I think it is time we start re-stating such conflicts in plain English, as in “Dr. Isacsson is a paid spokesperson for drugs manufactured by Lundbeck, Eli Lilly, and GSK.” I don’t know the extent of this author’s financial ties to these drug companies, but if they resemble those of typical high-profile psychiatric researchers, he should be saddled with this well-deserved label. That way, we can all be in a more informed position to evaluate the curious nature of this retracted paper, whose consequential results were buried.

  • cledwyn goodpuddings

    That article is symptomatic of the rampant scientism that is one of the most salient features of the contemporary zeitgeist. Albert Camus once said that suicide is the one truly urgent philosophical issue. Now it’s treated as a medical and scientific issue. God help us (not that I believe in god, or could believe in a god that would author such a botched job as the universe, not forgetting the human race).

    Apart from putting the reader to sleep and creating a mental backdrop against which thoughts of suicide and the futility and emptiness of existence come into greater relief, I fail to see the point of all these graphs and all this statistical data, apart from to suggest that what he says at least could be true.

    Robert Musil understood only too well that science, for all the good it has achieved, is nevertheless something of a Pandora’s box (yeah, I’m a scientific anarchist, an anti-science extremist terrorist guerilla!), that has unleashed an assortment of evils on the world (though to say so is considered lese-majeste).

    He discusses the “peculiar predilection of scientific thinking for mechanical, statistical, and physical explanations that have, as it were, the heart cut out of them.” He goes on, “the scientific mind sees only kindness as a special form of egotism; brings emotions into line with glandular secretions; notes that eight or nine tenths of a human being consists of water….. reduces beauty to good digestion and the proper distribution of fatty tissue; graphs the annual statistical curves of births and suicides to show that our most intimate personal decisions are programmed behavior.”

    Of course, this last example of the reductionism of positivism bears directly on this discussion, and needs no further comment.

    He goes onto state that underneath all the rhetoric about the love of truth animating such ideas, lies a predilection, originating in the infernal regions of the human mind, and in which one can detect an undertone of malice, a predilection for robbing others of their illusions, which, to the extent that is done to crush illusions inimical to the welfare and interests of others, is not a bad thing, but when done purely out of spite, against people whose very existence presupposes a measure of illusion if the individual is not to be plunged into a state of abiding melancholia or fear, is just depraved. This can be seen in psychiatry, where people are persecuted for being delusional, although it must stated that psychiatrists merely wish to replace the individual’s delusions with their own.

    The notion that all you have to do is pop a pill to overcome your misery is perhaps one of the most ridiculous of the age. It says a lot about the illiteracy, in relation to what it means to be human, about the proponents of such a view. Then again, is there really a desire to “cure” misery?

    I don’t think there is. What really matters is that the true sources of much misery are kept from awareness, by dint of a systematic policy of obscurantism and mystification regarding the origins thereof, which, if understood, could have a seismic impact on human society, for numerous reasons, not the least of which is that it would force us to recalibrate our expectations concerning that fata morgana in the desert of human suffering, happiness, and to frankly acknowledge the role of social injustice and cultural prejudice in human misery, as well as to revise our attitudes towards people whom fortune has frowned upon.

    For this reason, there is a generalized hostility towards any view of human misery that locates it outside of the individual and implicates human society and culture, something which men are averse to either because it is inimical to their own interests, or because of other inertial forces in society that ensure widespread opposition to progress and its agent, truth, such as man’s status-quo bias.

    A society is only as receptive to the truth as the truth is as receptive to its interests.

    One of these truths, I would say (and the list of occasions for misery extends ad infinitum), is that men are miserable because they are doomed desire in perpetuity. Man spends his life longing for whatever he hasn’t got, and resenting those who have got it, who likewise resent the men who resent them. Man is such an an envious creature because anything that he doesn’t possess seems to him to be the wellspring from all happiness flows, whereas what he does have is, eo ipso, undesirable. Montaigne attested to this when he said in one of his essays that he always thought that only that which he didn’t possess was eminently desirable.

    Another source of misery is man’s heteronymous character, his dependency, specifically here on the opinions of others. Men have this native distrust of their own judgement which renders them a slave to the judgments of others. If these others reflect back to him a negative image of himself, then he will be miserable.

    Society is averse to this truth not just because it offends against our conception of ourselves as autonomous, rational agents, but because it is very defensive of its prejudices. We need people to hate and those people whom we can use as an outlet for hateful feelings, so that any acknowledgment of the role of societal prejudice in tutoring others to loathe themselves, which we see in attitudes towards homosexuals, the poor, “the mentally ill”, the obese, the ugly etc., is ultimately at a disadvantage, and will not find favor as readily as theories that allow us to revel and luxuriate all the more in the hatred wherein so much of the pleasure we feel resides. For this reason, views that demonize such groups, themselves born largely of the visceral disgust people upon which this hatred is founded, will always be eagerly seized upon, be they views about the sinfulness of homosexuality, the laziness of the poor and downtrodden, the parasitical uselessness of mental patients (none of which, of course, are my own views).

    Another common source which society is averse to the acknowledgement of is the harsh reality of man’s response to human adversity. Men are like the proverbial summer birds that fly away upon the approach of winter. Prosperity and power make one the focal figure of the attentions of others, whereas, when fortune frowns upon you, you become socially invisible, consigned to a slow, mentally agonizing death on the margins of society, which is the fate of depressed people, “schizophrenics”, old people, homeless people, diseased people, you name it, the harsh reality is that, contrary to the bullshit, self-elevating rhetoric to the contrary, such people lead very lonely lives, while society worships sports narcissists, idiots, bullies and tyrants.

    I could go on and on about this. Nevertheless, there is a strong desire to reduce these problems to brains and statistics, and to believe that by popping an anti-depressant we can do away with misery, and the suicide that delivers us from it.

  • cledwyn goodpuddings

    I don’t think much can be done about societal prejudice against society’s victims though. We hate those we hurt. If we are to live with our crimes of commission and omission in this regards, then a self-justifying narrative is needed to dignify our failure as moral beings to help those who need it, as well as our cruelty and egotism, anything that allows us to partake of this cannibal’s orgy we call human existence in good conscience.

    Wherever you find society’s refuse, you’ll also find about their persons a constellation of hate-charged attitudes, felt in proportion by those around them as they feel the need to justify their mistreatment. “Mental patients are useless parasites, dangerous, smelly, poo-slingers!”; “People are poor because they are lazy!”; “Homosexuality is a crime against nature, and the work of the devil!”; “You make your own luck in this world!”; “People who smoke cannabis need to grow up!”; and on, and on, and on.

    Yet we have the unmitigated cheek to deprive such people of that most basic of rights; to wit, the free disposal of one’s existence. We bring people into this horrible world, only to torment them, and such is the extent of our depravity, we deprive them of their only egress, suicide, and claim that this is compassionate, whilst also claiming that suicide is sinful and selfish (and yes, it is of course a truism that suicide is selfish, as is having children, as is forcing someone to stay alive).

    What’s worse, we deprive their act of its poetry, of its meaning, its tragic import. Suicide is not a protest against the world, against the callous spectacle that human society presents to the eye of any man of noble character, sensibility, and high ideals; it’s not a protest against the human condition; nor a retreat from the nightmare of existence, no, it’s a bloody disease, to be understood by the examination of the brain, to which all suffering is being reduced, and anyone who argues against this is accused of being “anti-science”, is just given the usual bullshit about how, “the brain is a complex organ…”, which has become a way of skirting around the issue of the reductionism inherent in the neuroscientific framing of human experience.

    Have these people ever entertained the possibility that people are topping themselves to escape a world in which quacks and scientific nihilists are hell bent on depriving life of all its poetry and romance, because of the various ways they stand to profit thereby, people who, unlike the great artists and philosophers, are not interested in understanding human suffering, but in mystifying and controlling it, and exploiting all the confusion for their own advantage?

    Harold Goddard, the great Shakespearean critic, once said, to paraphrase, that ours is an age that no longer wonders at existence, but merely wants to control it. A piquant observation.

    There is a certain frontier beyond which the application of the scientific method only serves to further confuse an already confusing issue. Human suffering is a matter for philosophical inquiry.

    Part of the appeal of the treating of human experience as a matter of scientific inquiry is that it allows mediocrities and fools to fool themselves that they can arrive at an understanding of what it means to be human simply through the application of the principles thereof, without having to make the Herculean effort required by the truly great explorers of the human condition, and human nature, such as Schopenhauer, Shakespeare, and Bergman. For this reason, mediocrities all over the world have eagerly seized upon this idea that the secrets of what it means to be human can be accessed through the simple subjection of humanity to scientific observation. It allows people who know next to nothing about what it means to be human to delude themselves that they actually know something.

    As well as this, it justifies the marginalization of the voices of people with direct experience like myself, who know so much more than these bloody intolerable quacks because I live with this misery and despair every day, and have a real incentive to try and make sense of why I feel like this.

    By treating this as a medical and scientific issue, the feelings and opinions of the patient can be disregarded, much as if you were to start complaining about the feeling of depression from being diagnosed with cancer to an oncologist.

    The line of reasoning goes like this; in order to understand “mental illness” (which mostly refers to human misery), specialist knowledge is required, ergo what the patient says is of no consequence, because of his lack thereof.

    This an example of the anti-dialogical reasoning which is common in relations between oppressors and oppressed peoples. The medical and scientific model enshrines the notion that specialist, esoteric knowledge is required to understand the experiential and behavioral problems psychiatrists deal with. In consequence of this, a hierarchical relationship beneficial to the interests of the oppressor inevitably obtains. This is one of the reasons why the medical and scientific model is defended so vehemently by psychiatrists.

    Not that psychiatrists always disregard the voices of the patient. No. There is a certain species of authoritarian brown-noser amongst mental patients who, in their desire to please the object of their adulation (the man of authority, the psychiatrist), become, to use Shakespeare’s felicitous expression, glass-faced flatterers, so-called because they reflect back, as if in a mirror, the desires and opinions of others in order to ingratiate themselves thereby.

    Sadly, there are many of these authoritarian brown-nosers amongst patients, desperate to please those who symbolize the power and authority that gives them a hard-on, and to a proportionate extent they are desperate to distance themselves from the culturally designated class of inferiors, the mental patients, a phenomenon you admittedly see on both sides of the divide.

    Such people identify with the oppressors largely out of a hatred of their own people. This is common amongst oppressed peoples, and largely explains the support of such people for their oppressors; it’s their way of convincing themselves, and others, that they are not really like the culturally-designated inferiors they have been classed with.

    Such people are of course, listened to. The rest of us are ignored.

  • cledwyn goodpuddings

    And I can say all this with authority vested in me by the fact that I am one of the few people writing extensively on this issue who doesn’t stand to profit financially from it.

  • cledwyn bulbs

    That should be “to the extent that IT is done.”

    That should be, “although it mus BE stated.”

    That should be “doomed TO desire in perpetuity”.

    That should be “the wellspring from WHICH all happiness flows.”

    That should be “visceral disgust people FEEL…”

  • Phil_Hickey

    Brett,

    Good point!

  • ronk thonk

    How many drank alcohol or used illicit drugs AMA as they took their prescribed meds? Most, if you trust statistics on the consumption of alcohol as per the typical person living in the U.S.

  • all too easy

    “(not that I believe in god, or could believe in a god that would author such a botched job as the universe, not forgetting the human race).”

    “And I can say all this with authority vested in me by the fact that I am one of the few people writing extensively on this issue who doesn’t stand to profit financially from it.”

    As GOD, why would you need money? Let the world spin without you, tonight, Superstar.