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Regarding http://psychcentral.com/blog/archives/2011/08/04/doctor-is-my-mood-disorder-due-to-a-chemical-imbalance/

 

My response underneath Dr Pies answers.

 

The issue of suicide is extremely complicated, and it always astounds me that some who vehemently reject the notion of a “chemical imbalance” as a cause of mental illness credulously embrace the idea of a “chemical imbalance theory of suicide.”

 

Suicide is a diverse, multi-caused, existential decision, that involves a complex interplay of numerous risk factors. Substance abuse, chronic illness, age over 75, parental history of substance abuse, and poor social supports are all risk factors for completed suicide. However, the best-established risk factor for completed suicide is the presence of a major mood disorder itself.

 

The American Association of Suicidology notes that the risk of suicide in people with major depression is about 20 times that of the general population. Individuals who have had multiple episodes of depression are at greater risk for suicide than those who have had one episode. [For more information, see http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets

 

Similarly, the suicide rate in bipolar disorder is many magnitudes higher than in the general population, and there is good evidence that the use of lithium reduces the risk of suicide very substantially [see see Baldessarini et al, J Clin Psychiatry, 2003; 64(suppl 5), 44-52.]

 

With regard to antidepressants (ADs): the term “suicidality” is very loosely used in the literature, and often, FDA and pharmaceutical company data do not carefully discriminate between, for example, having “suicidal thoughts”; making a suicidal “gesture”, such as a superficial cut on the wrist; or a serious suicide attempt using lethal means.

 

While a small percentage of individuals (mainly children and adolescents) may experience suicidal thoughts or exhibit self-injurious behaviors while taking an AD—usually early in treatment–there is no convincing epidemiological or clinical evidence showing any significant increase in completed (actual) suicides associated with AD use.

 

Thus, in the U.S., a joint meeting of the Psychopharmacologic Drugs Advisory Committee and the Pediatric Drugs Advisory Committee in September 2004 analyzed the short-term placebo-controlled trials of nine antidepressant drugs. The results demonstrated “a greater risk of “suicidality” during the first few months of treatment of those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials” (www.fda.gov).

 

In fact, there are several cross-national, epidemiological studies suggesting that antidepressant use may reduce the risk of suicide attempts and completed suicides. For example, a recent 27-year observational study of antidepressants [Leon et al, J Clin Psychiatry, 2011;72:580-586] concluded that “…antidepressants were associated with a significant reduction in the risk of suicidal behavior”, which was defined as a reduction in actual suicide attempts or completed suicides, while taking ADs.

 

Similarly, A study of suicide rates and antidepressant use in the U.S.(1996-98) concluded that “increases in prescriptions for SSRIs and other new-generation non-SSRIs are associated with lower suicide rates both between and within counties over time…” [Gibbons et al,Arch Gen Psychiatry. 2005 Feb;62(2):165-72].

 

Another study in Hungary examined the connections between suicides and the consumption of antidepressants in the period of 1999-2006 [Kalmar S,Neuropsychopharmacol Hung. 2011 Jun;13(2):59-72.] The study concluded,

 

“The results of the analysis supported the hypothesis that in spite of some contradictions, there is a connection between the increase in antidepressant use and the decrease in the number of suicides. The increased use of antidepressants is one of the factors contributing to the decrease of suicides.”

 

That said, many mood disorder specialists do become concerned when a patient with bipolar disorder–often misdiagnosed as having unipolar major depression–becomes agitated and irritable while taking an antidepressant. This may well increase that person’s risk of acting out in a self-injurious manner, or becoming violent. This is owing to the inappropriate use of antidepressants, in individuals who are best treated with mood stabilizers and supportive psychosocial therapies.

 

Now, regarding “addiction”: while the term “addiction” is variously defined and understood, there is no credible evidence that antidepressants are “addictive,” in the sense physicians apply to addiction to opiates, sedatives, barbiturates, alcohol, and related substances.

 

However, there is a subset of patients who may become resistant to their antidepressant, over time. Furthermore, inappropriately rapid discontinuation of an antidepressant can lead to an uncomfortable withdrawal syndrome, usually characterized by a flu-like syndrome of nausea, vomiting, muscle aches, and fatigue. Usually, this is short-lived, and reversible with restoration of a small dose of the medication. This syndrome is quite unlike the potentially life-threatening withdrawal syndrome seen, for example, when someone goes “cold turkey” off barbiturates.

 

That said, for a small minority of patients whose antidepressant was discontinued too quickly, their withdrawal effects may persist for weeks or even months, based on some case reports. The key to avoiding these problems is to taper the medication very, very slowly–over a period of 3-6 months, in my experience. In a practice extending over 25 years, and several hundred depressed patients, I never witnessed, or consulted on, a serious withdrawal reaction from antidepressants, when a very slow tapering period was used.

 

Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition, and who find antidepressant medication–ideally, in combination with psychotherapy–a life-saving treatment.

 

Ronald Pies MD

 

 

 

 

 

 

 

 

 

 

My response [awaiting moderation]

 

Dr Pies wrote:

"The issue of suicide is extremely complicated, and it always astounds me that some who vehemently reject the notion of a “chemical imbalance” as a cause of mental illness credulously embrace the idea of a “chemical imbalance theory of suicide.”"

 

My answer:

One only has the imbalance when one starts the medication. It really doesn't take Einstein to work this out.

 

Dr Pies wrote:

"While a small percentage of individuals (mainly children and adolescents) may experience suicidal thoughts or exhibit self-injurious behaviors while taking an AD—usually early in treatment–there is no convincing epidemiological or clinical evidence showing any significant increase in completed (actual) suicides associated with AD use."

 

My answer:

So there has never been a completed suicide in any antidepressant clinic trial with healthy volunteers? Are you saying that the FDA are lying?

 

Dr Pies wrote:

"Similarly, A study of suicide rates and antidepressant use in the U.S.(1996-98) concluded that “increases in prescriptions for SSRIs and other new-generation non-SSRIs are associated with lower suicide rates both between and within counties over time…” [Gibbons et al,Arch Gen Psychiatry. 2005 Feb;62(2):165-72]."

 

My answer:

Gibbons also objected to the black box warnings and is a paid 'expert witness' for GSK in litigation regarding Paxil. Hardly an independent view is it?

Re his study [above] Gibbons was wrong. The suicide stats he analyzed did not yet reflect the effect of the black box warnings and he ended up having to tell the New York Times the "early evidence" was actually not evidence at all but "suggestive." If you are going to quote 'experts' then please do your homework Dr Pies.

 

Dr Pies wrote:

"Now, regarding “addiction”: while the term “addiction” is variously defined and understood, there is no credible evidence that antidepressants are “addictive,”

 

My answer:

Well, it took me a total of 22 months to taper off Paxil. I am one of many thousands...or do you not accept anecdotal evidence?

 

Dr Pies wrote:

"Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition, and who find antidepressant medication–ideally, in combination with psychotherapy–a life-saving treatment."

 

My answer:

Not one single pharmaceutical company have carried out any study in relation to long term use of SSRis yet you, an MD, profess that these drugs are safe. The only 'fear-mongers' are the ones who promoted these types of medications with the "chemical imbalance" spin. It was never proven back then...and it has never been proven to date. They were promoted on a lie - surely that should raise alarm bells for even the most stubborn of individuals.

 

You refer to a very slow tapering regime - how slow? Who tells the doctor how slow to taper the patient?

 

Do you prescribe Paxil to women who are pregnant Dr Pies? Do you know it is a known teratogen? [see GSK V Kilker]

 

Patients should have informed consent, you owe it to them to warn them of the dangers...and not just the dangers written on the patient information leaflet. Read through the product monographs of all the SSRis then answer the following:

 

What are the benefits of taking an SSRi?

 

and

 

What are the risks?

 

I think you will find that the benefits clearly do not outweigh the risks.

 

Bob Fiddaman

Author of ‘The evidence, however, is clear…the Seroxat scandal’

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Hmm, I thought he was taking a break from the blog.

 

Fid, again, thank you for what you wrote.

 

Once again, I am speechless in reading what Pies wrote. But I don't know why I expect anything different. A tiger doesn't change its stripes.

 

Actually, I think I am insulting tigers so that might not be the best analogy:)

 

CS

Drug cocktail 1995 - 2010
Started taper of Adderall, Wellbutrin XL, Remeron, and Doxepin in 2006
Finished taper on June 10, 2010

Temazepam on a PRN basis approximately twice a month - 2014 to 2016

Beginning in 2017 - Consumption increased to about two times per week

April 2017 - Increased to taking it full time for insomnia

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Hey, guys, where is this discussion taking place? Links, please, we have readers who aren't keeping up with every little twist and turn.

 

One thing about Dr. Pies -- he's an Internet addict, and when he gets caught up in back-and-forth, he absolutely must have the last word.

 

If he were a member of a forum, he'd be checking it constantly to see how people respond to his posts.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Okay, I couldn't resist (Dr. Pies hates me, by the way):

 

 

“Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition….”

 

Dr. Pies, there you go again with the ad hominems. This is inflammatory and, as even you know, dirty pool in debates.

 

Plus, it indicates you have no respect for those injured by psychiatric treatment, and, because you so deliberately deprecate what they have to say, no interest in reducing the rate of those injuries. So it makes you look bad, doubly.

 

Again, I suggest you use your position to help patients by urging psychiatry to fill the gaps in the risk-benefit analysis and do honest studies of long-term adverse effects — as well as short-term adverse effects, such as suicidality. Psychiatry really circled the wagons on that one!

 

May I point out the rate of suicide is perhaps .0125%, while psychiatry’s estimated rate of depression ranges from 10%-50%. Obviously depression is no predictor of suicide. If vast numbers are being medicated prophylactically, they are being unnecessarily exposed to risks. Has there been some fear-mongering about suicide to promote antidepressants?

 

On the other hand, doctors have a higher rate of depression than the non-MD population. Perhaps they should start on antidepressants in medical school? It costs so much to train them, and they are so valuable to society, we wouldn’t want to lose even a fraction of a percent to suicide.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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The suicidology fact sheet (linked above) on depression and suicide stated that the lifetime risk of suicide among people with untreated depression is 20%. Wonder how they define "untreated". Does this include people who just quit their antidepressant last week? or last month? 6 months ago? Yesterday? If so, that's not an untreated population. They may be suffering adverse events resulting from the drug or discontinuation. I googled, and did not find the study. Are these "depressed" people, or are they "people who have at some point received treatment for depression"? There's a big difference. I don't think you can state what the lifetime risk of suicide among "depressed people" really is because nobody knows how many depressed people exist. The ones who can be identified are more than likely the ones who have sought treatment.

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Georgia, that's a good question. If you look at the pdf from that site, it says the information is from Gotlib & Hammen, 2002. I couldn't find Gotlib & Hammen, 2002. This is probably a textbook that has undergone revisions.

 

From the pdf at http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets

Major depression is the psychiatric diagnosis most commonly associated with suicide. Lifetime risk of suicide among patients with untreated depressive disorder is nearly 20% (Gotlib & Hammen, 2002). The suicide risk among treated patients is 141/100,000 (Isacsson et al, 2000).

You would have to contact suicidology.org to find out the exact reference, and then critique it. When you are curious about this stuff, this is the kind of digging you have to do.

 

It defies logic that one out of 5 depressed people commit suicide. The statistics just don't support that.

 

suicidology.org is a non-profit based in Washington, DC and exists on mostly grants ($6 million 2003-2006). The grantors are not listed. Here it the board of directors: http://suicidology.org/web/guest/about-aas/board-of-directors

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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"It defies logic that 1 out of 5 depressed people commit suicide."

 

If there's a 25% risk of depression, and a 20% chance that the "untreated" depressed will commit suicide, then a lot of people are dying of suicide. I'm skeptical.

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