Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.
Dr. Sussman is a consultant to and on the advisory boards of GlaxoSmithKline and Wyeth; and has received honoraria from AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, and Wyeth.
Suicide is the ultimate act of a hopeless and suffering individual. Those who know the victim frequently describe the suicide as senseless. Yet, the person who takes his or her own life experiences and perceives the future as more unbearable than death. Feeling trapped, unbearably agitated, or shamed, the victim sees death as a friend. However, to families and acquaintances, or to the health professional that may have treated that person, the suicide is inevitably traumatic. Everyone who cared about the victim is somehow diminished by the act.
Most recent publicity surrounding suicide has come from analyses of clinical trials that have implicated antidepressants as triggers of suicide among children and adolescents. Starting in 2003, reports appeared of a possible link between antidepressant use in clinical trials among youths and the emergence of suicidality. In addition to making front-page news, these findings triggered Senate hearings as well as a precipitous decline in the number of antidepressant prescriptions given to youths. The number of cases of child and adolescent depression diagnosed by primary care physicians declined as well. Both the diagnostic and prescription trends no doubt were accelerated by a series of black box warnings added to the product information. As it turns out, as the number of prescriptions dispensed and cases diagnosed have declined, there has been a precipitous rise in youth suicides. These findings have been noted in both the United States and the Netherlands.1 Next year, data may confirm that the hysteria about antidepressants costing more lives than they save is unwarranted. As such, this entire episode will become part of the curriculum of every medical, public health, and governmental affairs school as examples of a dysfunctional political and regulatory sytem. I feel confident in saying that, ultimately, this misconceived action by the Food and Drug Administration will be shown to have cost lives. Antidepressants will be shown to save lives. Psychiatric interventions that carry small risks to some patients should be viewed the same way other medical treatments are regarded, with the benefits for most patients outweighing the adverse outcomes for the very few.
One lesson that can be drawn from this is that the variables involved in causing suicide, its prediction, and its prevention are complex. Accordingly, the November and December issues of Primary Psychiatry will focus on recent evidence that improves our understanding of factors that lead to suicides as well as on strategies that can help prevent these events. Two shared risk factors for suicide attempts are a diagnosis of depression and young age. Robert J. Valuck, PhD, RPh, and colleagues, present a study that examines annual suicide attempts among managed care enrollees. The article describes the demographics, diagnoses, and prior treatment history of these individuals.
The recent black box warnings against antidepressants, with the possible consequences described above, make it even more important that toxicology studies be conducted after every attempted or completed suicide. However, Dirk M. Dhossche, MD, PhD, argues that toxicologic analysis should be conducted in every suspected suicide and other types of unnatural death. The results of toxicologic procedures can be useful for reconstructing some events before a suicide, such as impaired mental functioning due to intoxication with alcohol or other drugs, or, if prescription medication is detected, recent contact with a physician. Dhossche observes that examination for prescribed psychoactive medications may also be useful to estimate the frequency and type of psychiatric treatment before a suicide. One of the more significant findings from the study was that the majority of depressed patients who committed suicide had sought professional help within the month prior to their deaths, yet the majority of these individuals were not being treated with antidepressants at the time of their death. This suggests that underrecognition and undertreatment of depression remain a problem.
Yogesh Dwivedi, PhD, and Ghanshyam N. Pandey, PhD, discuss the role of the signal transduction molecule protein kinase A (PKA) in the pathophysiology of suicide. The article explains how psychological, social, and environmental factors are weak predictors of suicide. They offer a neurobiologic approach to understanding risk factors associated with suicide. The authors review the potential role of PKA, one of the crucial signaling molecules whose activation and expression may be involved in the pathophysiology of suicide. They critically discuss findings in human postmortem brain and in pre-clinical models that link stress to suicide attempts.
Mao-Sheng Ran, MD, PhD, provides a systematic review of studies conducted on suicide in Micronesia. Ran notes that suicide among different islanders has not been extensively studied. As with any geographic area, a limited knowledge of suicidal behavior interferes with the development of suicide prevention. The number of suicides in Micronesia has risen sharply over the past 40 years, especially among youths. In fact, youth suicide rates are amongst the highest in the world. One of the more surprising statistics in this article is that in Micronesia, <40% of suicide victims were linked to an existing mental disorder.
On a separate but related topic, as many suicidal patients are seen in emergency rooms, Leslie S. Zun, MD, MBA, and LaVonne Downey, PhD, present a study involving the use of a medical clearance protocol that reduces the number and cost of testing for psychiatric patients. The authors note that while the American College of Emergency Physicians published numerous guidelines and protocols for use in the emergency department, recommendations take into consideration the need to reduce the costs of testing for many conditions such as seizures, acute mental status change, and headache. These guidelines have not been published for the medical evaluation of psychiatric patients. The protocol described in this study did not require testing of psychiatric patients but, rather, left the option of testing to the emergency physician. PP
1. Gibbons RD, Brown CH, Hur K, et al. Early evidence on the effects of regulators’ suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 2007;164(9):1356-1363.