Suicide Attempts: Time Patterns Before and During Treatment

The debate over the 2004 Food and Drug Administration black box warning on antidepressants is barely waning. Are suicide rates higher or lower for patients on antidepressants, regardless of age? Has the FDA warning prevented deaths by suicide or unintentionally caused more? The FDA warning specifically referred to the use of antidepressants for treatment of pediatric and adolescent depression. Currently, there are clinical trials and observational studies that present conflicting evidence for the safe use of antidepressants, and clinicians have had to evaluate the evidence on their own. A new study by Gregory E. Simon, MD, MPH, and James Savarino, PhD, at the Center for Health Studies in Seattle, Washington, has received national attention from both the mainstream and medical press for its findings, which seem to vindicate antidepressants. The authors state that this study does not counter the FDA warning, however, and that parents and clinicians should continue to exercise caution when prescribing these drugs to young patients.

Simon and Savarino studied the time frames in which suicide attempts occurred for patients beginning new episodes of antidepressant treatment. Outpatient and pharmacy claims data were gathered from the database of a prepaid health plan serving 500,000 members in Idaho and Washington. The study’s criteria for new episodes of antidepressant treatment included no filled antidepressant prescription within the past 180 days, at least one outpatient visit with diagnosis of depressive disorder within 30 days of the initial prescription, and that the patient be ≥7 years of age. Suicide attempts were identified with hospital and emergency room claims attributed to attempted or completed suicides during the 90 days before and 180 days after new treatment episodes.

After filtering claims through these and other criteria, the authors identified 131,788 unique treatment episodes among 109,256 patients. Most treatment episodes,  approximately 55%, began with an antidepressant prescription from a primary practitioner; approximately 40% began in psychotherapy, and approximately 5% began with an antidepressant prescription from a psychiatrist.

The time pattern for attempted suicides was nearly identical for all three treatment groups, although the number of attempts was nearly doubled among patients ≤25 years of age. Among all patients from all treatment groups, however, the incidence of suicide attempt was highest in the month before beginning treatment, next highest in the month after beginning treatment, with a subsequent, steady decline occurring over the following 6 months. This data, according to the authors, “reflects the expected improvement in depression and suicidal ideation when starting treatment rather than any specific effect of either medication or psychotherapy.”

Incidence of suicide attempts was highest among patients prescribed antidepressants by psychiatrists (1,124 per 100,000), lower for those receiving psychotherapy (788 per 100,000), and lowest for those receiving antidepressants from a primary practitioner. However, Simon and Savarino believe that the data do not suggest that psychiatric care increases risk of suicide; rather, patients referred to psychiatrists had undergone an accurate assessment of risk by the referring clinician. That is, higher risk patients were referred to psychiatrists for specialty care rather than to other physicians. All three treatment groups, after all, showed a decline in suicide attempts following initial treatment episode.

Funding for this research was provided by the National Institute of Mental Health. (Am J Psychiatry. 2007;164(7):1029-1034) —LS


Phone Counseling Can Coax Males With Alcohol-Use Disorders Into Treatment

While alcohol screening, brief intervention, and referral to a specialist can reduce drinking, many people with alcohol-use disorders either do not respond well to short-lived interventions or do not receive treatment at all. Phone counseling may be of particular help to such individuals who have yet to be helped with their disorder.

Richard L. Brown, MD, MPH, and colleagues, at the University of Wisconsin School of Medicine and Public Health in Madison conducted a 12-month randomized controlled trial of a mail and telephone intervention for primary care patients with alcohol-use disorders who were not undergoing treatment. Systematic screening in 18 primary care waiting rooms around the Madison and Milwaukee, Wisconsin areas, as well as follow-up diagnostic interviews via telephone, resulted in 897 voluntary patients enrolled in the trial. Patients also earned a small fee at each step of the study, amounting to <$125. Up to six sessions of protocol-driven telephone counseling were provided to the patients and were based on motivational interviewing principles and stages of readiness to change. Counselors were assigned to the experimental group to help patients identify their goals and examine how their alcohol-use disorders affected their achievement of such goals. Pamphlets on healthy lifestyles were given to the control group.
In both male and female groups, more telephone counseling sessions were associated with greater decline in drinking. Male patients (N=199) showed a decline of 30.6% in risky drinking days compared to an 8.3% decline in the control group (N=201, P<.001), and total consumption declined by 17.3% compared to 12.9% in the control group (P=.001). Declines in the female groups were not as significant, with a 17.2% decline in risky drinking days in the experimental group (N=246) compared to an 11.5% decline in the control group (N=251; P=not significant [NS]). In addition, total consumption in the female experimental group declined by 13.9% compared to 11.0% in the control group (P=NS). Of note, males with alcohol dependence, as opposed to alcohol abuse, showed a 31.8% decline in risky drinking days over the course of 3 months compared with a 9.7% decline in the control group.

Limitations to the study include inadequate enrollment procedures, such as that the enrollment interview itself affected drinking behaviors independent of the phone counseling intervention sessions. Brown and colleagues are currently studying the benefits of phone counseling over a 12-month period.

Funding for this research was provided by the American Academy of Family Physicians Foundation, the Department of Family Medicine of the University of Wisconsin School of Medicine and Public Health, and the National Institute of Alcohol Abuse and Alcoholism. (Alcoholism: Clinical and Experimental Research. 2007;31(8):1372-1379). —DC


Evidence Is Limited on Efficacy of Talk Therapy and Behavioral Interventions for the Treatment of Psychosocial Disorders

When patients experience symptoms stemming from a psychosocial condition, such as major depressive disorder (MDD) or generalized anxiety disorder (GAD), a primary care physician (PCP) is often the first clinician to which the patient will present. In addition, patients may suffer from disorders that present with unexplained physical symptoms but are psychosocial in nature, such as somatization disorder, which can cause chronic physical symptoms.

However, research has shown that there are few evidence-based, nonpharmacologic treatment options for PCPs to provide patients who have mental health disorders. For clinicians, accurate diagnosis and treatment of such patients can be time consuming and patients may not have access to recommended pharmacologic treatment because of medication cost or other factors.

Researchers recently studied whether clinicians employing various therapy-based psychosocial treatment tools or behavioral interventions would be beneficial for patients who first present with psychosocial conditions. Led by Marcus Huibers, PhD, of Maastricht University in The Netherlands, researchers evaluated several randomized controlled trials, clinical trials, and controlled patient preference trials that studied the effectiveness of psychosocial interventions performed by PCPs for any disorder. Prior studies have shown that intervention has been effective treatment for psychosocial disorders, although studies have not examined the efficacy of these methods when performed by PCPs.

Huibers and colleagues included results from 10 studies, which addressed MDD, smoking cessation, alcohol abuse, unexplained fatigue, and somatization disorder, in their evaluation. All studies were gathered from The Cochrane Library, the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register, reference lists of relevant studies, and personal communication with clinicians.

The authors found that none of the studies showed conclusive evidence of the effectiveness or ineffectiveness of PCPs performing psychosocial interventions to treat patients with mental health disorders, except for problem-solving treatment for those with MDD. Problem-solving treatment focuses on helping patients recognize that symptoms may be caused by external problems and create solutions to those problems. Regarding the remaining interventions by PCPs—cognitive-behavioral therapy (CBT) for somatization disorder, CBT for unexplained fatigue, therapy for smoking cessation, and behavioral intervention for alcohol abuse—the authors found efficacy evidence to be either limited or conflicting.

Huibers and colleagues concluded that although results showed that therapy and behavioral interventions when performed by PCPs were not effective for patients with mental health disorders, PCPs should continue to use these or similar methods in the treatment of patients with psychosocial disorders. The authors said treatment methods used in evaluated studies did not cause any negative outcomes for patients as well.

The authors added that problem-solving treatment does show efficacy when PCPs utilize this intervention with MDD patients. However, the authors said as there is little evidence on the use of psychosocial interventions by PCPs overall, more research and use in clinical practice is necessary to determine the overall benefit of problem-solving treatment for MDD patients. (Cochrane Database Syst Rev. 2007;3:CD003494). —CP

Psychiatric Dispatches is written by Dena Croog, Carlos Perkins, Jr., and Lonnie Stoltzfoos.