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Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

BMJ 2014; 348 doi: (Published 18 June 2014) Cite this as: BMJ 2014;348:g3596

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Re: Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

First this paper suggests that FDA warnings led to a lower than expected increase in antidepressant usage. This is terribly unlikely. FDA warnings have rarely had effects like this. In fact companies have exploited warnings to increase sales - as for instance warnings about antidepressants and the risk of birth defects.

It is more likely that the relative decline in usage is linked to these drugs going off patent. At the time there was a very active marketing of mood-stabilizers for bipolar disorder with the message if your patient has become suicidal on an Antidepressant this is because they really have bipolar disorder and should have a mood stabilizer.

FDA's resources to influence prescribing pale compared to those of companies.

Second, the notion of a percentage increase in self-poisonings is ambiguous. It is possible for instance to have a relative increase in self-poisonings but fewer actual self-poisonings if for example there has been a bigger drop of self harm episodes involving lacerations and attempted hangings than in self-poisonings.

Third, this increase in self-poisonings is taking place against a backdrop of an explosion in oxycontin and related prescription narcotic abuse. These have been heavily linked to self-poisonings.

This paper gives us no data on the drugs involved in the self-poisoning episodes. If there were increases in self-poisonings involving oxycontin and other narcotics on the one hand and mood stabilizers on the other during this period, as seems highly likely, it would be almost impossible to make the argument being made here.

Fourth, the time frame here also coincides with the development of the Generation Rx phenomenon - involving children, teenagers and other young adults abusing prescription drugs and ending up in ER departments in increasing numbers. But there is not a hint of this possibility in this paper.

Fifth, there is no apparent openness in the paper to the possibility of antidepressant withdrawal related suicidal acts. In the unlikely event that FDA warnings were effective, some people may have come to grief because of withdrawal suicidality - but this is the fault of the medication rather than the warnings.

Finally if there has been a true increase in suicide attempts, this parallels an increase in the use of Mood Stablilizers, the clinical trials of which show almost exactly the same increases in suicidal act rates over placebo as is shown for the antidepressants.

There is in summary so little basis in the data presented here for the argument being made that this paper perhaps offers better evidence of an agenda than anything else.

Competing interests: I have been a consultant to most of the companies making antidepressants and an expert witness primarily for plaintiffs in medico-legal cases involving antidepressants.

21 June 2014
David T Healy
Professor of Psychiatry
Bangor University
Hergest Unit Wales LL57 2PW