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Alison Bass

Suicide rates as a public relations tool

EARLIER THIS MONTH, major newspapers reported the alarming news that suicides among young people were on the rise because of a precipitous drop in the use of antidepressants. This news was based on a study in the September issue of the American Journal of Psychiatry, which concluded that physicians had been scared away from prescribing antidepressants because of the Food and Drug Administration's decision in October 2004 to put black box warnings on the pediatric use of these drugs. The FDA mandated the warnings after finding an increased risk in suicidal thoughts and behaviors among adolescents taking antidepressants such as Prozac, Zoloft, Paxil, and Celexa.

In the wake of the study, several psychiatrists called for the black box warnings to be retracted. "It's time for the agency's warnings to be modified," opined Dr. David Schaffer, chief of child and adolescent psychiatry at Columbia University Medical Center in New York City.

News sources have since exposed a big hole in the journal's argument. Several experts quoted in The New York Times and The Boston Globe pointed out that while there was indeed an upturn in suicide rates among youths (an increase of 14 percent, or a total of 252 more deaths among youths under 19 between 2003 and 2004), the number of prescriptions for antidepressants in the same age group remained basically unchanged between 2003 and 2004.

According to data presented in the American Journal of Psychiatry study, prescription rates for minors did not drop sharply until a year later (between 2004 and 2005). Since suicide rates for 2005 are not yet available from the Centers for Disease Control and Prevention, there is no evidence of a connection between variations in youth suicide rates and antidepressant prescription usage. Furthermore, experts say that trends in suicide rates, like any epidemiological data, have to be looked at over the long term and a one-year variation in rates could be a statistical artifact, or mean something else entirely.

So what's going on here? Why are some in the psychiatric community, despite lack of evidence, working to convince the American public that the FDA may have erred in putting the most serious kind of warning possible on the use of these drugs in young people? In May, the FDA, after finding the same increased risk of suicidal behaviors among young adults taking the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), extended the black box warnings to young adults.

There is no doubt that many psychiatrists believe that antidepressants, particularly SSRIs like Prozac, Paxil, Zoloft, and Celexa, are helpful in treating depression in adults and adolescents. They have seen how these drugs have lifted the fog of despair from people with depression.

But there is another factor to consider: Who stands to benefit from the latest alarm about an apparent upturn in youth suicide rates? The sharp drop in the sale of SSRIs since 2004 has put a big dent in their manufacturers' bottom line. These companies have an enormous stake in reversing the current FDA warnings. That might explain why Pfizer (the maker of Zoloft) contributed $30,000 to cover the cost of collecting data for the American Journal of Psychiatry study, which was also funded by the National Institute of Mental Health. It's also worth noting that the two lead authors of the paper have disclosed financial conflicts of interest: Columbia professor of psychiatry Dr. John Mann has been a paid consultant to at least two SSRI makers, Pfizer and GlaxoSmithKline (the maker of Paxil), and Robert Gibbons has served as an expert witness for Wyeth Pharmaceuticals (the maker of Effexor, another SSRI).

This isn't the first time that suicide rates have been trotted out as a public relations weapon. Proponents of psychotropic drugs have long argued that suicide rates among adults and children fell after the SSRIs were introduced in the United States. However, an examination of long-term trends in suicide rates indicate that suicides were declining here and in other countries well before SSRIs such as Prozac, Zoloft, and Paxil were widely prescribed, says Julie Zito, associate professor of pharmacy and psychiatry at the University of Maryland. Zito says there are other plausible reasons for the decline in suicide rates over the last two decades, including a more stable economy, better access to mental healthcare, and gun control.

So until new evidence emerges showing, unequivocally, a rising rate of suicides among our youths and a link between those rates and reduced antidepressant usage, it would be wise to treat the latest salvo with a healthy dose of skepticism.

Alison Bass is a former medical writer for the Globe and author of the upcoming book "Side Effects: A Best-selling Drug on Trial."

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