On 20 March 2008, I arrived home from work to find my only child, 17 year old Toran, had hanged himself. Toran had been prescribed the antidepressant fluoxetine 15 days earlier, despite having no diagnosis of any mental disorder.
Within 20 minutes of my son being pronounced dead, I spoke to the duty Coroner and asked him to ensure that the inquest investigate the role of fluoxetine in his death. Having witnessed his adverse reactions to the drug, there was no doubt in my mind that it was the cause of death.
Toran’s medical file includes an entry the next morning to ‘note Maria’s grief reaction in blaming mental health services for Toran’s suicide.’
Was this a grief reaction? Did my immediate assessment that my son’s suicide was antidepressant-induced have any basis in fact? Could a drug prescribed to 11% of all New Zealanders really cause people to take their own lives? The desire to understand how my bright, healthy, popular and dearly loved son could take his life, was the beginning of a quest which has consumed me for almost four years.
The data I gathered was both deeply disturbing and profoundly painful. New Zealand, according to the OECD, has the highest rate of youth suicide in the developed world. Shockingly, this rate is twice that of the US and Australia and five times that of the UK.
The Child and Youth Mortality Review Committee in New Zealand reports that more young people die of suicide than of all medical causes combined and that 10% of the deaths of our 10-14 year olds are suicides. Suicide deaths in New Zealand are double the number of road traffic fatalities.
During a lengthy inquest, three years after Toran’s death, mental health services argued that Toran’s suicide was caused by major depressive disorder not fluoxetine. This is despite the fact that a team of mental health experts who reviewed his case 14 days before he died found he did not have depression or any other mental disorder. Could this be true? Could Toran have had an undiagnosed mental disorder severe enough to cause him to end his life but undetectable by his friends, family and two psychiatrists?
US born and NZ based ‘suicidologist’ Annette Beautrais asserts that 90.1% of those who die from suicide are mentally ill, with mood disorders the most common disorders in suicide victims.
Given New Zealand’s youth suicide rates, did this mean that New Zealand children are twice as mentally disordered as their American and Australian peers and five times madder than children in the UK? It appears not as the NZ Ministry of Health estimate that 47% of New Zealanders will meet the criteria for a mental disorder during their lifetime is consistent with the prevalence rates in the US, Australia and the UK.
Male suicides in NZ outnumber female suicides three to one and according to NZ research, female secondary students are twice as likely as male (males 9.0%, females 18.3%) to report levels of depressive symptoms that are considered to be serious and in need of professional assistance. If depression is so strongly correlated with mental disorder, and girls are more likely to suffer depression, why do boys in New Zealand complete suicide three times as often as girls? Is this because depression in boys is less likely to be treated? Not according to the Mental Health Commission who report that males account for 59% of children and youth who accessed secondary mental health services.
If boys are accessing secondary mental health services more frequently than girls, why are they completing suicide at such high rates? Are our state of the art services provoking rather than protecting against suicide? The Annual Report of the Director General of Mental Health it is clear that mental health care is strongly associated with suicide. The Director General reported in 2011 that the rate of suicide for those who had been in contact with mental health services during the previous year was 21 times the rate of suicide of those who did not receive mental health treatment. Specifically, the rate of suicide in service users was 206 per 100,000 while that of non-service users was 9 per 100,000. If 90.1% of these people had mental disorders, why were those accessing services 21 times more likely to kill themselves than those not accessing services?
Intuitively, one would suspect that those accessing services had more serious disorders and that this would account for their higher suicide rates but the diagnostic information provided by the Director General in his 2007 annual report would suggest otherwise. Information on the diagnosis of those who ended their lives under the care of mental health services showed the largest diagnostic category was ‘other.’ Depression (18%), Schizophrenia (11%) or Bipolar (9%) combined resulted in fewer suicides than ‘other’ which presumably includes a range of ‘minor’ DSM-IV diagnoses and, importantly, those with no diagnosis at all.
The key difference between these populations is not their diagnosis but their contact with mental health professionals. New Zealand data shows the The majority (75%) of those who die by suicide have contact with primary-care providers in the year prior to death, and one third have contact with mental health services. In the final month before death, 49% of suicide victims have contact with mental health services.
Mental Health treatment in New Zealand employs medication as a first line treatment, despite the fact that antidepressants are not approved for use in children under 18 years in and our regulator’s advice that the risks outweigh the benefits of prescribing these drugs to children and adolescents.
The Coroner found that Toran’s care by mental health services was deficient. Our regulator found that fluoxetine was the most likely cause of his suicide. Their assessments of the circumstances leading to Toran’s death, having reviewed the evidence align with mine – the difference is that they cannot be dismissed as a grief reaction.