In 2008, Professor Roger Mulder, head of psychiatry at Otago University published research in which he concluded “Antidepressant treatment is associated with a rapid and significant reduction in suicidal behaviours. The rate of emergent suicidal behaviour was low and the risk/benefit ratio for antidepressants appears to favour their use.”
10 years before he had stated that “the development of improved [psychiatric] treatment and management strategies for young people with psychiatric morbidity may be a very effective approach to reducing youthful suicidal behaviors.
Last week, he presented at two conferences to mark world suicide prevention day and, after having conducted a thorough review of the current evidence stated that psychiatry’s medical model of suicide prevention was “a 20- or 30-year experiment which hasn’t worked.”
It takes courage and integrity to make changes to your beliefs and approach when a review of current evidence points to the need to take a different tack and to make your changed views public. Medical professionals who do this are often accused of attacking their own profession, criticizing or undermining their colleagues and being fickle. In reality they are staying true to the values of reflective practice, patient-centred care and evidence-based medicine. The reality of challenging the medical approach to suicide prevention from within the profession of psychiatry is that those who stick their heads above the parapet, following the pioneering steps of heroic people like Professor David Healy, often face many negative consequences. In a small country like New Zealand, Professor Mulder exposes himself to ostracism from his colleagues.
In his conference presentations, he stated that a medical/psychiatric paradigm has dominated approaches to suicide since WWII, targeting high risk groups with psychological/pharmacological interventions and that this paradigm has largely failed to influence suicide rates. In Professor Mulder’s view “New approaches are required – possibly public health, sociological, community or combinations in addition to, or instead of, medical approaches.”
Given the Director of Mental Health reports the rate of suicide by those who have used mental health services within the previous year is 18 times higher than that of those who have not used services in the year prior to their death, CASPER would argue that rather than failing to influence suicide rates, the evidence is that mental health treatment has in likelihood increased them. In fact, 137.6 suicides per 100,000 for those who have used mental health services in the last 12 months compared to 7.6 per 100,000 for those who have not had recent mental health involvement.
Professor Mulder presented the evidence that traditional psychiatric models of suicide prediction and prevention are not working, psychiatrists are acting in their own rather than their patients’ best interests, that the risks of antidepressants outweigh any benefits and that very few psychiatric interventions have been shown to reduce the incidence of suicide.”
In relation to suicide risk assessment, Professor Mulder told the conference participants that psychiatrists are very poor at predicting suicide risk. He described current suicide risk assessment as “an organisational attempt to tame clinician anxiety rather than improve patient care” and admitted that “patients may be detained to reduce staff anxiety rather than for their treatment needs.” with patients seen as a source of threat to a clinicians professional standing. Professor Mulder confessed he had engaged in this behavior himself.
His recommendations to psychiatrists were to
– Be humble.
– Acknowledge the uncertainty of our knowledge base.
– Re-educate the community that we are poor at predicting rare events like suicide.
– Educate health workers about the risks of risk assessment.
– Accept that mental illness models are neither necessary nor sufficient to explain suicide
In addition to being someone willing to honestly assess the lack of efficacy of the psychiatric approach to suicide prevention and courageous enough to tell it like it is, Professor Mulder is the Chair of CASPER’s Scientific Advisory Committee. For those not familiar with CASPER, it is the charity I started following my son’s antidepressant induced suicide and an organization that rejects the medical model of suicide in favour of a sociological model. The advisory committee chaired by Professor Mulder provides independent advice to CASPER supporting us with expert advice on research associated with suicide prevention and on our own research programme.
Professor Mulder’s committee will take the same approach with CASPER as it has with mental health professionals providing an honest evaluation of the evidence that underpins our programmes and helping us conduct rigorous evaluations of our interventions. It is critically important to us that our approaches and actions are rigorously challenged and underpinned by the very best evidence, that we prevent deaths; not just count education sessions.
We thank Professor Mulder for his courage and integrity and for taking on the role of leading a team of professionals in providing expert advice to CASPER. We look forward to having our beliefs and approaches challenged and to being kept honest and effective so that we provide the best possible interventions, information and advice.
Mulder RT, Joyce PR, Frampton CMA, Luty SE. Antidepressant treatment is associated with a reduction in suicidal ideation and suicide attempts Acta Psychiatr Scand 2008: 118: 116–122
ANNETTE L. BEAUTRAIS, PETER R. JOYCE, ROGER T. MULDER, Psychiatric Contacts Among Youths Aged 13 Through 24 Years Who Have Made Serious Suicide Attempts, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 37, Issue 5, May 1998, Pages 504-510