Suicides Are Increasing – And So Are Antidepressant Prescriptions

Martin Plöderl, PhDMichael P. Hengartner, PhD
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Suicide rates decreased steadily from the mid-eighties until the new millennium in the USA and, on average, in Organisation for Economic Cooperation and Development (OECD) countries.1 In Europe, suicide rates decreased until around 2007 in most countries.2 Parallel to this drop of suicides, prescriptions of SSRI’s, the new generations of “antidepressants,” gradually increased. This led to numerous publications arguing that the negative correlations between antidepressant prescription rates and suicide rates was evidence that antidepressants are likely helpful in reducing suicide because they can alleviate symptoms of depression, one of the major risk factor for suicide.

Authors of these papers often had financial or other ties to the pharmaceutical industry (e.g., Ulrich Hegerl, Göran Isacsson, John Mann, Zoltan Rihmer).

In 2004, a kind of shock wave hit mainstream psychiatry when the FDA released the black box warning about prescribing antidepressants to children and youth. Not long after, Robert Gibbons and others published a now widely cited paper, based on data from 2003 to 2005, reporting that the black-box warning led to a reduction in the prescribing of antidepressants which was associated with an increase of suicides among young people.3 However, although the article was published in the high-ranked, peer-reviewed American Journal of Psychiatry, the statistical analysis and the related conclusions by Gibbons were quickly shown to be in error; there simply was no increase of suicides associated with the decrease of antidepressant prescriptions (see Jureidini, 20074 and Stone, 20145; see also Robert Whitaker’s report).

From 2000 onwards, suicide rates in the USA started to rise again (among youth around 2007). In most countries in Europe, suicide rates stopped declining or even increased again starting around 2007. However, antidepressant prescription rates steadily increased from the mid-eighties until today. As a result, the association between increased antidepressant rates and reduced suicide rates has faded with each passing year. Even worse for mainstream psychiatry, if you look at the past 10 years, antidepressant rates are associated with increased suicide rates.

Yet, as this has occurred, there has been, in our opinion, a strange silence. There has been a lack of research updates on the trend of increases in suicide rates as prescriptions of antidepressants have risen. And what about research reports on the long-term outcomes of the FDA black box warnings? Two papers pointed out that suicide rates did not increase as a result of the black box warnings in the United States and in Canada (Rhodes, Skinner, McFaull, & Katz, 20136 and Stone, 2014), but these papers were also “silenced” in psychiatry, since they were much less cited (9 and 36 times, respectively) than the Gibbons et al. paper that was cited 569 times (citation-frequency assessed via Google Scholar on August 12, 2018).

Other attempts to show that the FDA warnings led to increased suicides (Lu et al., 2014,7 cited 115 times) have also been debunked (see comments to the Lu article and Philip Hickey’s blog “Suicidal Behavior After FDA Warnings” here on MIA).

This silence about increasing suicide and antidepressant rates, and the silencing of studies that disproved harmful effects of the FDA warnings, was interrupted by at least two noteworthy incidents that demonstrate some deep-seated form of “evidence-resistance.” First, Robert Gibbons simply kept on claiming that the black box warning led to an increase of suicides (LA Times, Feb. 06/2012). Second, a research group around Zoltan Rihmer published a paper in 2015 about suicide trends and antidepressant prescription rates in Hungary, but only used data up until 2006, excluding the time span afterwards when suicide rates increased again (Otuyelu et al., 20158). This way, they of course could prove that increased antidepressant prescriptions came along with reduced suicide rates. No word about the restricted time frame or the increase of suicides in recent years in the limitation section of the paper. They even claimed that their results were an indirect proof of the harms of the FDA warnings (of course citing the debunked 2007 Gibbons et al. paper). They said that, since there was no related warning in Hungary, antidepressant prescriptions kept on rising in young people whereas suicides kept on falling. Otuyelu also cited another paper that “proved” the harms of the black box warning (Katz et al., 20089), despite opposing evidence available at that time (Rhodes et al., 2013).

All of this is the background to our recent research on this topic. Recently, when we became aware of a newly published paper in the Journal of the American Academy of Child & Adolescent Psychiatry that analyzed trends of suicidality and mental health utilization of young people in the US, we wondered why the authors did not also include the results for prescriptions rates, despite that data being available.10 However, since the data was in the public domain, we were able to investigate the association of the suicide attempt rate with drug prescriptions for mood disorders (most likely antidepressants) among adolescents for the years 2004 to 2016.

Our analysis was rejected for publication by the Journal of the American Academy of Child & Adolescent Psychiatry and by JAMA Psychiatry. We were finally able to publish the paper in Epidemiology and Psychiatric Sciences (Plöderl & Hengartner, 201811).

Unfortunately, variables for years prior to 2004 could not be compared to later years, but with the available data we could still explore changes in the rate of prescriptions and suicide attempt rates following the FDA warning. The data is based on the annual National Survey on Drug Use and Health, a nationally representative survey among the US population. Past year major depression was assessed with a structured interview, and participants were asked if they had taken prescribed medication for their mood problems in the past year. We used this as a proxy for use of antidepressant medication. Prior suicide attempts were also assessed. This suicide attempt variable seemed to be a valid indicator of past year suicide risk, since it correlated high with the yearly suicide rates of the same age group (r = 0.75, p < .05).

Our analysis revealed that the rates of prescriptions, suicide attempts, and suicides decreased in the years following the FDA warning in 2004 but started to rise again in recent years. This is also confirmed by large and statistically significant correlation coefficients. Obviously, this contrasts with the assumption that the FDA warning led to an increase of suicidal behavior. On the contrary, it seems that reduced prescriptions lead to a reduction in suicidal behavior. It also indicates that the FDA warning had no enduring effect, since prescriptions to youth are on the rise again.

The usual interpretation by mainstream psychiatry is that our findings are an artefact: young people attempting suicide are more likely to receive mental health treatment, and this produces the found association. This explanation, however, does not fit with the fact that our findings apply both to adolescents with and without a major depression diagnosis. Persons without major depression are rarely suicidal; therefore, in these youths, the strong correlation between suicide attempts and antidepressant prescriptions is hardly explained by diagnosis alone. Also, antidepressant prescription rates increased before the suicide attempt rates did, as indicated via a statistical technique called changepoint-analysis.

prescriptions and suicide

Given the limitations of our study, it is important to look for replications. Indeed, our findings are similar to that of a study by Gupta, Gersing, Erkanli, & Burt (2016).12 By using patient data from psychiatric settings, Gupta et al. found that antidepressant prescriptions decreased from 79 to 60% from the period before the black box warning (2000-2003) relative to the period afterwards (2004-2009). The relative risk for suicidality decreased substantially by around 60-70% as well.

Of note, the relative risk for homicidality and other violent events was also reduced around 60-70%. These findings are exactly what would be predicted by the outcomes of randomized controlled clinical trials. In these trials, young people using antidepressants had higher rates of both suicidality and aggression, compared to those taking placebo.

With our study results, as with all such correlational data, it must be mentioned that causality cannot be inferred, and there are other strong arguments regarding why such data must be interpreted with caution. However, as stated above, our findings are in line with those from randomized controlled trials, where young people taking antidepressants indeed had higher rates of suicide attempts and other forms of suicidality (Healy, Le Noury, & Jureidini, 2018;13 Sharma et al., 2016;14 Stone et al., 200915). Put together, these data strongly suggest that antidepressants can cause suicides and aggressive behavior.

Disturbingly, our study and others reveal that the black box warning is now ignored in many countries, since antidepressant prescription rates for children and youth are on the rise again (Bachmann et al., 2016;16 Otuyelu et al., 2015). This increase is happening despite increasing certainty that antidepressants are rather ineffective and most likely cause suicidal behavior in young people.

It seems that the current strategy in mainstream psychiatry to deal with the problematic evidence base is to recommend fluoxetine, because it was reported as being the most effective drug with no increase of suicidality (Brent, Gibbons, Wilkinson, & Dubicka, 2018;17 Cipriani et al., 201618). Again, problems with these studies and the excess of suicidal events under fluoxetine in the trials continue to be ignored. As with other reports critical of antidepressant prescriptions, these inconvenient findings are not properly acknowledged. As a result, mainstream psychiatry will continue to claim that antidepressants effectively reduce suicide risk, despite compelling evidence to the contrary.

Show 18 footnotes

  1. Ludwig, J., & Marcotte, D. E. (2005). Anti-depressants, suicide, and drug regulation. J Policy Anal Manage, 24(2), 249–272. https://doi.org/10.1002/pam.20089
  2. Fountoulakis, K. N., Kawohl, W., Theodorakis, P. N., Kerkhof, A. J. F. M., Navickas, A., Höschl, C., … Lopez-Ibor, J. (2014). Relationship of suicide rates to economic variables in Europe: 2000–2011. British Journal of Psychiatry, 205(06), 486–496. https://doi.org/10.1192/bjp.bp.114.147454
  3. Brent, D. A., Gibbons, R. D., Wilkinson, P., & Dubicka, B. (2018). Antidepressants in paediatric depression: do not look back in anger but around in awareness. BJPsych Bulletin, 42(01), 1–4. https://doi.org/10.1192/bjb.2017.2
  4. Jureidini, J. (2007). The black box warning: decreased prescriptions and increased youth suicide? American Journal of Psychiatry, 164(12), 1907–1907.
  5. Stone, M. B. (2014). The FDA Warning on Antidepressants and Suicidality — Why the Controversy? New England Journal of Medicine, 371(18), 1668–1671. https://doi.org/10.1056/NEJMp1411138
  6. Rhodes, A. E., Skinner, R., McFaull, S., & Katz, L. Y. (2013). Canada-Wide Effect of Regulatory Warnings on Antidepressant Prescribing and Suicide Rates in Boys and Girls. The Canadian Journal of Psychiatry, 58(11), 640–645. https://doi.org/10.1177/070674371305801110
  7. Lu, C. Y., Zhang, F., Lakoma, M. D., Madden, J. M., Rusinak, D., Penfold, R. B., … Soumerai, S. B. (2014). Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. BMJ, 348(jun18 24), g3596–g3596. https://doi.org/10.1136/bmj.g3596
  8.  Otuyelu, E., Foldvari, A., Szabo, E., Sipos, V., Edafiogho, P., Szucs, M., … Sandor, J. (2015). Antidepressant drugs and teenage suicide in Hungary: Time trend and seasonality analysis. International Journal of Psychiatry in Clinical Practice, 19(3), 221–225. https://doi.org/10.3109/13651501.2015.1061017
  9. Katz, L. Y., Kozyrskyj, A. L., Prior, H. J., Enns, M. W., Cox, B. J., & Sareen, J. (2008). Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults. Canadian Medical Association Journal, 178(8), 1005–1011. https://doi.org/10.1503/cmaj.071265
  10. Han, B., Compton, W. M., Blanco, C., Colpe, L., Huang, L., & McKeon, R. (2018). National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults. Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 20-27.e2. https://doi.org/10.1016/j.jaac.2017.10.013
  11. Plöderl, M., & Hengartner, M. P. (2018). Antidepressant prescription rates and suicide attempt rates from 2004 to 2016 in a nationally representative sample of adolescents in the USA. Epidemiology and Psychiatric Sciences, 1–3. https://doi.org/10.1017/S2045796018000136
  12. Gupta, S., Gersing, K. R., Erkanli, A., & Burt, T. (2016). Antidepressant Regulatory Warnings, Prescription Patterns, Suicidality and Other Aggressive Behaviors in Major Depressive Disorder and Anxiety Disorders. Psychiatric Quarterly, 87(2), 329–342. https://doi.org/10.1007/s11126-015-9389-8
  13. Healy, D., Le Noury, J., & Jureidini, J. (2018). Paediatric antidepressants: Benefits and risks. International Journal of Risk & Safety in Medicine, 1–7. https://doi.org/10.3233/JRS-180746
  14. Sharma, T., Guski, L. S., Freund, N., & Gøtzsche, P. C. (2016). Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ, i65. https://doi.org/10.1136/bmj.i65
  15. Stone, M. B., Laughren, T., Jones, M. L., Levenson, M., Holland, P. C., Hughes, A., … Rochester, G. (2009). Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ, 339, 1–10.
  16. Bachmann, C. J., Aagaard, L., Burcu, M., Glaeske, G., Kalverdijk, L. J., Petersen, I., … Hoffmann, F. (2016). Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005–2012. European Neuropsychopharmacology, 26(3), 411–419.
  17.  Brent, D. A., Gibbons, R. D., Wilkinson, P., & Dubicka, B. (2018). Antidepressants in paediatric depression: do not look back in anger but around in awareness. BJPsych Bulletin, 42(01), 1–4. https://doi.org/10.1192/bjb.2017.2
  18. Cipriani, A., Zhou, X., Del Giovane, C., Hetrick, S. E., Qin, B., Whittington, C., … Xie, P. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet, 388(10047), 881–890. https://doi.org/10.1016/S0140-6736(16)30385-3

25 COMMENTS

  1. Thank you for this informative article Dr. Ploderl and Dr. Hengartner.

    When it comes to Pharma Psychiatry there is a lot of ignoring research that doesn’t support the popularly accepted theories. This is not the only branch of medicine/science where this occurs, but it may be the worst.

  2. Thank you so much Martin Plöderl & Michael P. Hengartner – this is superb!

    And yet, will it make a scrap of difference? Mainstream Psychiatry’s refusal to accept the years of data on this goes well beyond “evidence-resistance.” To this day, lead psychiatrists use Gibbons et al to justify spreading out-and-out fiction to the media. For instance, in July 2017 Prof Carmine Pariante put out a statement that… “we know very well that every time an alarm reduces the rates of prescription for antidepressants, suicide rates increase, including in adolescent and young adults.”

    Prof Pariante is fully supported and endorsed by the Royal College of Psychiatrists, and he is trusted by journalists because of his expert status and reputable credentials bestowed on him by the Science Media Centre. Last year I pursued a serious official complaint against the SMC about Pariante’s statement. Here’s what happened…
    http://www.auntiepsychiatry.com/red.aspx?ha=smc

    • Dr. Charlatan has written numerous scientific papers in support of the discipline of iridology. He is fully supported by the College of Iridologists where he earned his advanced degree. The journalists trust him because he is an expert in the field of Iridology and has many credentials and awards from the Center for Phrenologists, Iridologists, and Alchemists.

      A little academic incest going on at this mutual admiration center? 😀

      • Prof Pariante is just trying to keep the plates in the air long enough to calm down the current furore and get to his next job.

        The methods he uses could have come from an MBA Marketing course. If the case against you is overwhelming, pick small areas where you can claim a win. (a) So he picks one item out of the depression scale, and although that is riddled with publication bias, claims a win. This one doesn’t seem to fool anyone.
        (b) If the response curve is bell shaped, then at the end of bell must be some people who respond. Apart from the obvious jokes, he ignores the placebo effect. This one has people scratching their heads long enough to move on to the next topic.
        If , on the other hand, as in front of parliament, he is faced with a gullible audience, he goes flat out with “all the studies….working on the core of depression…no doubt about it….”.

          • To be honest, he and others on the SMC will be hoisted on their own petards. For example, the statements they made via the SMC in February 2018 to try and mislead the public simply incriminate them in dishonesty.
            “compelling evidence for efficacy” Glyn Lewis
            “confirms that they are safe and effective” Carmine Pariante
            “puts to bed the idea antidepressants don’t work” Prof Anthony Cleare
            “confirms existing evidence that antidepressants do work” Prof Allan Young
            “much more effective than placebo” Prof David Taylor
            Not one of them would attempt to defend these statements and are probably regretting they made them.
            Just a quick reminder, the effect size for Prosac in the meta-analysis to which they are referring was a clinically invisible 0.24, and all the UK’s first choice antidepressants fell below NICE’s minimum threshold of 0.30. I think they have a case to answer.

          • To Everybody , I’m not certain how to definitely stop Prof Pariante but I think this should get him pissed off . Bear with me . Many people have seen this others have not. In 1975 the great comedian John Belushi did some comedy skits as a samurai warrior in very unusual occupations . His character was based on the performance of the great Japanese actor Toshiro Mifune in Yojimbo . For example do a search John Belushi Samurai delicatessen , and John Belushi Samurai dry cleaners .
            Now with a little imagination any one who is able could create countless comedic skits of Samurai Anti-Psychiatry Shop . Anything ,like various neuro-toxic pills ,snake head staff logos , shock machines , DSM books ,etc associated with psychiatry could be dealt with by the Samurai shop owner as various people bring in their particular request and why , to have a psychiatric object cut into pieces by the Samurai anti-psychiatry shop owner , in very funny comedic skits. These could be lots of short films for YouTube or even a feature length movie . Maybe a real Japanese sword expert with a sense of humour could play the main character or anyone else. Maybe Auntie Psychiatry might also want to cartoon a whole new book with these skits . I do think film , the Skits on YouTube and/or elsewhere might take off and get millions of views. Anyone out there Feel free to use this idea for the purpose to at the very least help take psychiatry’s power away or even better , to help send psychiatry sooner into the dustbin of history. Who knows maybe a place in MIA could also be set aside for these filmed skits where those who wanted to could write and refine them together .

          • Psychiatry is not based on reason. It appeals to people’s emotional needs for security, relief from guilt, chronic misery from life problems, and low self esteem…it DOES help all undiagnosed folks feel good about how “sane” they are. And it makes them feel safe because they can protect society from all the Evil SMI.

            The answer? Ridicule shrinks. Make them into villains, buffoons or both. Online skits and ebook stories. Satirical/troll sites. Shrinks’ credibility is based on discrediting and demonizing others. Discredit and demonize them till they become laughing stocks and no one listens to their lies. Psych lies only have power if you believe in them. Like voodoo curses.

  3. Long ago, in Michigan, a Gertrude Black, MD regularly used mega B1 when treating suicidal ideation on a schedule of a 500mg initial dose, plus 100mg every hour thereafter until the ideation faded (I’d also suspect a long-term maintenance follow up). Naturally, her patients never told their local shrinks (this was back in the days when doctors could go to jail for using vitamins in large doses in their practices).

    • I’m low in magnesium, iron, B12, D3, and other stuff. I don’t know if this caused my depression and anxiety–I was always trying starvation diets as a teen because adults told me no one could ever love a fatty.

      Of course the “meds” sapped my body of nutrients too. Years on neuroleptics have really sapped away my magnesium and other good things. Oddly enough, the psych folks banned vitamins. Those are bad for you. Lol.

      • The psych folks banned you taking vitamins because nutrients are bad for them, not you. They’d have to learn new techniques, new approaches and that their attempted persecution of the late A. Hoffer, et. al. was riddled with ignorance. They’d also have to trust patient reports and become bereft of drug company perks like “conferences” at warm weather resorts during the winter because they didn’t prescribe enough of their “angel’s” drugs.

    • A bunch of rich, powerful “doctors” afraid of becoming obsolete when the truth prevails. And a society of wooses who consider emotional pain not just intolerable but an aberration. Plus the shrinks can prevent mass shootings and suicide with their Psych Magic. They provide the sheep with a sense of security–unfounded though it is.

      Ever read the play An Enemy of the People by Ibsen?

      • i don’t think most people are -permitted- to have the same emotional range as in years, generations past. obey authority at school–or else! suffering is for losers! know your place! who, in this day and age, has time to cry? time to reflect? i mean…i do, which…oddly enough, is one of the “perks” of being a “mental patient” (under very limited circumstances…”play the hand you’re dealt,” basically…).

        its also worth noting that psychiatry has been thoroughly deconstructed, debunked, the works. Mental Health, Inc. is not growing and taking over our schools, our homes, our minds because its “treatments” are effective or even all that tolerable…

        society needs psychiatry, especially in an era in which inequality has grown internationally, the costs of any sort of education that -might- lead to job stability and upward mobility have sky rocketed, and religions have lost their hold over our spirits and souls…which might explain the incredible number of M.Divinity people in secular mental health, inc. and the booming industry that is “Christian counseling.”

        This is…I believe the phrase is “disenchantment of the world,” what happens when modernization saps us of our humanity, one way or another.

        • Yes psychiatry has been thoroughly debunked and discredited…but no one off this site seems to know that. Everyone I talk to believes in the chemical imbalance “metaphor” without any question because they saw it on a drug commercial. And TV wouldn’t lie.

          Googling articles by the American Psychiatric Association is way too HARD man! And you gotta read them too. They use those real big words. Double plus ungood!

          Idiocracy meets Brave New World with a little 1984 thrown in if you get out of line by thinking too much.

  4. Yet another example of why people should no longer trust their medical professionals :

    “Huge numbers still registered at practices have either died or moved away… but GPs receive £151 for each one despite a crackdown pledge”

    http://www.dailymail.co.uk/news/article-6098431/Scandal-3-6million-NHS-ghost-patients.html

    When a patient dies in the UK, the GP medical records should be returned to Primary Care Support England. Would hope people could check here, but I doubt you could trust that either:

    https://pcse.england.nhs.uk/services/gp-records/accessing-medical-records/

  5. I had to go for my three month check up with my GP this week. She’s always trying to get me to take statins and have colonoscopies and get a cardiologist and I always tell her no to all of that. This week she added in something new. Are you depressed and do you want an antidepressant. I just sat there staring at her until she looked up from her computer and actually looked at me. Then I started laughing and said that antidepressants would be the very last thing I’d ever consent to take since they were the very thing that caused all of my problems and got me into the “hospital” in the first place! I told her it would be a cold day in hell before I took those devil’s tic tacks. I think my imagery was lost on her since she’s a Hindu but it made me feel better anyway. She and I have never talked about my “diagnosis” since she’s the third doctor I’ve had since going to the clinic. The first one knew about it but it’s never been mentioned since. But all of a sudden out pops the question, “Are you depressed and do you want antidepressants?” I laughed and told her to never ask me those questions again. Case closed.

    • Beautiful fake science from Stephen Soumerai (Professor of population medicine, Harvard).

      He shows a 40% reduction in youth antidepressants in the 18 months following the first warning, in one US state, Tennessee, in 2003.

      And connects it with an increase in youth suicides in the USA from 2004 to 2016. So, apples and pears, and at different times too. We clearly aren’t supposed to notice that 18 months in one state in 2003/4 is not the same as 12 years for the whole country.

      It gets worse. His graph shows a 25% increase in youth suicides from from 2006 to 2012 in the US. In that period, for the US, antidepressant prescriptions in children and adolescents actually INCREASED by 25% (Christian J. Bachmann, 2016). Professor Soumerai, the increase in youth suicide you cite is correlated with MORE antidepressants, not less.