A Hopelessly Flawed Seminar in “The Lancet” About Suicide

9
3480

On 14 May 2022, The Lancet published the seminar, “Suicide and self-harm.” Lancet seminars are “Disease-oriented clinically focused overviews for the generalist, covering epidemiology, pathophysiology, diagnosis, management, and prevention. These clinical overviews are always externally peer reviewed.”

The seminar was very long, 14 printed pages, with 142 references. Many people consider Lancet a highly prestigious journal and, whatever you think of the journal, it is highly influential. It is therefore important that what gets published is honest, trustworthy and based on the best available evidence. This was not the case.

Lancet has immunized itself against criticism. A journal that, in its instructions to authors, writes that “Letters for publication in the print journal must reach us within 2 weeks of publication of the original item and should be no longer than 250 words” does not invite criticism and a sound scientific debate. Many people will not know that an article has been published before it is too late to criticize it, and 250 words are much too little if an article is flawed in several ways. If journals were really interested in serving the progress of science, there should be no time limit for letters that point out fatal flaws in an article.

The Lancet seminar is one of the most misleading articles about suicide I have ever seen, but I shall only mention a few issues. The authors write:

“Research has also identified associations between suicidal behaviour and dysregulation of the hypothalamic–pituitary–adrenal axis and serotonergic neural transmission.26,27

The authors try to resurrect the stone dead myth about a chemical imbalance in the brain being the cause of psychiatric disorders, which prominent psychiatrists have called an “urban legend.”

The two references the authors provide in support of this myth are untrustworthy. The first alludes to epigenetic modification of genes, alterations in key neurotransmitter systems, inflammatory changes, and glial dysfunction in the brain as causal factors.

The second reference is similar. Its authors suggest hypothalamic-pituitary-adrenal (HPA) axis dysfunction, which “in turn can be traced back to genetic predisposition” and “early life stress-related epigenetic mechanisms.”

Please consider this: If a house burns down and we find ashes, it doesn’t mean that it was the ashes that set the house on fire. Similarly, if a lion attacks us, we get terribly frightened and produce stress hormones, but this doesn’t prove that it was the stress hormones that made us scared. It was the lion. No genetic predisposition or “chemical imbalance” is needed for this.

The total failure of the much touted biological psychiatry has been documented numerous times, but the psychiatrist won’t give up. They continue to produce misleading brain scan studies, brain chemistry studies, and genetic studies, and psychiatric textbooks for students of medicine, psychology and psychiatry are full of this. I have read the five most used textbooks in Denmark and will soon publish my own where I discuss what is wrong with the official textbooks in relation to these issues and a lot more. The tentative title is “The truthful textbook of psychiatry.”

Among risk factors for suicide, the seminar authors mention “harmful substance use.” They do not mention depression pills even though they double the risk of suicide, both in children and adults. This is taboo. It is also taboo to mention that other psychiatric drugs, e.g. antiepileptics, which misleadingly are called “mood stabilizers,” double the risk of suicide. And it is taboo to mention that the psychiatric profession itself increases the risk of suicide markedly, much more than what can be explained by its use of harmful drugs.

A Danish register study found that admission to a psychiatric ward increased the suicide risk 44 times, and, surprisingly, the potential biases in the study were conservative, i.e. favoured the null hypothesis of there being no relationship. An accompanying editorial noted that there is little doubt that suicide is related to both stigma and trauma, and that it is entirely plausible that the stigma and trauma inherent in psychiatric treatment – particularly if involuntary – might cause suicide. The editorialists believed that a proportion of people who commit suicide during or after an admission to hospital do so because of conditions inherent in the hospitalisation.

The seminar authors write that “The use of medication to prevent suicide is controversial” and that there is a “possibility of exacerbating suicidal thoughts, particularly in young people.11

This is dishonest. There is a load of meta-analyses, including the one made by the FDA in 2004, that show that depression pills double the risk of suicide in children and adolescents, the age group we want to protect the most against suicide. But FDA, which is much too industry-friendly, downplayed what they found. When FDA employees published their results, they also reported a doubling of the suicide risk but concluded in their abstract: “Use of antidepressant drugs in pediatric patients is associated with a modestly increased risk of suicidality.”

The seminar authors speak about a possibility of exacerbating suicidal thoughts, and only suicidal thoughts, not suicidal behaviour or attempts or suicide, and the FDA employees use the term associated with. All of this is wrong. These drugs not only increase suicidal thoughts, but also suicidal behaviour and suicide attempts. Worst of all, they also increase suicides. We use the term associated with in observational studies where we are uncertain about a cause-effect relationship. We do randomised trials because they can prove cause-effect relationships. And only modestly increased? No. The FDA employees should have concluded that depression pills may cause children to kill themselves. They write that “The overall risk difference for all drugs across all indications was 0.02 (95% CI, 0.01-0.03).” Thus, for every 100 children treated with a depression pill, two become suicidal. This is anything but modest for drugs that do not even have clinically relevant benefits.

The seminar authors do not quote any of the many meta-analyses that have shown that depression pills increase the suicide risk. Not one. Instead, they quote a book (their reference 11) written by the last author of the seminar and by Robert D Goldney who has published a totally unreliable review about depression pills and the risk of suicide. His paper is a classic example of how one should not do a review. He cherry-picked those observational studies that supported his idea that antidepressants protect against suicide.

Goldney cited studies in the Nordic countries that linked antidepressant prescribing with a reduction of suicide, but these studies are totally unreliable. Nordic researchers have shown that

there is no statistical association between the increase in sales of SSRIs and the decline in suicide rates in the Nordic countries. These authors reported that the decline in suicides in Denmark and Sweden pre-dated the introduction of SSRIs by ten years or more!

The Nordic researchers had no conflicts of interest while Goldney had “received honoraria and research grants from a number of pharmaceutical companies.” Of course he had. With such flawed reviews, of which there are numerous, Goldney must be worth far more than his weight in gold for the drug industry.

What Goldney did is what I call the UFO trick. It is very common in science to mislead your readers this way, and it is about not losing power or giving up on your wrong ideas. If you use a fuzzy photo to “prove” you have seen a UFO when a photo taken with a strong telephoto lens has clearly shown that the object is an airplane or a bird, you are a cheat. When randomised trials have documented that depression pills double the suicide risk, we can assign all the observational studies that tell the opposite story to the graveyard of untrustworthy research, if there is any room left there.

The seminar authors write that “treatment of underlying psychiatric conditions through medication can reduce suicidal behaviour.”

The authors give no references to this dishonest information. Which are the miraculous drugs that can reduce suicides? All that I know is that psychiatric drugs increase suicides.

A little later, the authors write: “Evidence from several studies, most of which were observational, suggests that antidepressants might reduce the risk of suicide.91” But suggest and might reduce is not the certainty in the sentence just above: can reduce. They use the UFO trick again and quote a review that reported that meta-analysis had found that “antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered.” These meta-analyses were of observational studies, and all meta-analyses of randomised trials have shown the opposite.

In the next sentence, they write: “However, some research has found an association with increased risk of suicide-related outcomes in young people.”

The is blatantly false. When the FDA looked at all relevant research, not just some research, and indeed the best we have, all the randomised placebo-controlled trials, it was clearly a causal relation and not just an “association”.

In the ensuing sentence, they write: “The evidence base is far from complete, since many randomised trials exclude people at heightened risk of self-harm or suicide.11,91

This is utter nonsense. We have all the data we need to conclude that depression pills double suicides. The authors use the trick philosopher Arthur Schopenhauer in his book, The Art of Always Being Right, calls diversion:

“If you are being worsted, you can make a diversion – that is, you can suddenly begin to talk of something else, as though it had a bearing on the matter in dispute and afforded an argument against your opponent … it is a piece of impudence if it has nothing to do with the case, and is only brought in by way of attacking your opponent.”

The authors claim that “Lithium has been associated with reduced suicide rates in people with bipolar disorder and depression, which might be a specific effect not seen with other drugs designed to stabilise mood.92–94

So, this seems to be the wonder drug that reduces suicides. However, most lithium trials are highly unreliable because of withdrawal effects. Patients were on lithium before they were randomised and some of those who got placebo experienced a cold turkey, which increases the risk of suicide.

A Swedish psychiatrist and I reviewed the placebo-controlled trials and included only those where the doctors had not harmed the patients in the placebo group, i.e. lithium naïve patients. We found 45 eligible studies but only four studies reported any suicides or other deaths. Some suicides and deaths were likely missing. A systematic review of psychiatric drug trials found that only half of the suicides and deaths are being reported. There were only three suicides, all on placebo. So much for the widely touted idea that lithium reduces suicides. We simply do not know.

The latest fad in psychiatry is ketamine. The authors write that “Ketamine has shown promise.” Of course it has. Give the patients hallucinogenic agents so they will forget about their troubles. Ketamine is commonly used as a street drug. Why not LSD, which some psychiatrists are trying to revive?

Ketamine seems to work mainly through stimulation of opioid receptors. My colleagues and I have explained why this drug and its S-enantiomer, esketamine, should not be used.

There is a glimpse of light in the darkness of the seminar. The authors write that “cognitive behavioural therapy and related treatments have the strongest evidence base for reducing suicidal ideation and repeat self-harm compared with treatment as usual.”

This is correct, but the authors quoted a review that included self-harm even though self-harm does not always imply a suicidal intent. My research group therefore did a review where we excluded self-harm studies. We found that psychotherapy halves the risk of a new suicide attempt in people acutely admitted after a suicide attempt. Our systematic review was published in 2017 but was not among the seminar authors’ 142 references even though it sends a very strong message: Do not use pills but psychotherapy if you want to prevent suicide in patients at very high risk of suicide, those who have already tried to kill themselves.

It is disappointing that Lancet publishes highly misleading articles like this seminar but it has happened numerous times before, also in relation to psychiatry. I shall only mention the two recent network meta-analyses by Andrea Cipriani et al., one in children and one in adults.

Cipriani et al. concluded that fluoxetine was significantly better than placebo for depression in children and adolescents and was also better tolerated than duloxetine and imipramine. However, they mostly used published trial reports. When David Healy and I restored the two pivotal fluoxetine trials by analysing the clinical study reports submitted to the FDA, we found that fluoxetine was ineffective and unsafe (Int J Risk Saf Med, in press).

About Cipriani et al.’s second network meta-analysis, I published the article, Rewarding the companies that cheated the most in antidepressant trials, on Mad in America. Later, my research group showed that the outcome data reported in Lancet differed from the clinical study reports in 12 of the 19 trials they examined.

Lancet is not the source to go to if one wants reliable information about depression pills. It is the extended marketing arm of the pharmaceutical industry, just like the New England Journal of Medicine is, also in relation to denying that depression pills cause suicide.

***

Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

9 COMMENTS

  1. Seems like we need to pay a lot more attention to understanding suicides, because there has been such a rise in the number of spree shootings, and first and foremost these are suicides.

    Many in the political realm want to chalk it all up to “Mental Illness”. I don’t agree with that at all.

    Joshua

    • I like you Joshua.

      You are important. A fine free thinker who is in touch with passionate feelings of dismay.

      In my many jobs I once did a stint at radio broadcasting. The man I worked with was a Catholic priest. I recall him chuckling once. I asked him to be generous with his joke. He just said that a fierce old lady was always phoning the radio reception, to ask for his advice. He said she always said the same refrain two or three times in the same chat. She said….

      “Mens pigs!”

      That was it. No embellishment. No explaining. No convincing the audience.

      I have never forgotten her fist clenched, defiant, liberating purity of passion.

  2. The Lancet publication’s authors intentionally misrepresent suicide’s associations because the “mental health” status quo has the blessings of the state to model “mental illness” primarily as constitutional or personal failure (biological illness or “maladaptive” behavior) instead of as a consequence of trauma. The latter would call too much attention to the state’s or the community’s contribution to others’ emotional/cognitive conditions. It’s easier, more profitable, and more personally/professionally gratifying to infantilize the suffering who, of course, ensure the continued value of the clinician. Any who vigorously disagree with the status quo can be conveniently censored as purveyors of misinformation.

    Thanks for the review, Dr. Gøtzsche.

  3. “The total failure of the much touted biological psychiatry has been documented numerous times, but the psychiatrists won’t give up.”

    Thank you for sharing my frustration, Peter.

    “I have read the five most used textbooks in Denmark and will soon publish my own where I discuss what is wrong with the official textbooks in relation to these issues and a lot more. The tentative title is ‘The truthful textbook of psychiatry.'”

    Many thanks to the well researched doctors – and particularly you, Peter – who are publishing the truth about psychiatry. Since the psychiatrists and psychologists assume their “clients” are “w/o work, content, and talent” – prior to even looking at our work – and “irrelevant to reality.” Then they attempt to steal our work – once they finally bother to look at it – since it’s “too truthful.”

    I do so hope you will include in your book, Peter, my research finding that the antidepressants and antipsychotics can create “hallucinations” and “psychosis,” via anticholinergic toxidrome. And that the antipsychotics can create the negative symptoms of “schizophrenia” as well, via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    The only symptom difference between anticholinergic toxidrome poisoning and the theorized “schizophrenia,” is the “patient” will be “hyperactive” instead of “inactive.” But the client will still be made ungodly sleepy by the neuroleptics, which makes it difficult for the psychiatrists to distinguish between anticholinergic toxidrome and their “invalid” DSM disorders.

    If, by any chance, you’d like to include artwork that visually describes psychiatry’s iatrogenic “bipolar epidemic” – as described by Robert Whitaker in his ‘Anatomy of an Epidemic’ – in your textbook. Please let me know, since I have a lot of rather disturbing artwork that visually depicts that modern day, iatrogenic psychiatric epidemic … and, thankfully, my escape from it.

  4. Thanks so much for this, Dr. Gotzsche.

    It’s very frustrating that these drugs continue to be prescribed, though there are some hopeful signs. At the institution of higher learning where I practice, Student Health no longer prescribes junk m eds at nearly the rate they used to– and when they do, it’s at lower doses and with an exit plan, generally a quick one– 90 to 180 days.

    Also, when I send clients back to their psychiatrists insisting that they report side effects that they have reported to me, they seem to be quicker to reduce dosage or discontinue, though the tapers still seem very fast to me.

    I wish that we were drug testing perpetrators of mass shootings for SSRIs. I’m sure they get a tox screen for just about everything else, and occasionally, I think that in some states here in the US, we do test for SSRIs. If anyone is collecting that data, I wish we could have a look at it.

    –Catalyzt

  5. Thanks Peter for a great critique of the Lancet seminar. It is very concerning that these journals are nothing more than extension of the marketing departments. Our doctors rely on these journals and don’t even ask critical questions. The public pays the price.

    As someone who was intimately involved with helping get blackbox suicide warnings on these antidepressants, I can’t believe we are still having these conversations. We must keep our eyes wide open as more and more people are being prescribed these depression pills and suicides rise. They will be blamed on pandemic and “mental illness” and certainly not the pills.

  6. I’d argue that we’re psychotic by nature. What is truth, but belief? It can be affected socially, sure, but realiity is not dependent on council. It can also be experienced independently. That’s the nature of the beast. We’re all lost in this paradoxical echo chamber of infinite realities, where everything is and isn’t a choice at the same time, and there’s nothing that these control craving animals can do to change the binary nature of the reality they simultaneously and independently create at the same time.. Or is there?

    I feel like we as humans naturally gravitate toward what we need.. Missing certain minerals? Experience geophagia.. No motivation? Experience addiction to a dopaminergic agonist. Like coffee, or crack cocaine! Experiencing a macro-level psychotic fracture of God’s mind at the micro level? Experience the creation of the internet, and unending curiosity as an individual in a dimensional fold, amongst endless slight variants of yourself, all living the same, but different lives!

    Until there is a fusion, a coming together of these realities, where we’re all subject to each others experience, I think this “fractured experience” will continue.. I feel that on a soul level…

    Before I was born, an entire 4 weeks had passed since this bun was done, and for some reason, I wouldn’t come out.. Doctors could NOT find a reason for my mom not being able to go in to labor, and try as they did, it could not be induced.. Ultrasounds were showing that I had seemingly pushed myself, with my feet, further upward, as if naturally trying to AVOID being born.. I did this so much in fact, that I had moved my moms organs, and created a pocket in her womb..

    Enter emergency c-section. They had to completely remove my mothers intestines to get me out, and put them back in.. I was dead upon arrival, and completely purple from a lack of oxygen. I was put in an oxygen tent, resuscitation was attempted, and after 11 minutes passed, they gave up.. During paperwork about my death however, my heart started beating, and cries alerted the doctors to my return.. An estimated 13 minutes had passed between dearth on arrival, and return of life.

    The whole ordeal, to me, makes it sound like what I know inside, I knew before being born.. Like I was trying to abort, like I instinctively knew I didn’t want to do this.. But here I am.. By some divine force of hand it seems. Maybe it’s because I know I have some kind of job to do here.. Like the rest of you, I must achieve this goal.. This coming together.. This “return to source.”

    It’s so painful though… The damage I sustained from the birth complications left me with dopaminergic complications, and other issues.. As far as I/we know.. Autism, OCD, Gilles de la Tourettes, ADHD, oppositionally defiant by nature.. Very impulsive, with RLS, and a natural phobia of being restrained or bound, or locked inside a small space, like a closet, or jail cell.. Being buried alive or strapped to a table, most of all (which sucks, because with my issues, and how the system works, being strapped to a table is pretty common. Especially during a crisis, when I am most likely to experience RLS.)

    Remember when I was talking about humans gravitating toward what they need, naturally? As if subconsciously? (Most definitely subconscious.) Well, this happened to me. It was especially apparent when viewed through the lens of the collective understanding of ADHD. I’d seek contexts and experiences that brought on dopaminergic activity.. After my first sip of coffee, I winced at the taste.. But after about 35 seconds or so, I felt that dopaminergic activity start up, and instinctively started chugging that hot, nasty coffee.. It advanced to opioid addiction, and then dependendence later on in life, I feel mostly because treatment with Ritilin was revoked earlier in my life around the age of 12 during the D.A.R.E. campaign, under the pretext tha ADHD usually goes away with adulthood.

    I feel this was an excuse for the doctor to avoid any accusations during that particular flare-up of the “war on drugs” in this war-for-profit era.. This time it was capitalizing on doctors relationships with big pharma.. (ADHD meds are cocaine for kids, they’re over-prescribing because of gift packages to doctors from big pharma for writing scripts etc.)

    All of that of course, lead to my treatment with antispychotics, and of course, due to my disruption of class, due to being taken off of my ADHD meds (which also substantially helped my Tourettes,) which exacerbated my neurological conditions, caused permanent damage, and resulted in tardive akathisia, which THEN almost resulted in suicide after a couple years of it with no explanation from doctors as to why it was happening..

    Thankfully, some impacted wisdom teeth saved my life, and lead to an operation where I was granted a week long prescription for hydrocodone. Naturally, after taking hydrocodone and feeling almost every single hellish or annoying symptom fade away, it was like a sudden serenity…

    Like experiencing silence for the first time in a sea of chaos and noise.. Of course, the doctors didn’t care, refused to write a script after seeing the results, and then went through a laundry list of beta blockers, and any mention of suicide lead to being strapped to a table in a psych ward!

    I was labeled an addict, a dreg of society, a useless eater.. I was nothing but a problem for everyone around me, even when I found a way to silence myself.. The resort to my condition was not “socially acceptable,” and frowned upon, because of the masochistic, christian lens that we refuse to remove from the collective stack, in a medical sense…

    Thankfully, that’s being undone, because we’ve come a bit further on that “return to source.” Some empathy is happening in the medical world.. Anything that doesn’t generate profit is fought heavily, as we’re seeing with the demonization of doctors who spoke up during covid, and strayed from the mainstream narrative, thankfully though, for people in my situation, and many homeless people who’re addicted to illicit street substances, “recovery programs” are embracing replacement therapies, which is the best bandaid I can think of, short of correcting the issue entirely.. Currently I go to a clinic once a week, for week long supplies of methadone (as we’re going through an “opioid epidemic” and it’s the only way to get a prescribed opioid without a bunch of BS, though guidelines are being worked on,) and every month, at the same clinic, I see a psychiatric neurologist who prescribes me adderall, and this is the most stable I’ve ever been. My case is a little different.. Someone experiencing a shortage of dopaminergic activity resulting from a bad societal model and lack of ability or resources to find your niche, treated with a dopaminergic agonist that can lead to physiological dependence, when no geographic or contextual cure is available in the future, is going to help in the long term.. But if you have brain damage, medicating, much like prosthesis to limb loss, is going to be your best answer.. At least until we figure out how to induce growth and reparation of target cells.. And likely, that option will only be available to the priveleged.

    However, it proves the point of this article, and also the article on this site (can’t remember the name) written by a doctor who spoke of his troubles after quitting an SSRI, only to find the complete rejection of the iatrogenic perspective, because the psychiatric mainstream model promotes ignoring the root cause, and prescribing what’s missing because of it, (or finding a workaround to stimulating the neurological transmitters that aren’t firing where they’re wanted.) He equated this with a person experiencning stress hormones from being frightened by a lion, and a doctor diagnosing the issue of stress being experienced to the stress hormones, and not the lion.. Because fixing society is difficult, and requires that we all make a change, instead, we seek to profit on finding a way to rig the machine, so to speak.. Something we’re too damned good at, being tool users.

    Just like the reality of things, I could go on forever, but I will end with this.. The issue is complex, but the nature of things dictates CHANGE. Embrace that, as comforting and scary as it may be, and if you need to, comandeer a paddle.. Everyone has a right to some control over the direction in which they’re going…

    That’s a euphemism for self-medicating..

LEAVE A REPLY