Critical Psychiatry Textbook, Chapter 8: Depression and Mania (Affective Disorders) (Part Eight)

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Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he continues to detail the ignorance and denial about the increased suicide deaths caused by depression pills. Each Monday, a new section of the book is published, and all chapters are archived here.

The suicide issue in relation to depression pills has been one of the most hotly debated issues in psychiatry. But the debate should stop now. Researchers have again and again demonstrated that depression pills double suicides both in children and adults, and are even supported by foot-dragging drug regulators in this.7

It is very threatening to the psychiatric guild that the most-used drugs in psychiatry increase suicides and violence, and the textbooks reflect that, unfortunately, the organised denial continues. They were highly untrustworthy about the suicide risk, which they consistently downplayed or denied to such an extent that the advice was outright dangerous.

Red and white pills have spilled from a crystal dish along with red liquid

One textbook noted that there is an increased risk of suicidal thoughts and behaviours up to 25 years of age,16:584 which is what the FDA stated in 2004, but many reviews have been published later showing there is no age limit. Two textbooks that referred to this young age group failed to warn that any dose change, including a decrease, increases the suicide risk.16:538,19:215

A third textbook mentioned under harms gastrointestinal symptoms, sweating, headache, insomnia, sedation, weight gain, sexual dysfunction, serotonin syndrome, and inner unrest.17:659 It noted that, in some cases, particularly when treating children and youngsters, akathisia can be seen at the start of treatment, which can be extremely uncomfortable, and that, possibly, the akathisia may even give rise to suicidal thoughts or actions, and it is therefore very important to follow the patients closely at the start of treatment.

There are several errors in this advice. Akathisia is not “particularly” seen in children; it is not “possible” that akathisia can cause suicidality, it is certain; and the patients should not only be followed closely at the start of treatment, but also later, particularly at times of dose changes. In fact, every minute they are on the drug, as suicide can come out of the blue. It is a fake fix.

The level of ignorance and denial about one of the most important issues in psychiatry is astonishing and deadly. One textbook mentioned that there is considerable debate about the suicide risk, and that suicide awareness programmes in Sweden and Germany have educated doctors, increased the use of depression pills, and decreased suicides.16:538

This is the UFO trick at its worst. The best evidence we have shows that the pills double suicides, but the psychiatrists used flawed evidence based on before-after studies with no control group that tells them what they want to hear.

One textbook noted that randomised trials have shown that depression pills tend to increase the suicide risk, especially in young age groups, in connection with the start of treatment.18:132

Yet again: It is not a tendency, it is a fact, and it is not only at the start of treatment.

Later, this book claimed that it is highly disputed if SSRIs can increase suicidal thoughts in the beginning of the treatment even though it acknowledged that large meta-analyses of randomised trials “suggest” that suicidal thoughts and acts can occur.18:238 All the authors of this book are psychiatrists. They dispute unequivocal facts to protect their guild interests, and to say “suggest” is dishonest. When placebo-controlled trials have proved something, against all odds as no one is interested in finding out that the pills increase suicides, it is not a suggestion, it is a fact. Moreover, it is not only at the start of treatment; it can occur at any time (see the FDA’s warning above).7,371

This textbook explained that psychomotor inhibition often subsides before the mood rises, which gives the necessary energy to carry out any suicidal ideation.18:132 This was also stated in another book, which described an increased suicide risk only at the start of treatment.19:294 It has never been documented that the pills increase the suicide risk because they remove any psychomotor inhibition. This is part of the psychiatric folklore and a smart way of turning a drug harm into something that looks positive: You see, it is because the drugs are so good, isn’t it?

A third textbook was also dangerously wrong. It mentioned that untreated depression can be harmful and cause suicidality, and recommended SSRIs.17:668 In a 20-page chapter about preventing suicides, a psychiatrist and a psychologist claimed that SSRIs seem to reduce the extent of suicidal thoughts.17:811 They did not provide any references to this blatantly false statement, and in the next sentence, they contradicted themselves by adding that it has not been shown that depression pills or “mood stabilising” medication have an effect on the extent of suicidal behaviour or suicide.

It is a false dichotomy to distinguish between suicidal thoughts or behaviour and suicide. But the nonsense abounds in the literature because the drug industry and the psychiatrists have an interest in ignoring the suicides the pills cause.

Lundbeck’s research director, Anders Gersel Pedersen, once argued, in reply to my criticism of Lundbeck,386 that it has never been shown that there is a clear relationship between suicidal behaviour, suicide attempts, and suicide.7:95,387 But a suicide starts with a thought about suicide, which leads to preparations for suicide, a suicide attempt, and suicide. Evidently, the risk factors for serious suicide attempts are very similar to those for suicide,388,389 and the placebo-controlled trials have shown an increase in suicidal thoughts, suicidal behaviour, and suicides.7,381-385 That not all meta-analyses have shown a significant increase in suicides is only because the drug industry has hidden them. We should not reward the industry for committing fraud that is lethal for our patients, but this is what mainstream psychiatry has done for decades.

It is wrong when the “suicide experts” claimed in this textbook that an effect has not been demonstrated of depression pills or mood stabilising drugs on suicidal behaviour or suicide.17:811 It is surely an effect, albeit a harmful one, that both depression pills7,381-385 and antiepileptics390 double the risk of suicide.

One textbook noted that the serotonin metabolite 5-hydroxyindoleacetic acid is decreased in people who have had several suicide attempts or who died by violent methods.16:537 If this were correct, we would expect SSRIs to decrease the suicide risk, as they increase serotonin, but they do the opposite. The biochemical pseudoexplanations for psychiatric phenomena do not add up.

Leading psychiatrists don’t abandon their wrong and dangerous ideas. Leading professors of psychiatry and spokespersons for general practitioners still claim that depression pills protect even children and adolescents against suicide,7,159 and websites are also misleading. Our 2018 review showed that 25 (64%) of 39 popular websites from 10 countries stated that depression pills may cause suicidal ideation, but 23 (92%) of them contained incorrect and sometimes dangerous information.90 Only two (5%) websites noted that the suicide risk is increased in people of all ages.

A textbook noted that, in most Western countries, the suicide rate dropped markedly while the consumption of depression pills increased.18:131 This is one of psychiatry’s most horrible UFO tricks. There is a wealth of such studies; they are all of poor quality; and some are fraudulent. I discuss these studies over six pages in another book,7:96 which I shall briefly summarise here.

In a 2011 radio programme, Ulf Wiinberg, the CEO of Lundbeck, which sells several depression pills, claimed that SSRIs reduce suicides in children and adolescents. When the stunned reporter asked him why the package inserts warned against suicide attempts, also for Lundbeck’s drugs, he replied that he expected they would be changed by the authorities!

The radio interview took place while Lundbeck’s US partner, Forest Laboratories, was negotiating compensation with 54 families whose children had committed or attempted suicide under the influence of Lundbeck’s depression pills.

Already back then, only four years into my explorations in psychiatry, I had seen and heard an overwhelming amount of nonsense about psychiatric drugs, but this was so much over the top that I published an open letter to Lundbeck about the radio programme on a science website.386 The next day, Anders Gersel Pedersen responded,387 citing several studies that were so deeply flawed that I failed to understand how a research director could misinform to this degree.

An example was a 2007 paper by Robert Gibbons who reported an increase in suicide rates after the FDA and EMA in 2003 and 2004 had warned against using depression pills in young people.391 Critics quickly pointed out the dishonest science Gibbons had employed to make his case.392 He didn’t use the same calendar years for SSRI prescriptions as for suicides, and the fact was that the number of suicides for people below 24 years of age declined when the prescribing of SSRIs to youth decreased.

This is not the sort of error a scientist accidentally makes. It seems to be a deliberate attempt to tell a story that fits a preconceived end.392 In the Netherlands, which Pedersen also referred to, the academics were incensed with Gibbons and his statistical antics (Gibbons is a statistician, which is hard to believe), and they noted that the increase in suicides in the Netherlands was so small that it wasn’t statistically significant. They found Gibbons’ conclusions astonishing and misleading and stated that he and his co-authors had been reckless to publish such claims.392

Gibbons has published at least ten papers telling stories that are false.7:96 Sweden has its own version of Gibbons, Göran Isacsson, who has also published study after study that are entirely misleading.7:97 Like Gibbons, he has concluded the opposite of what his data show.

So-called experts in suicide prevention aren’t any better than Gibbons and Isacsson. They are highly biased towards drug use and cherry-pick the studies they quote despite calling their reviews systematic.393 Suicide prevention strategies always seem to incorporate the use of depression pills,393 even though they increase suicides, which also happened in a suicide prevention programme for US war veterans.394

One textbook listed 10 risk factors for suicide and commented on suicides during and after hospitalisation,18:131 but it did not mention the specialty’s own contribution to the suicide risk, which is increased 44 times for patients admitted to a psychiatric ward.247

Another book was contradictory and lacked important information.16:538 It claimed that “only a few” randomised trials had been performed of psychosocial and psychotherapeutic interventions to prevent suicide and suicide attempts in risk groups. But on the next page, it stated that “several” trials had been performed in patients with a previous suicide attempt to find treatments that reduce the risk, and that several of these studies had shown an effect of outreach treatment, possibly with home visits, and of cognitive behavioural therapy and dialectical behaviour therapy, specifically for borderline patients.

The authors referred to only one study in their literature list,395 which was not a randomised trial, but an observational study. Perhaps it played a role for the citation that 10 of the 12 authors of this study were Danish. It showed that patients who, after deliberate self-harm, received a psychosocial intervention at suicide prevention clinics in Denmark had a significantly lower risk of self-harm, suicide, and death by any cause than patients who did not receive such an intervention. The researchers had used a propensity score and 31 matching factors, but no amount of statistical adjustment can correct for the fact that patients who decline to get the intervention will have a poorer prognosis than other patients (confounding by indication).

It is unscientific to write that “several” studies have shown this and that and to quote a flawed study instead of randomised trials. We do systematic reviews of randomised trials to find out what we may conclude when we include all relevant studies in our assessments.

Self-harm does not always imply a suicidal intent. My research group therefore did a review of suicidality where we focused on cognitive behavioural therapy because most trials had used this method. We found that psychotherapy halves the risk of a new suicide attempt in people acutely admitted after a suicide attempt.272

This is a very important result, and it is not limited to cognitive behavioral therapy. Emotion regulation psychotherapy and dialectical behaviour therapy are also effective for people who harm themselves.396

We have the unfortunate situation that mainstream psychiatry recommends depression pills, even for children, to prevent suicide even though they double the suicide risk whereas we do not hear much about using psychotherapy to prevent suicide, even though it halves the suicide risk.

This is a sign of a specialty in ruins. It is also bizarre that when a textbook mentioned that the suicide risk is increased at the start of treatment with depression pills, it added that this is also seen at the start of psychotherapy.18:132 It looks like an excuse for using harmful pills to postulate that other interventions also increase the suicide risk. There was no reference, but the fact is clear: Psychotherapy decreases the risk of suicide.272

Since 10% of patients with affective disorders commit suicide, and their life length is reduced by about 10 years,17:373 it is very important that all psychiatrists become thoroughly educated in psychotherapy. This is currently not the case. Many psychiatrists don’t even know how to practice psychotherapy and others have had a short course. I have been taught obstetrics at medical school—a short course—but have never felt qualified to deliver a baby.

In 2015, I arranged an international meeting about psychiatry in Copenhagen in relation to the launch of my first book about psychiatry. Five women who had lost a son, a daughter, or a husband to drug induced suicide, when there was no good reason to prescribe a depression pill, decided to come on their own account and tell their story.7:79 My program was full, but I made room for them. This was the most moving part of the whole day. There was stunning silence while they recounted their stories, which can be seen on YouTube.397

Something can be done. The usage of depression pills in children and adolescents increased by 59% in Denmark from 2006 to 2010, but in the following six years, I constantly made clinicians and the general public in Denmark aware of the suicide risk of depression pills. During this period, the usage dropped by 41% while it increased by 40% in Norway and 82% in Sweden.8:84,398

In 2018-19, I alerted the Boards of Health in the Nordic countries, New Zealand, Australia and the UK to the fact that two simple interventions, a reminder from the Danish Board of Health to family doctors and my constant warnings on radio and TV, and in articles, books and lectures, had caused usage of depression pills to children to be almost halved in Denmark, from 2010 to 2016, whereas it increased in other Nordic countries.399

I noted that this was a serious matter and explained that “The consequence of the collective, professional denial is that both children and adults commit suicide because of the pills they take in the false belief that they will help them.”7:149

I urged the boards to act but got no replies, late replies, or meaningless replies that looked like bullshit to me, which philosopher Harry Frankfurt considers short of lying.400 I received a report from the Swedish Drug Agency that contradicted the package insert for fluoxetine in Sweden, and some of the so-called experts the agency had used had financial ties to manufacturers of depression pills, which they had not declared.

In 2020, I wrote to the boards again, this time attaching a paper I had published about their inaction.399 The Icelandic Directorate of Health replied that they had asked the psychiatrists in charge of child and adolescent psychiatry to give their opinion nine months earlier, but that they had not responded despite a reminder. Their excuse was that they did not have time. I replied: “They should be ashamed of themselves. Children kill themselves because of the pills and they don’t have the time to bother about it. What kind of people are they? Why did they ever become psychiatrists? What a tragedy for the children they are supposed to help.”

I informed Robert Whitaker about this. He replied that the inaction by the medical profession regarding the prescribing of psychiatric drugs to children and adolescents is a form of child abuse and neglect, and institutional betrayal.

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To see the list of all references cited, click here.

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4 COMMENTS

  1. This chapter has left me feeling less certain compared to the others because the criticism against suicide studies didn’t directly address the global statistics, which show a significant decline in suicide rates over the past four decades in most countries, despite a substantial increase in antidepressant usage. The exceptions to this trend are primarily the USA and South Korea.

    To support my point, I would like to refer you to long-term suicide rate data for Northern Countries alongside sales of antidepressants. You can find the data at the following link:
    https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-10-62

    Upon examining this data, it doesn’t appear that there is a correlation between antidepressant prescriptions and suicides in either direction. Suicides had already become less frequent before antidepressants were introduced, and their rate of decline remained relatively unchanged for a while as prescriptions increased. What I would have liked to read is an explanation of why we should be cautious about drawing direct conclusions from this data, as it is one of the few psychiatric datasets I find convincing.

    Given the conflicting data, I find myself extremely uncertain and unsure of what to believe. When looking back approximately 40 years since the introduction of antidepressants to the market, numerous changes have occurred. There has been a significant increase in the availability of entertainment, including computers, mobile phones, the internet, and dating apps. Additionally, poverty has decreased significantly.

    Technological advancements and reduced poverty are likely contributing factors to increased comfort and reduced suicide rates, which influence the data on antidepressants. However, does this mean that even if antidepressants contribute to a doubling of suicides, they have been a minor factor compared to other causes such as quality of life and social relationships? Furthermore, if other factors have contributed to the decrease in suicide rates, did antidepressants remain a minor factor?

    If antidepressants were causing a significant number of suicides, one would expect the increasing number of antidepressant prescriptions to be reflected in suicide statistics. This correlation, however, is not observed. Additionally, I have not come across any data indicating the percentage of suicides among individuals diagnosed with depression out of all suicides in the population. If this percentage is small, then the global statistics would not provide much insight, as suicides resulting from antidepressants would not be reflected in them.

    There is also the possibility that the decline in suicides would have continued for a longer period but has ended prematurely due to the increasing usage of antidepressants. Nevertheless, I lack the ability to determine the truth, and in the absence of a rational explanation for the aforementioned issues, I find myself in a state of doubt and uncertainty.

    Could anyone assist me in interpreting this perplexing mystery with certainty?

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