Psychiatric Journals’ Pro-Pharma Publication Bias Hides Suicide Risk of Antidepressants

Selective publication bias in top psychiatry journals was not explained by the quality of the studies, but by financial ties to pharma.

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A new study finds that top psychiatry journals are more likely to publish antidepressant studies with favorable results—and that these studies are more likely to include lead authors with financial ties to the pharmaceutical industry. Studies finding results unfavorable to industry are relegated to non-psychiatric journals and, occasionally, low-ranked psychiatric journals.

“Studies reporting favorable results were more frequently published in psychiatric than non-psychiatric journals and were more often conducted by lead authors with financial conflicts of interest (fCOI). Within psychiatric journals, lead-authors with fCOI published in journals with higher impact factor and ranking,” the researchers write.

The study was conducted by Martin Plöderl at Paracelsus Medical University in Salzburg, Austria, and Simone Amendola and Michael P. Hengartner at the Zurich University of Applied Sciences, Switzerland. In keeping with their findings, the study was published in a prestigious—but non-psychiatric—journal, the Journal of Clinical Epidemiology.

Pile of pills in blister packs backgroundCritics sometimes argue that study quality is the main factor in publication—that it just so happens that all the favorable studies conducted by pharma are of good quality, while all the unfavorable studies by independent researchers are of poor quality.

However, the researchers found that study quality did not explain the selective publication they identified. Instead, it appears that top psychiatric journals tend to publish researchers who are funded by pharma, and thus find favorable results, whether the study is of good quality or not—and good quality studies by independent researchers, who are more likely to find unfavorable results, end up in the bin.

Hengartner sums it up succinctly on X:

“Studies of authors with fCOI were NOT of higher quality than studies of industry-independent lead-authors.”

The researchers warn that this creates a false image of the safety and efficacy of antidepressant drugs. If industry-funded studies, which find favorable results for antidepressants, are published in the top psychiatric journals, while studies of the same quality that are independent but find unfavorable outcomes are shunted into non-psychiatric and low-ranking journals, then the evidence base in the top journals of the specialty is biased and misleading.

Positive studies in top journals in the specialty are more likely to receive media coverage and be taken seriously by journalists, academics, and psychiatrists themselves. Thus, beginning with a biased set of studies creates an exponentially expanding bubble of misleading information.

In this particular study, Plöderl, Amendola, and Hengartner focused on observational studies of the link between antidepressants and suicide. Because death by suicide is a rare event, it is difficult to study in small, randomized controlled trials (RCTs), so observational studies—which follow larger groups of people over time—are our main source of information about this outcome.

Thus, in this context, studies that were considered “favorable” to industry were those that found no link between antidepressants and suicide, while “unfavorable” studies were those that did find such a link. (There were no studies that found antidepressants actually reduced suicide.)

The researchers identified 27 studies that met these criteria published between 1990 and 2020.

Studies that were published in psychiatric journals (typically by researchers with financial ties to pharma) found, on average, no link between antidepressants and suicide. Studies that were published in non-psychiatric journals (typically by independent researchers) found, on average, that antidepressants increased suicide. This was true for both death by suicide and suicide attempts:

“For suicides, the meta-analytic results of the 17 study results published in psychiatric journals indicated no significantly increased risk for patients treated with antidepressants (RE=1.20, 95%-CI=0.92 to 1.58) (Table 2). In contrast, the 10 study results published in non-psychiatric journals reported a significantly increased suicide risk (RE=1.83, 95%-CI=1.25 to 2.70), test for subgroup difference: p=0.05. Similar findings were found for suicide attempts as outcome and for suicides and suicide attempts combined, and subgroup differences were statistically significant (both p<0.01).”

Yet the quality of the studies in both psychiatric and non-psychiatric journals was about the same, and when the researchers accounted for quality in their analysis, it actually increased the selective publication effect they found rather than mitigating it:

“Mean study quality was almost identical for studies published in psychiatric and non-psychiatric journals (M=7.47, SD=1.62 vs. M=7.70, SD=0.95, t=0.41, df=25, p=0.69) and controlling for study quality in a meta-regression model provided similar or even stronger evidence for lower risk estimates in psychiatric journals compared to non-psychiatric journals (Table 3).”

The results for journal prestige were less powerful—higher-ranked journals were more likely to publish favorable studies, but once study quality was included in the analysis, this effect was no longer significant. However, higher-ranked journals were also more likely to publish researchers with financial ties to pharma—and this remained significant after adjusting for study quality.

Antidepressant drugs have been consistently linked to increased suicide attempts and deaths. Studies have repeatedly shown that antidepressants increase suicide risk, particularly for children and adolescents, with some studies finding more than doubling the risk of suicide and at least one analysis finding a sixfold increase.

Studies have also found that antidepressant drugs worsen outcomes in the long term, even after controlling for the baseline level of depression severity.

Indeed, Plöderl, Amendola, and Hengartner were unable to find even a single study that supported the idea that antidepressants reduce suicide, with the “favorable” studies in their research being those that found the drugs simply don’t increase suicide. Yet, as they write, antidepressants are often given to those with severe depression and those at the highest risk for suicide, with the reasoning that the drugs will somehow reduce this risk—despite the lack of evidence for any such effect.

“Antidepressant treatment is often considered important in the prevention of suicide, especially in adults with depression, even though the best evidence from meta-analyses of RCTs and observational studies indicates that antidepressant use has no clear effect on suicidal behavior or that it may even increase suicide risk,” they write.

They add that in this context, antidepressant use is based on “unsubstantiated claims” of suicide reduction, despite the possibility that the drugs actually increase it, making the use of these drugs a public health issue that needs to be addressed:

“That antidepressant use may increase suicide risk thus potentially poses a serious public health issue given the widespread prescription of these drugs and unsubstantiated claims to the contrary within academic psychiatry.”

Plöderl, Amendola, and Hengartner conclude that the research base from psychiatric journals is biased, with selective publication of favorable results by researchers with financial ties to pharma, which has nothing to do with study quality. They write that researchers and clinicians need to read studies about antidepressants and suicide risk in non-psychiatric journals to obtain an unbiased view of the evidence.

Ultimately, Plöderl, Amendola, and Hengartner write that independent researchers conclude that the drugs increase suicide risk. Psychiatry’s denial of this fact through selective publication of favorable industry-sponsored studies has led to the current public health crisis of increased suicide deaths due to antidepressant use.

 

 

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Plöderl, M., Amendola, S., Hengartner, M. P. (2023). Observational studies of antidepressant use and suicide risk are selectively published in psychiatric journals. Journal of Clinical Epidemiology. Published online August 04, 2023. DOI:https://doi.org/10.1016/j.jclinepi.2023.07.015 (Link)

14 COMMENTS

  1. If you’re going to use antidepressants in some kind of therapy, you always want to see if your patients have dysperceptions, which can lead them to lose their marbles when exposed to such drugs without taking precautionary measures to prevent these related disasters.

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    • I don’t think there is a meta-analysis that shows that any form of dysperception perception/meassurement reduced suicides in populations starting antidepressants.

      There is one among minors, AFIR, but that was I think the third analysis of the “same” studies and the efficacy of psychotherapy in reducing suicide was not that great, when compared to not starting antidepressants.

      Then there is the Swiss experience that antidepressants make things worse, w/wo psychotherapy. And in that/those clinic/s they try to avoid them and use psychotherapy only.

      And that’s kind of the point of this article? That the biases contribute to misperceptions, and probably mitigations of risks?.

      Sounds like precautionary, but it also sounds like false sense of security, particularly because they do cause impulsivity. And from little I get it’s pharmacodynamics are erratic in individuals, and between them.

      And there is no tool, clinical, laboratory or radiological that can predict more than 5% and some point of percent of those who actually commit suicide. And that probably was published with a positive publication bias, which, well, can be reasonable expected given the results of this paper, and at least the recent tribulations of Peter Gotzche.

      Recently in Mexico, the oficial stats body published that 10% of the population thinks of suicide OFTEN, and the rate of suicide in Mexico is around 7 in 100,000. So the positive predictive value of that thought, assuming those who die by suicide have it OFTEN, which is not a GIVEN, would be, well, less than 1 in a 1,000, closer to 7 in 10,000. So clinically useless, and using it counterproductive, noxious, damaging, harmfull. And against science…

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  2. That question has caused me a lot of uncertainty. Mainly for global suicide curve mostly lowering a lot at the same time as antidepressants came to market.

    Therefore, I am extremely thankful for this kind of studies that will help me to get a clearer picture. Some co-occurrences in statistics will easily result in wrong conclusion.

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  3. One question: It has become evident that many users of antidepression drugs like them. Is it because they bear similarity to illegal stimulants giving a pleasant feeling?

    Similar phenomenom seems to be with all other psychiatric drugs when the users defend them passionately calling them life saving.

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    • “It has become evident that many users of antidepression drugs like them. Is it because they bear similarity to illegal stimulants giving a pleasant feeling?”

      Yes, that’s precisely what happens. But saying “prescription” sounds better than “fix”.

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      • I wasn’t looking for a fix, in fact I hated taking any medications and didn’t do illegal drugs. I was prescribed Prozac over 30 years ago and before the internet for headaches and pain which didn’t make sense to me at the time and put off taking it for several months because I hate taking medications. When I started taking it my headaches and pain stopped and I felt so much better. I made several attempts to stop Prozac but each time it would make me extremely ill. That’s when my doctor told me I had a chemical imbalance and why I needed to take Prozac for life just like someone who takes medication for diabetes and high blood pressure. I trusted my doctor and by no means looking for what you call a fix.

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        • So, it would be fair to sum up your narrative, respectfully, that you had an apparently transitory condition, you got medication, tried to quit the medication after improvement, received a permanent condition diagnosis NOT described as drug related. And now you think this new permanent condition was drug related?.

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  4. So as a proposal while antidepressants are used way way less, if at all, it would be reasonable and productive por PLOS/Pubmed/NLM to have a specific “journal” devoted to, aaarggh… psychiatry…

    Sounds like a compromse, an ugly one.

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  5. A past friend of mine who works at a drug trial company once told me, if a pharmaceutical company doesn’t like the results of a drug trial they will use a different drug trial company until they get the results their looking for to submit to the FDA. The FDA only looks at the current drug trial, none of the previous drug trials are reviewed.

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    • I think pharma companies are required to submit all trails done on a particular drug for approval. Positive, negative or otherwise.

      The thing IIRC is that the FDA only requires 2 positives trials in most cases to approve a drug “regularly”, and the rest of the boxes are not available outside the FDA, sometimes not even inside. They just “sit” there gathering dust, but they are there, all of the trials.

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  6. Growing up I remember flipping through the assortment of psychiatric journals that were automatically sent to our home. Most contained seductive ads for psychiatric “medication”. Now all I do is turn on the tv — which tells me everything I need to know about “psychiatry”….

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