The package inserts for antidepressants warn that the drugs increase the risk of suicide. For fluoxetine, the Danish package insert says that suicidal thoughts “may increase when you start taking antidepressants because the medication takes a while to work, often around 14 days, but sometimes longer;” and that “clinical studies have shown that there was an increased risk of suicidal behaviour in adults under the age of 25 with psychiatric disorders.”
This information is not entirely accurate. The effect of the medicines does not start after a given number of days but comes very gradually. Even after six weeks, which is the trial duration in most trials, the difference in depression symptoms between active substance and placebo is so small that it is less than what psychiatrists consider clinically relevant. Therefore, many so-called critical psychiatrists believe the medication does not actually have any beneficial effect on depression.
It is misleading to say that suicidal thoughts may increase at the start of treatment. They can come at any time, especially at times of dose changes, either increases or decreases, which the US Food and Drug Administration (FDA), but unfortunately not the Danish Medicines Agency, therefore warns about.
It is also wrong to give the impression that the increased risk of suicide stops when you turn 25. When the FDA analysed all the trials in 2006, there was a curve in their report that showed that the suicide risk increased right up to the age of 40.
The placebo-controlled trials show that the suicide risk of depression medication is doubled in children and young people. This has been known for 17 years. In 2019, a new analysis came out that included what happened after the patients had stopped their participation in the trial. It turned out that the medication, also in adults, not only doubles the risk of suicide, but also completed suicides. The analysis reflects reality, because in clinical practice you also stop taking the medication at some point.
Thus, we have solid knowledge—from the most reliable research that exists, the placebo-controlled trials—that depression drugs double the risk of suicide and completed suicides, and that there is no age limit.
However, the official narrative all over the world is the exact opposite. The storyline is that depression drugs protect against suicide.
Recently, one of my colleagues did a Google search on “suicide and antidepressants” (in Danish), and one of the top entries was from Psychiatry in the Capital Region claiming that antidepressants do not increase the risk of suicide or violence.
I repeated the search on 25 September to find out to which extent the public is being misinformed. It turned out to be very massive and systematic. I describe here the top 10 entries.
At the very top was a report from the Centre for Suicide Research. The researchers found that antidepressants increase the risk of repeated suicide attempts by 50%, but they then adjusted their analyses for a wide range of factors such as having children under 15, age, sex, occupation, psychiatric contact and use of various psychiatric drugs. After this, they concluded: “This study shows that the use of antidepressants, including SSRIs, in the time after a suicide attempt does not increase the statistical probability of repeating one’s suicide attempt.”
It is elementary knowledge that it is statistically completely wrong to adjust for something that is part of the causal chain. Serious mental illness can lead to psychiatric contact and the use of other psychiatric drugs and to a suicide attempt. When you adjust for causal factors in the causal chain, you can make a true correlation disappear completely. This mess was supported financially by Lundbeck, a Danish drug company that sells several antidepressants, and whose director once claimed in a radio broadcast that antidepressants protect against suicide.
Number two on the list was a message addressed to Danish citizens from Psychiatry in the Capital Region with the title, “Risk of suicide and violence is not affected by antidepressant therapy.” They referred to a Danish registry study, and there were no reservations whatsoever about the conclusion. This was serious misinformation of the public. Registry studies are biased in numerous ways and, of course, cannot invalidate the results obtained in placebo-controlled trials, which clearly show that antidepressants increase the risk of both suicide and violence.
Number three was even worse. Psychiatry in the Capital Region stated in the headline that “Antidepressants do not increase the risk of suicide” and in the subheading that “Fluoxetine and venlafaxine do not increase the risk of suicide among young people. Among adults and the elderly, the drugs protect against suicide.” They referred to a highly unreliable meta-analysis by Gibbons from 2012, which, according to psychiatrist David Healy, is a concoction of an earlier meta-analysis from 1991, which is equally unreliable. Gibbons used statistical modelling, and he has published many highly unreliable studies claiming that antidepressants protect against suicide. Several researchers have demonstrated that his studies are so dishonest that it is not a question of errors, but of deliberate cheating. Gibbons has been an expert witness in lawsuits for two pharmaceutical companies that sell antidepressants.
Number four was an article from Psykiatrisk Tidsskrift, an industry-funded throw-away magazine, entitled “Antidepressants increase risk factors for suicide,” and with the subheading, “A new Cochrane study shows that antidepressants increase the risk of mental health problems that can lead to suicide and violence.” My research group had reviewed the placebo-controlled trials of adult healthy volunteers. We found that antidepressants double the risk (risk ratio 1.9) of adverse effects that the FDA has determined increase the risk of suicide and violence. This was erroneously stated in the article as a risk of 15.2% versus 10.3% (giving a risk ratio of only 1.5). These figures are plucked out of thin air. They do not appear in our article at all.
Number five was an agreed wording for all antidepressants from the Danish Medicines Agency about the text in the package inserts: “Since an improvement in the depression may not be seen until after several weeks of treatment, the patient should be followed closely until an improvement is seen. General clinical experience shows that the risk of suicide may increase in the early stages of recovery.” One gets the impression that the risk of suicide may increase before the medication has had any effect.
The Danish Medicines Agency thus claims that antidepressants reduce the risk of suicide, which is deeply irresponsible. Furthermore, “general clinical experience” is unreliable. The Agency should have said that the placebo-controlled trials show that the risk of suicide is increased, not just at the start of treatment, but at any time, and especially with dose changes.
Number six was an article in Ugeskrift for Læger (Journal of the Danish Medical Association) by psychiatrist, PhD, Marianne Breds Geoffroy, with the title, “Youth suicide and antidepressants” and the subtitle, “Peter Gøtzsche claims that antidepressants have driven young people to suicide. But how can he know that?” It’s very simple. One of the strongest risk factors for suicide is previous suicide attempts, so when the medication increases the risk of suicide, some people will surely succeed. Psychiatrist David Healy and I have described many of these cases. Geoffroy begins her article with: “Peter Gøtzsche writes that it is antidepressants that have ‘driven young people to suicide.’ If that is correct, then why are not all children and young people who have depression and are given antidepressants driven to suicide?” Well, even if some die in traffic, we don’t all die. Geoffroy had received fees from Lundbeck, Eli Lilly and Novartis, all of which sell antidepressants.
Number seven was a mention in Ugeskrift for Læger of psychiatrist Lars Søndergaard’s PhD thesis. It was based on Danish registries, and Søndergaard found that there was “a reduced risk of suicide associated with continued treatment for all groups of antidepressants,” exactly the opposite of what the randomised trials have shown.
Number eight was my comment on the National Board of Health’s website. Professor of psychiatry Poul Videbech had claimed in the Board’s journal, Rational Pharmacotherapy, that undertreatment with antidepressants is dangerous because of the risk of suicide. I pointed out that this cannot be the case because antidepressants increase the risk of suicide. I wrote to the Board that Videbech was wrong on several other points and asked them to publish my comment in the journal, because announcements from the National Board of Health are given great weight. The Board replied that they do not have a debate forum in the journal and normally do not publish comments, but in this case, they made an exception.
Number nine was a mention on videnskab.dk (science.dk) of my research group’s meta-analysis of clinical study reports Eli Lilly had submitted to the European Medicines Agency. We demonstrated that duloxetine increases the risk of suicide and violence 4-5 times in middle-aged women with urinary incontinence compared to those given placebo. Later, the FDA announced that during the follow-up phase of these trials, there were 2.6 times as many women who attempted suicide than among other women of the same age.
Number ten was my article in Jyllands-Posten, a national newspaper, from 3 February 2018, “Another tragic suicide on depression pills.” The parents of Rasmus Burchardt had contacted me after their son had hanged himself in their bathroom 18 days after his doctor had prescribed mirtazapine for sleep problems and school fatigue. They had not been warned that depression pills can cause suicide and wanted me to write an article about it to warn others. They didn’t even know that Rasmus had been given a depression pill. Among other things, I wrote in Jyllands-Posten:
“This tragic story is unfortunately quite typical of suicides caused by depression pills. They often come without warning and the method is usually very violent, e.g. hanging, shooting or jumping out in front of a train, which guarantees that the attempted suicide attempt succeeds, as opposed to the more common approach of taking an overdose of pills, which is often a cry for help.”
“Many of these suicides never come to the attention of the authorities because it is a widespread but erroneous belief that depression pills protect against suicide. Therefore, many suicides are never reported. The pharmaceutical companies have also hidden many suicides and suicide attempts in their clinical trials. In fact, this is so widespread that it is justified to call it a research fraud with deadly consequences.”
“I agree with the parents that the authorities are not living up to the responsibility they have towards the public. Neither do the psychiatrists. Professor and psychiatrist Lars Kessing claimed in the ‘Evening Show’ on 15 April 2013 that antidepressants protect against suicide.”
My article created debate. Psychiatrist Poul Erik Buchholtz from Risskov claimed (JP 15 Feb) that depression pills prevent suicide among severely depressed patients, but there is no evidence for this. Buchholtz also believed that psychotherapy as the only treatment for severe depression is an impossibility. That is also wrong. My research group demonstrated in a 2017 meta-analysis that psychotherapy for patients who have attempted suicide halves the risk of another suicide attempt. Severely depressed patients should therefore get psychotherapy, not pills.
The denial was total. In Jyllands-Posten’s journalistic coverage of my article (JP 3 Feb), child and adolescent psychiatrist Professor Per Hove Thomsen also led the readers astray in his defense of the pills. He found it thought-provoking that in a period when the consumption of happy pills increased in Denmark, the number of suicides fell from around 1,500 to 700. Such data cannot be used for anything. Decreases or increases in suicides have many reasons, and in the USA (and in several other countries) suicides increased significantly in the same period when the consumption of happy pills also increased significantly, but the psychiatrists never say anything about this.
In the journalistic coverage, the chairman of the Danish Society for Family Medicine, Anders Beich, said that the long waiting list for psychiatrists can be disastrous, because it is dangerous to have depression, which in itself can lead to suicide. What is dangerous is that doctors change the reality and tell the public that depression pills prevent suicide.
Videbech also appeared. He wrote in an article (JP 10 Feb) that for children and young people there was possibly a “slightly increased risk of suicidal thoughts and behaviour, but not of completed suicides.” The analysis, Videbech referred to, found a doubling of the suicide risk in children and young people. This cannot be called a “possibly slightly increased risk.”
Videbech referred to a study by Kessing and colleagues, financed by the Lundbeck Foundation. Kessing was on Lundbeck’s payroll, and he found that in children and adolescents, “Those treated with SSRIs had a highly statistically significant and strongly increased rate of suicide compared to those not treated with SSRIs” (rate ratio of 19). But he concluded the opposite: “not treating severely depressed children and adolescents with SSRIs may be inappropriate or even fatal.” The authors presented another analysis in which they had adjusted for psychiatric hospital contact. The rate ratio was still increased, 4.47, but it was “no longer quite significant.” As mentioned, it is completely wrong to adjust for psychiatric hospital contact. Such contact increases the risk of suicide among psychiatric patients 44 times. The correction removed a true association between SSRIs and suicide.
With reference to Kessing’s misleading study, Videbech (JP 10 Feb) believed that many suicides among children and young people could have been avoided if treatment with antidepressant medication had been more widespread.
Psychiatrists have failed their responsibility towards the public to a catastrophic extent by claiming that depression pills protect against suicide when they do the opposite. I do not know of any other medical specialty whose practitioners systematically misinform the public to this extent.
Textbooks of psychiatry used by students of medicine, psychology and psychiatry contain a litany of misleading and erroneous statements about the causes of mental health disorders, if they are genetic, if they can be detected in a brain scan, if they are caused by a chemical imbalance, if psychiatric diagnoses are reliable, and what the benefits and harms are of psychiatric drugs and electroshocks. Much of what is claimed amounts to scientific dishonesty, and the textbook authors often cite research that is plagued with fraud or serious manipulations with the data.
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.
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