February 6, 2008

What Else Causes Suicide? You'll Never Guess

1995.volvo.850.11067-E.jpgIn which I take the semiotic logic of medication induced suicidality to its inevitable, silly end.

Using nothing more than a Volvo.  And without lawyers.

With the recent news that anticonvulsants double the rate of suicide, I got to thinking: isn't Klonopin (clonazepam) an FDA approved anticonvulsant?

Sure, it has different pharmacology than the other 11 studied, but Lamictal, Lyrica, Depakote, etc are equally  different.  So if we're going to pretend that we never had to take pharmacology in med school, if we're talking class effect, then Klonopin gets the warning.

Which may mean that all benzos should get the warning, since, well...

But why stop there?  Antidepressants carry the warning across pharmacology.  SSRIs, TCAs-- even Seroquel has the warning ONLY because it's now an "antidepressant" for bipolar disorder.  Again, the FDA would like us to pretend that doctors had every M, W, F 9am-10am off in med school.  We're not postulating the pharmacology is the cause, since they are all different-- we're saying it's a class effect.  Ok, well, what else is an antidepressant?

Well, a number of medicines not FDA approved.  Lithium, even though that's supposed to reduce suicide.  CBT or other therapies?  They must ultimately act on some biological pathway, right?

...inevitably, there can only be one conclusion: psychiatry causes suicide.  You are all on notice.

And so, reductio ad absurdum, let's all stop this nonsense.

Some have trouble with my seemingly out of hand dismissal of a link between medications and suicidality.

The problem, like everything else, is semantics.

If they had said meds cause dysphoria, or confusion, I'd buy on board.    The problem is the link to suicidality-- a complex behavior.  If SSRIs cause suicide, then they should just as logically promote the sudden need to buy a Volvo.  Yes, that specific.  Not cause a feeling of emptiness you need to fill with a material object, or even the sudden need to purchase an object-- but rather the specific need to buy a Volvo.  These warnings aren't saying the patients are miserable, they're thinking of running away from home, or cheating on their spouse-- they are thinking of killing themselves.  Not other people, either-- themselves.

You might say that the med is simply one factor, it adds to other things--  like another log on a fire.  Ok, fine.  But that's not the same as causing suicide, it's not even the same as "increasing the rate" of suicide.    Being on an antipsychotic for schizophrenia may lead to more regular credit card payments since you're thinking more clearly, but no one would ever say Zyprexa doubles the rates of Visa payments, even if it were semantically accurate.

I have an additional philosophical problem with it all:  these warnings don't just exaggerate a medication's side effects, they demote suicidality to little more than a side effect.

In essence, these black box warnings reduce the complexity of suicidality into less of a behavior or activity and more of a reaction, a reflex.  You might think that's not the intention, and I'm sure you'd be right, but that is the result.   Note that no one is attributing any other complex behaviors to these meds as a side effect-- not increased marriage, or desire to learn French, etc.

Suicide thus becomes MORE of something that can happen to you and LESS of something you do because you feel a certain way.  It's subtle, but it matters.  It's a corruption of language to escape the-- well, nausea-- of massive freedom; it says behaviors occur, not get chosen. 

Psychiatry rarely argues nature vs. nurture anymore, not because it's been solved but because it's become irrelevant-- either way, you were now made and will inevitably act accordingly.