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.


Fair enough, but what would... (Below threshold)

February 6, 2008 8:48 PM | Posted by Arthur Bane: | Reply

Fair enough, but what would you tell a patient that comes to session to ask about an increase in suicidal thinking being a side effect of treatment? The warnings must be based on something. After all, they read it in the paper, and they're the ones taking the pills, they're not seeking to redefine the semantics of psychiatry.

Vote up Vote down Report this comment Score: 1 (1 votes cast)
OMG, I was taking not only ... (Below threshold)

February 6, 2008 9:20 PM | Posted by Sally: | Reply

OMG, I was taking not only an anti-depressant, but also klonipin when I bought my Volvo, really I was. Before that I bought a Toyota. Does this mean the drugs helped or not so much?

Vote up Vote down Report this comment Score: 1 (1 votes cast)
IN a prominent Children's h... (Below threshold)

February 6, 2008 11:14 PM | Posted by Stephany: | Reply

IN a prominent Children's hospital, I stood my ground with the attending big ass, that my daughter was "ativan, buSpar,Zoloft,Seroquel" in reaction, therefore the class of drug did not matter it was the mechanism of action within her body ability to perform.

This may not appear coherent in reading, because it was 8 weeks of this type of discussion. One on call pdoc from Sweden told me to "shove off, there are one class of drugs and she cannot play cards now, she is psychotic, and unless you find a school with a psychiatrist in charge..." then he swiftly walked away in an arrogant bliss.

What was the question again? because there are no answers until we ask the correct one.

*he really did give her a deck of cards, and because she handed certain ones back, they deemed her psychotic.

Serious and sick story here, and I lived it. Then the hospital paid 1/4 million in compensated care for that.

Vote up Vote down Report this comment Score: 1 (1 votes cast)
If 4 people in the AED stud... (Below threshold)

February 7, 2008 12:42 AM | Posted by mfvmd: | Reply

If 4 people in the AED studies committed suicide, and none of the kiddies in the FDA's antidepressant metaanalysis did, doesn't that make AEDs infinitely more likely to cause completed suicide?

Gotta run. My kid's hitting himself in the head with his hand again -- oops, I meant "displaying increased suicidality."

Vote up Vote down Report this comment Score: 0 (0 votes cast)
Alright, you heard it hear ... (Below threshold)

February 7, 2008 2:56 PM | Posted by Will: | Reply

Alright, you heard it hear first. Well, you actually heard it first in my comment on your last post. I think that the only plausible mechanism for increased suicidal ideation in these patients is the combination of (burden of illness) + (burdensome treatment) leading toward an increased amount of subjective stress experienced by the individual. We know dialysis does this. But I also found an article in the British Journal of Clinical Pharmacology (2001, 52:313-318) linking beta blockers to increased risk of completed suicide in people with CAD, and another article in the European Journal of Clinical Pharmacology (2007, 63:591-596) linking antiotensin receptor blockers to completed suicide. (The authors caution that this data should be interpreted cautiously.) Finally for now, there is the study in the British Medical Journal (1998, 7:741-745) linking calcium channel blockers to increased risk of suicide. The major difference here is that these studies all use completed suicide, as opposed to suicidal ideation, as an endpoint, so they are suggestive but not clearly similar. One assumes the presence of suicidal ideation (and attempts) would be higher than the actual number of completed suicides. I submit that they support my hypothesis that (burdensome illness) + (burdensome treatment) means lower quality of life and more stress, which in some vulnerable individuals, would reach expression as suicidal ideation and behavior. Just my $0.02. Love your blog, btw.

Vote up Vote down Report this comment Score: 0 (2 votes cast)
That sounds kind of like ju... (Below threshold)

February 7, 2008 3:02 PM | Posted by Ozgur: | Reply

That sounds kind of like just avoiding legal action. If one could say antidepressants cause any specific complex behavior, better cover the opposite behavior of the ones that they are supposed to cause. Incredibly lame.

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.

One funny and illuminating commentary on that phenomenon is Dan Savage's "Savage Love" column article, "How'd That Happen?"

A link to that is here:


[Just text, but not text for all ages.]

Vote up Vote down Report this comment Score: 0 (0 votes cast)
I'm going to play devil's a... (Below threshold)

February 7, 2008 5:03 PM | Posted by Jim: | Reply

I'm going to play devil's advocate...

While it may be true no one would link medication to other complex behaviors (e.g., Visa payments), that may be because for patients at-risk of suicide no one really cares if they pay their bills or buy a Volvo, etc., they care if they are committing suicide. Even with the differences in number needed to harm, isn't an increased risk of suicide still an increased risk?

Can't some complex behaviors can be correlated to medication use? Ritalin lead to a decrease of certain types of impulsive behaviors...I mean, in the end, aren't we hoping all psychiatric medications have effects on the complex behaviors of patients?

Alone's response: Again, I'm not saying that the meds can influence suicidality (either positively or neg). It's pretty clear that meds that are designed to affect the brain should have an effect on behavior. (Consider the following: if meds can alter your emotions, why can't they alter your thoughts? It's logically consistent that you will be able to have thoughts-- actual thoughts-- that you could never had had without taking the med.) But the emphasis on the med is grossly misplaced: it's like saying comp rooms in Vegas increase the risk of cheating on your spouse, which sounds true, but I hope you understand that it was neither the room, nor being comped, nor even Vegas itself that lead you to cheat; those facilitated a behavior you were partly on the way to doing. Any of those things alone couldn't have done it (let's say)-- it took all four. But here we have a black box warning: "Being comped leads to infidelity.")

For me, what matters is how we value things. In my example, does "comped" carry value equivalent to "infidelity?" But if we left it like that, then we have reduced "infidelity" to little more than a hedonic outlet, equivalent to being "comped." Not only does it diminish personal responsibility, but it actually says that "infidelity" is very difficult to AVOID-- i.e. the default is that you will cheat, not that cheating is something you must pursue-- because even being comped can influence it. It says, "you think you won't ever cheat? You're much weaker than you think, there are limits to your self control..."

Vote up Vote down Report this comment Score: 4 (4 votes cast)
Spot on in this one. I have... (Below threshold)

February 9, 2008 10:29 AM | Posted by driver: | Reply

Spot on in this one. I have long thought that the specificity of "causes suicide" is just ridiculous. It really is equivalent in specificity to buying a volvo.
Granted, some medications do seem to cause very random-seeming yet very specific behaviour (e.g. ambien eaters). But eating is certainly not as complex as suicide and one is not literally unconscious while one contemplates or carries out suicidal actions.

Vote up Vote down Report this comment Score: 0 (0 votes cast)
What these drugs have in co... (Below threshold)

February 9, 2008 10:18 PM | Posted by Jessadriel Darkmountain: | Reply

What these drugs have in common is that they relieve the symptoms of depression by blunting emotion. However, most depression has both a situational component and a maladaptive cognitive component, which medication does nothing to ameliorate. If these are not addressed, when the patient continues to experience dissatisfactions, suicidal or homicidal ideation may occur, especially if it had been previously habitual. However, it is possible that because of medication-induced emotional blunting or dissociation, feelings of regret, remorse or compassion which ordinarily prevent such ideation from becoming action would no longer have a restraining effect.

Vote up Vote down Report this comment Score: 3 (3 votes cast)
This is the thing, it's pre... (Below threshold)

February 10, 2008 8:45 AM | Posted by Sally: | Reply

This is the thing, it's pretty obvious that these drugs are supposed to remove anxiety and create a sense of contentment just this side of intoxication. SSRI's relieve anxiety and inhibitions causing suicide in this way: You give them to a person who was referred to you because they were confined after an unsuccessful suicide attempt. The drug will help relieve this person of the fear and anxiety that interfered with his thinking causing his previous suicide attempt to be unsuccessful while allowing him to experience optimism that suicide will land him in a better place, again, as I've said before, these drugs just produce a mild state of intoxication, nothing else, so the changes in behavior are similar to the changes in behavior seen in a man in a bar who after a few drinks picks a fight - he wanted to fight before he got drunk but was (probably wisely) afraid or the person who takes LSD and jumps off of a cliff thinking the can fly.

The drugs do temporarily "cheer a person up" but that is generally for the comfort of the people around them and, again, just compare these drugs with the big daddy of legal mood altering drugs alcohol. We all know that the early stages of alcohol intoxication are cute and charming and the end stages are well, violence. SSRI's are the same. It's only mentally stable people that can handle an ssri buzz and no one is mentally stable all of the time but certainly they make suicide more likely in a suicidal person much like they make house cleaning more likely in a person who already wanted to clean their house. And even worse, they make people more impulsive, more likely to act on any fleeting thought, whether it's a casual thought of suicide after trying on swim suits, a casual thought of killing your boss after an argument, or whatever.

Vote up Vote down Report this comment Score: -1 (1 votes cast)
“What Else Causes Suicide? ... (Below threshold)

February 10, 2008 4:17 PM | Posted by herb: | Reply

“What Else Causes Suicide? You'll Never Guess” --- The Last Psychiatrist

I’m sorry to be so crass as to respond by suggesting something which has been a long time very obvious to me; severe depression causes suicide either untreated or treated with or without Volvos.


Vote up Vote down Report this comment Score: 4 (4 votes cast)
There is a lot to be said f... (Below threshold)

February 16, 2008 1:33 AM | Posted by Stan Stamerson: | Reply

There is a lot to be said for anti anxiety medication removing any pre-existent anxiety one might have about killing oneself, thereby making it much easier to go through with the arduous task of dying, which seems largely comprised of allowing oneself to die and avoiding doing anything that might allow the chance of intervention.

Arguably, the medication itself, in removing anxiety, is helping parts of the person die so that its easier to cope with reality. Reality effectively becomes smaller, less going on, and easier to process, hold in ones head, and less to worry about or get nervous about. This can instill one with a false sense of confidence about whatever it is that one is holding in ones head at a given time. Nothing can be said to apply across the board here, but it would make sense that removing emotional anxiety makes whatever task one is intent on committing easier to go through with, whether its giving a speech, yelling at by your boss, getting pulled over, robbing the liquor store, or killing yourself is largely left up to the imagination of the person on the medication, which is outside of the control of anything other than nature/nurture.

The responsibility of the psychiatrist to know whether or not the medication will work for a specific case increases over time. Arguably however dealing with a life of anxiety and taking a pill to escape anxiety are completely separate and distinct things that have no place in the same treatment. Medication alters nature in a questionably predictable fashion depending on the individual, communication indicates nurture and can change it albeit more slowly, at a rate that is easier to appreciate and account for. I think there is a lot to be said for prescribing something because its easier than helping people work through their problems, why not just remove the problem? Because the problem might be the only thing that keeps them alive... With the problem out of the way, what more is there to live for? Perhaps supervision would be sufficient, and the medication might still help if the supervision and guidance was sufficient for the individual in question. Drugs often seem viewed as a solution instead of the tool they are.

Vote up Vote down Report this comment Score: 0 (0 votes cast)
Devil's Advocate says: afte... (Below threshold)

February 20, 2008 2:23 PM | Posted by Larry Smith: | Reply

Devil's Advocate says: after a suitable round of lawsuits, we'll see Wellbutrin and all other dopamine reuptake inhibitors and agonists labeled with a warning that it leads do infidelity, ruins marriages, etc. Granted, hypersexuality in reaction excess dopamine can easily be proven in rodents (see Komisaruk et. all, The Science of Orgasm for a review). But infidelity? Is there a plausible link that regardless of external factors infidelity occurs? A monogamous human might have more sex with their partner, if the partner agrees to it, may look for someone else if sex drive trumps other aspects in a relationship, or may just masturbate more. Which of these more or less complex behaviors should be listed in the black box?

Vote up Vote down Report this comment Score: 0 (0 votes cast)
Actually I think you've got... (Below threshold)

February 20, 2008 9:38 PM | Posted by Sara: | Reply

Actually I think you've got your head in the sand. I absolutely believe antidepressants and antipsychotics for that matter literally cause suicide. I've seen it right before my very eyes. First the obsessive rumination over violent thoughts that normally would be transient that the victim simply cannot let go of. I don't know what chemistry is making this happen but it's totally out of character and totally out of control. Violent intrusive thoughts that will not go away. Then there's the loss of impulse control and the dissociation that makes you feel like you are outside of yourself looking in. This happens and it goes away when the drug is taken away (called challenge, dechallenge, rechallenge in case you don't know and it's the gold standard for causation). It has next to nothing to do with the person's own circumstances or personality. I don't think you are being funny when you compare experiences like this to buying Volvos or paying Visa bills. And I wouldn't want you to be my psychiatrist even if you were the last one on the planet.

Vote up Vote down Report this comment Score: 1 (1 votes cast)
We live in a litigious soci... (Below threshold)

February 20, 2008 10:27 PM | Posted by Your Wandering Mind : | Reply

We live in a litigious society. Soon they’ll have “suicide warnings” posted near all high bridges, on guns, razor blades, and the front of fast moving trains. It’s one crazy world!

Your Wandering Mind

Vote up Vote down Report this comment Score: 0 (0 votes cast)
Volvos are too specific: if... (Below threshold)

February 22, 2008 9:27 AM | Posted by anotherpanacea: | Reply

Volvos are too specific: if increased energy and efficacy makes you want to have better access to travel and the world, that's enough of a causation to make it worth listing the possibility of vehicular buying habits. Buying a Volvo is like hanging yourself; it ignores all the other methods (of travel, of self-annihilation) available.

If Camus is right, then suicide is the essential philosophical question of our age. We can tell dozens of stories of how patients begin to ask that question for the first time while on medications whose effects include serious outlook and personality changes, but I lean on this one: when you begin to understand your own physicality, that mood and identity are physical rather than essential attributes, existence becomes a question that you are free to ask. It's Augustine in spades: "I became a question to myself," because 'myself' appears to be something other than a thinking being. Rather, 'I' am an object in the world, a robot made of meat, an effect rather than a cause, and as an effect 'I' seem to cause more grief than joy, even for myself, as a meat robot 'I' seem to be malfunctioning, and as an object, 'I' seem to be broken or poorly made. That's the human condition in our world.

So why not suicide?

Vote up Vote down Report this comment Score: 1 (1 votes cast)
If you really believe that ... (Below threshold)

February 23, 2008 9:55 AM | Posted by Sally: | Reply

If you really believe that a chemical change in the brain caused by a pill can't cause behavior, then you have to also believe that a chemical change in the brain caused by the brain itself due to some mental illness can't cause behavior, or in other words, regardless of the "chemical balance" in your brain, there must be outside stimulus to "cause" suicide.

Vote up Vote down Report this comment Score: 1 (1 votes cast)
If you do not believe a che... (Below threshold)

February 24, 2008 10:22 PM | Posted by one: | Reply

If you do not believe a chemical can cause suicide thoughts. Try Chantix on for a nice change of pace. "Normal" will become a dream that is unattainable.
Antidepressants are being prescribed to help reduce the rate of suicide while other novel drugs are being handed out freely that help with other health problem. Patients have no idea that this drug stimulates dopamine and is released from the hypothalamus.
If one has never been subjected to this way of life and does not even know about depression/suicide, then how do they even know what is happening to them if they are not given the information to make a decision about this medication BEFORE taking it.
One can agree with the just take your medication attitude, but that can change when the bad experience with a drug happens to you and not someone else.

Vote up Vote down Report this comment Score: 0 (0 votes cast)
Had time to waste this morn... (Below threshold)

February 29, 2008 9:41 AM | Posted by Anonymous: | Reply

Had time to waste this morning. Below is a reply to your
"competency to commit suicide" article; I can no longer comment on it directly, because comments are closed.

To pick up your gauntlet regarding the right to suicide, here's a shocker from those "backward" Swiss, and it's a year old, about the same as your article:

Swiss High Court: Mentally Ill have a Right to Assisted Suicide

A bit of googling reveals that people travel to Swiss just for this purpose. Make sure you ask your patients if they plan to travel there ;p

Vote up Vote down Report this comment Score: 0 (0 votes cast)
I was a bit skeptical about... (Below threshold)

February 29, 2008 1:43 PM | Posted by Anonymous: | Reply

I was a bit skeptical about the veracity of that report about the Swiss court decision. I found the original in German, a language that I do not read/speak. It contains "Dignitas" and "Pentobarbital" so it's probably the right document...


Vote up Vote down Report this comment Score: 0 (0 votes cast)
You forgot the best one: br... (Below threshold)

March 9, 2008 4:48 AM | Posted by Larry Smith: | Reply

You forgot the best one: breast implants!


Alone's response: Nope--


Vote up Vote down Report this comment Score: 0 (0 votes cast)
As Swiss (double nationalit... (Below threshold)

March 22, 2008 8:02 AM | Posted by Gene: | Reply

As Swiss (double nationality), I feel I should point out that this country is as close to direct democracy as there exists on earth. The individual is understood to have both enormous control and responsibility for his own life and others (civic duty).
The "right to suicide" should not be confused with euthanasia. The latter has never been legal here. This means you have to be able to find a doctor who agrees with you that suicide is in your best interests.
Dignitas has recently come under serious fire here for helping a couple of people die by helium inhalation, which was a way of getting around a doctor's prescription.
It is actually very difficult to find a Swiss doctor if you are from a foreign country to help you commit suicide, direct contact is next to impossible. Dignitas is the only agency who will even listen to a foreign plea for help, there's lots of questions to be answered, medical reports to be reviewed etc. before they will come to a decision and rarely (compared with how often they are contacted) do they accept.
That said, it is probably only a question of time before the doors will be permanently shut to anyone who is not a resident of Switzerland. The Swiss like consensus and discretion, seeing their name in print in (foreign) newspapers horrifies them as badly as it would have for any fräulein in the 19th century from a good family.

Vote up Vote down Report this comment Score: 0 (0 votes cast)
If you really are a psychia... (Below threshold)