Antidepressants are always in the news, but the messages coming across are often contradictory. For example, in most countries the use of antidepressants has increased since the year 2000 (although so has the use of anti-hypertension and anti-diabetes medications), yet worldwide less than a fourth of people with depression receive adequate treatment. Some patients are coming forward with accounts of severe side effects and difficulties with stopping antidepressants, but equally other patients describe life-changing beneficial effects, even at a young age.
The recent Interim Report on Suicide Prevention, just published by the House of Commons Health Select Committee, discusses whether antidepressants are beneficial in preventing deaths by suicide. Every year, there is approximately 1 death by suicide for every 10,000 individuals in England. Suicide is the biggest killer of men under 49 years of age, of all people aged 15-24, and of mothers in the year after they give birth. Suicide is raising in prisons, and disproportionately affects people in the lowest socio-economic groups and living in the most deprived areas.
The report offers clear recommendations for ameliorate this situation, from supporting public mental health and the ongoing efforts to reduce stigma, to accelerating the establishment of dedicated mental health services in every hospital. And it discusses antidepressants. Reassuringly for both professionals and patients, the report states:
Whilst we heard concerns in some written submissions about the role of drug treatments and suicide, the evidence we heard from Professor Louis Appleby, Chair of the Government's suicide prevention advisory group, and Professor Carmine Pariante of the Institute of Psychiatry, was that there is greater risk from not using medication where appropriate, provided that this is following evidence-based guidelines.
I was indeed called by the Health Select Committee to present evidence on this issue, in representation of the British Association for Psychopharmacology, a learned society that promotes research and education.
In front of the Health Select Committee to present the evidence on antidepressants and suicide, on 29 November 2016. I am the guy with glasses at the bottom right corner; sitting next to me is Professor Louis Appleby.
I was asked to clarify how we can reconcile two contrasting lines of evidence: on the one hand, there have been reports that antidepressants may increase suicidal thoughts and behaviours, especially in children and adolescents; on the other hand, antidepressants are effective drugs for the treatment of depression, and depression is one of the leading causes of suicide. This contrast partly comes from the confusion between suicide and suicidality.
Suicide is the act of purposely ending one's life. Suicidality is a set of thoughts and behaviours that are related to suicide but are less likely to be lethal; it includes thoughts and preoccupations about suicide as well as acts of self-harm such as cutting.
Suicide and suicidality are distinct mental health problems. For example, suicide is three times more frequent in men than women, yet suicidality is three times more frequent in women than in men. Suicidality is frequent: around 5% of the population; suicide is 500-time less frequent. There is of course an association between suicidality and suicide: half of all suicides have previously harmed themselves. However, these numbers also indicate that literally millions of people in England experience suicidality but (fortunately) do not end their lives.
Indeed, suicide and suicidality tap into different dimensions of emotional processes and mental suffering. Suicide is often the tragic consequence of a persistent state of hopelessness and helplessness in the context of a severe mental illness, and it usually entails some planning and preparation as well as a choice of violent means of harm that are unmistakably lethal, such as jumping from a height or an overdose with poisons or large quantities of a medication. Suicidality, instead, is often an expression of distress, inner tension and acute despair, and the associated self-harm acts are usually impulsive and pursued to find some relieve.
So, what do the experts say about antidepressants and suicide? What did I tell the Committee? In a nutshell, there is evidence that some antidepressants may increase the risk of suicidality, especially in children and adolescents, but there is no evidence that antidepressants increase the risk of suicide, neither in adults nor in children and adolescents. In fact, studies have shown that suicide rates decrease as antidepressant prescriptions increase. Indeed, and most worryingly, the recent decrease in the rates of antidepressant prescriptions in children and adolescents (since warnings about antidepressants and suicidality have been issued) has led to more suicides in these groups, not less. Overall, following antidepressant treatment it is 10 times more likely to experience an improvement in the depressive symptoms than to experience an increase in suicidality.
But how do we address this potentially increased risk of suicidality by antidepressants? We need to maximize the beneficial effects of antidepressants while minimizing their possible negative effects. We, doctors and mental health professionals, should prescribe antidepressants only to individuals that are most likely to benefit from these medications, so that these benefits outweigh the risks.
Evidence-based clinical guidelines clearly state that antidepressants should be considered as a first-line treatment only for adults with moderate or severe major depression, that is, when the emotional suffering and the functional impairment reaches significant levels, and should not be used for transient or mild states of emotional distress. In children and adolescents, the bar for using antidepressants is even higher: only in case of severe depression, thus reaching emotionally and functionally incapacitating levels, or when other treatment strategies do not work. When possible, antidepressant medications should be complemented with psychotherapy.
For those patients who have emotional difficulties but who are not severe enough to require antidepressants, we can support them with our presence and we can help them mobilizing the healing power of their inner resources and of their family and social networks. We can reassure them that life brings suffering at times of changes and losses, and that this is ok. We can tell them that they do not need antidepressants: they only need time to recover.
At the same time, we must make sure that patients who need antidepressants are recognized by health professionals, are not prevented from accessing help because of stigma, and do embrace our advice when we prescribe the antidepressants that they need.
This way, antidepressants will continue to save lives.
Disclosure: around than 10% of the funding supporting my research comes from pharmaceutical companies interested in the development of new antidepressants; the remaining 90% comes from the UK Medical Research Council, the NHS, the European Commission and research charities.