March 22, 2004

Prozac Kills?

by Nick Morgan

As you may have heard, suspicions are surfacing that certain anti-depressants could actually cause suicide, or suicide related bahavior.

    The FDA said it was not clear whether antidepressants contributed to the emergence of suicidal thoughts and behavior, but, at the urging of the advisory panel, the agency decided to issue the warnings before it completed a thorough review of the drugs.

Apparently various studies have been done, but what I'd like to know is whether suicide or "suicide-related behavior" is detected mostly during the first few weeks of taking the medication, when patients' brains are adjusting to the drug. And it's certainly worth knowing how "suicidal" patients were before starting on medication. A hypothesis worth testing would be: "Seriously depressed persons, before taking medication, are too fatigued and hopeless to take any action in response to their condition; but during the early medication adjustment stage, some depressed people may find their energy restored, but not their suicidal feelings, thus increasing the chance that action will be taken."

I'm no psychiatrist, but it sounds like a worthwhile question to answer.

March 22, 2004 03:09 PM | TrackBack
Comments

Also, it seems unlikely that the drugs could "cause" suicide. For there to be that type of causation, it should be true that prior to taking the drug, the person had a healthy mental state such that suicide was not even a possibility.

Certainly, the person's mental state could not have been all that healthy--otherwise, there would have been no need for the drugs.

Posted by: Sean S at March 22, 2004 03:38 PM

Wow, these past two posts are excellent examples of the disturbing tendency of law students/lawyers to take their formidable reasoning skills, apply them to something they know absolutely nothing about, and end up with absurd analyses that only seem reasonable to other people who know nothing about the subject. I'm not sure what it is about law students that makes them feel qualified to speculate on just about anything, when most other people would realize they should probably keep their mouths shut to avoid sounding foolish.

The drugs are being questioned because suicidal behaviors and tendencies have appeared in a statistically meaningful number of persons who have taken the drugs, and who showed no clinical suicidal tendencies before they began taking the drugs. To suggest that these drugs couldn't have 'caused' the suicidal behaviors because the patients were not in a 'healthy mental state' when they began their treatment -- because they were depressed -- is embarrassing. The patients had no suicidal tendencies before; they did after. The fact that the drugs might not have the same effect on someone who lacked clincal depression in the first place -- that they wouldn't cause someone with a 'healthy mental state' to immediately run to the top of a building and jump -- is irrelevent. Drugs that are supposed to be helping people cope with clinical depression are doing so only at a cost of giving them suicidal tendencies as a side-effect -- a cure arguably worse than the disease. And I don't even want to comment about the idea that "depressed" people are really just suicidal people who "are too fatigued" to kill themselves, and that the anti-depressants are really just giving them enough energy-boost to carry out their hidden desires ("good thing they didn't get ahold of a Mountain Dew -- they'd have probably taken someone else down with them"), except to say that no, this is definitely NOT a "hypothesis worth testing."

Posted by: Joe at March 22, 2004 04:13 PM

Joe:

I took issue with the word "cause." I still take issue with the word "cause."

You say the "person had no suicidal tendencies before; they did after." Therefore, the drugs caused the suicidal tendencies.

I wouldn't rule out the possibility that the person had suicidal thoughts prior to taking the drugs, but overcame those thoughts with a positive outlook as to the possible effects of the drugs. Then, when the drugs failed to work, the thoughts increase and the tendencies manifest. In that case, however, I do not feel that the drugs cause the tendencies. Rather, the realization that the drugs would not alleviate the prior suicidal thoughts, cause the tendencies. This is just one hypothetical example as to why to question causation; Nick provided another one.

Perhaps as a law student, I have learned to examine all possibilities--some of which might appear to be "foolish." So be it.

Posted by: Sean S at March 22, 2004 05:01 PM

Well Joe, as law students, we often don't have time to conduct our own clinical research to test claims made by media outlets, so we have to rely to a certain extent on what these news stories actually say. The AP story describes the following signs to watch out for: "[W]orsening depression or suicidal thoughts at the beginning of anti-depressant therapy or whenever the dose is changed." (emphasis added). The experience with the drug is worded like this:

Parent after parent described children who had become extremely agitated or anxious shortly after starting the antidepressants, and seemingly sudden impulses that turned deadly.
I don't see anything in the AP story to support your claim that only people "who showed no clinical suicidal tendencies before they began taking the drugs" then developed suicidal tendencies, and it seems entirely plausible (again from reading the AP story) that suicidal feelings, even if slight, were present before the suicides.

If you are going to insult law students and blog with them (while using an address at law.harvard.edu), then I suggest you start acting like a legal scholar: actually citing some of your propositions that you are using to insult others. The goal here is to learn and discuss.

Posted by: Matto Ichiban at March 22, 2004 05:20 PM

Joe, I appreciate people telling me I'm wrong, especially if they're right--but the insulting and angry tone of your comment is absolutely unnecessary. Got it?

First, if your complaint is with law students opining on subjects about which they know little, then I'm left wondering why you haven't bothered to establish your own credentials on the matter. If this is actually something you know quite a lot about, then I'm listening (seriously).

Second, I'm afraid your ridiculing my proposed question is not persuasive. The studies conducted so far have employed varying measures of "suicidal behavior" and if it is the case that pre-medidcation depression in some instances includes severe fatigue (a well established symptom), then lack of suicidal activity would be consistent with my hypothesis. If you think there's a study that shuts out my hypothesis, then please point me to it--I'd like to know.

Third, the impassioned tone of your post seems to be a reaction to doubts about the dangers of antidepressants. If they do, in fact, cause suicide, that's awful, and something needs to be done about it. If you had supposed I was trying to quell suspicions about these dangers, you were wrong. My post was simply meant to articulate a curiosity about why the drugs are doing this, not whether they are--a curiosity, in fact, that was first expressed to me by a doctor, and later confirmed as possible by a psychiatrist I know. My post presented no danger of misleading the public about the potential harm of these drugs.

Your views are welcome here, Joe, but I don't understand why you'd bring a tone more likely to make enemies than change minds.

Posted by: Nick Morgan at March 22, 2004 05:21 PM

Two parts Joan Crawford, one part Genghis Kahn!

Posted by: Brian at March 22, 2004 05:52 PM

Ok, I should probably just duck and run at this point, but I'm diving back in anyway...

First, my sincerest apologies for an "insulting and angry tone." I was intending light mockery, but not bitter ridicule (at least not of any of you personally), and I think that I came across too harshly. I'm not actually angry at all, just shocked by the willingness of many law students to assume they know a great deal about anything besides the law (and anything else they have direct experience with). I wasn't really attempting to insult anyone's intelligence, just to criticise the general willingness of law students to assume that their analytic abilities give them a sufficient basis from which to intelligently discuss a variety of issues about which they have limited background knowledge. I'm actually interested in this question much more than I'm interested about anything having to do with depression medications, and it was this question that led me to respond to your posts in the first place. Is this a result of the type of people that are attracted to law school in the first place (arrogant and outspoken ones??), or do three years of socratic method instill a false sense or intellectual prowess in otherwise normal people?

Matto, if you are suggesting that my law.harvard.edu email address somehow makes suspect any criticisms I have of law students, I think just the opposite it true - I wouldn't feel so confident saying anything about the way that so many of them are/are not if I weren't a law student myself. (I wouldn't hazard an opinion without having some familiarity with the subject matter, see?). If your criticism is just that I didn't cite any research, well I'll be up front and say that I don't have any on me right now, and don't care enough to go look any up. I assumed the AP article (which I didn't read) discussed the current research.

Sean, my criticism is not that you consider all possibilties, its that you presume (1) to know what the possibilities are and (2) that your presumptions might be meaningful when you don't have any knowledge about the subject. (Again, I don't even know you, so I can't really make such a general statement about you, I'm just (a) in part going on your statements from above, and (b) using 'you' as a proxy for a lot of law students whom I do know and have observed. So don't take all those 'you's too personally). And of course, you are right, if the people were suicidal at first but then became not suicidal because they were so hopeful that their new drugs would help them and then become suicidal once again when the drugs do not work, then it doesn't make much sense to say that the drugs 'caused' the suicidal tendencies. Instead, we would say that the drugs failed to cure the suicidal tendencies. But most of these poeple are not being treated for suicidal tendencies, but for depression, two ideas that you seem to have hopelessly conflated - they are very different clinical phenomena, and while there is some correlation between the two they are separate diagnoses.

Nick, I may have misunderstood your original post. It is a clinical possibility that part of the cause is that the antidepressants reduce the overwhelming fatigue often accompanying depression. But this cannot be the whole story (which was what I thought your first post was suggesting) -- when people exhibiting suicidal tendencies are given antidepressants and then exhibit more suicidal tendencies (or act on those tendencies), we would not say that the drugs "caused" those tendencies, since they were already present. The effect of the drugs on the reduction of fatigue could perhaps explain this. But the problem that is causing so much concern is that people who are not exhibiting suicidal tendencies, but simple clinical depression, are given these drugs and subsequently begin exhibiting (or worse acting on) suicidal tendencies, and that this is happening alarmingly often. It makes perfect sense to say that these drugs are 'causing' the suicidal tendencies, even if the causal mechanism is not fully understood. And it seems that, while reducing fatigue may play some role in this process, it cannot be the whole or even the major explanation because depression + energy does not equal suicide (or suicidal tendency).

As for my 'credentials', I'm afraid they're not sterling. My spouse is working on a ph.d in clinical neuropsychology, and has done some research with depression and anti-depressant medications. I don't know a lot; I know just enough to know that the two original posts were not only wrong, but wrong in a way that suggested the authors didn't even faintly understand the questions. Which, again, is what interests me - many law students seem to be uniquely willing to answer questions that they don't understand (and that most people would be wiling to admit that they don't understand), and I don't know what causes this. Do they think they understand questions that they do not, or do they think they are so good at considering different possibilities that it doesn't matter whether they know what they are talking about or not? My wife, for example, works at the juvenile court, and is astounded by the continual comments and 'helpful' suggestions offered by lawyers, who for some reason never seem to comprehend that they might not be making any sense at all. Has anyone else noticed this (I know they have - I've talked to them), and does anyone have any ideas about what is driving this 'professional overconfidence'?

Posted by: Joe at March 22, 2004 07:38 PM

Joe, apology accepted.

I think if you look at the wording of my "hypothesis" (which, by the way, I did not intend to support as true, but merely to raise as a question) you might say we agree to some extent. I used language like "increasing the chance that action will be taken," and I did not say the fatigue issue would be a complete explanation--this seems consistent with your statements that fatigue, etc., could perhaps partially or in some cases explain the problem. If, as it seems, you're willing to give me a little credit, then I think your statement that "the two original posts were not only wrong, but wrong in a way that suggested the authors didn't even faintly understand the questions" goes too far, or at least fails a basic standard of charity.

I tend to be pretty cautious about writing about stuff that's over my head, and that's why my post was at most suggestive. I wouldn't have even mentioned the hypothesis if I hadn't been told by a psychiatrist I know that fatigue-relief might be related to the suicide phenomenon. So I can't say I willingly join the class of over-condient law students you're concerned about.

However, and more to the question you're interested in, I think the problem of dipping into unfamiliar intellectual territory is largely a blogger phenomenon. Stuff turns up in the news, bloggers have thoughts about them, and they write those thoughts. Blogs aren't peer reviewed journals, and so long as writers are careful not to misrepresent the facts, I don't think there's really annything wrong with it. But you may be right that this is peculiarly a law-related phenomenon, and I'd suggest (without any expertise, mind you) that lawyers and law students are constantly pressured to grasp situations of every sort. We're expected to understand how businesses are run, how pollution works, how careful carpenters ought to be, and just about everything else out there. Practicing and learning law is often about understanding the way totally alien stuff works, so it wouldn't suprise me if law-types were in the habit of at least feeling comfortable approaching alien subjects and feeling them out. And I feel comfortable sharing these thoughts even though I'm not a sociologist / psychologist specializing in law student and lawyer behavior. You don't always need an advanced degree to make interesting and even helpful contributions. :)

I'm a bit too swamped to get mired in comments, so the last word is yours if you want it.

Posted by: Nick Morgan at March 22, 2004 08:22 PM

Nick, I guess I'll take the last word since I've got to find some way to kill the next 20 minutes, and I've exhausted all my usual methods of time-wasting. I think you are correct in suggesting that lawyers are often forced to confront alien situations, and are expected to discuss them intelligently. Yet most good lawyers actually develop a thorough familiarity with their specific area of practice, and know enough not to answer any questions or presume any uncommon knowledge about anything else (at least without consulting a partner who specializes in that area or some other expert). Yet many law students and some lawyers (bad ones, I would argue) seem to think that the fact that they are asked to tackle a wide variety of questions implies that they are qualified to give a wide variety of answers -- based on their sheer reasoning skills. There is a common perception that lawyers 'think they know everything,' and there are a disturbingly large number of lawyers who vindicate this perception by opening their mouths to opine about things that might sound right to them and to other laypersons (might even sound intelligent/well-reasoned), but sounds like gibberish to experts in the field. You are forgiven - after all, you're right this is a blog and free-thinking is encouraged - but that doesn't change the fact that there are too many lawyers (certainly more than in other professions) who reach out and make exactly these same kinds of arguments/analogies in the real world where it really does count. And they go on to ARGUE the merits of their uneducated views with people who know better, and often refuse to back down (because arguing is, after all, their real specialty). And this doesn't just occur in the context of litigation (where it might make sense for them to defend their position to the bitter end no matter how incredulous), but also in interpersonal and other informal relations. Ask people who interact with a lot of lawyers (besides other lawyers), and 9 out of 10 of them will tell you that this is their impression. I find this disturbing, and while I recognize that many (most?) lawyers (and certainly most good lawyers) do not act this way, too many do, and I'm just trying to figure out why.

Posted by: Joe at March 22, 2004 11:28 PM

Joe, if you think lawyers and law students are uniquely likely to attempt to analyze issues of which they have little in-depth knowledge, see the rest of the blogosphere.

Posted by: PG at March 23, 2004 10:26 AM

>I wouldn't rule out the possibility that the person had suicidal thoughts prior to taking the drugs, but overcame those thoughts with a positive outlook as to the possible effects of the drugs. Then, when the drugs failed to work, the thoughts increase and the tendencies manifest. In that case, however, I do not feel that the drugs cause the tendencies. Rather, the realization that the drugs would not alleviate the prior suicidal thoughts, cause the tendencies. This is just one hypothetical example as to why to question causation; Nick provided another one.

If this were the case, taking a placebo would increase the incidence of suicidal tendencies, which it does not.

Posted by: random person at March 23, 2004 12:18 PM

True

Posted by: Sean S at March 23, 2004 12:24 PM

Joe,

I think you might be making an unfair stereotype based on anecdotal information. Maybe there is a tendency for, dare I say, Harvard law students and educated lawyers to engage in such intellectual overreaching, but I didn't see anything resembling that among my peers. Thus, the answer might be people who attend the higher rungs of academia might already have swelled heads and think they know everything. No offense, but the bombastic nature of your response is a bit ironic given your point.

That being said, I myself am no mental giant, having the disposition of a hackish stand-up comic.

I've also never bought into this: law school teaches analytical thinking or reasoning skills. Law school teaches... well, the law. The concept of persuading someone that situation A is more similar to situation B than situation C is something as old as Abe Vagoda.

Posted by: Brian at March 24, 2004 08:59 AM
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