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Despite decades of progress in developing psychiatric medications, there has been little change in the rate of suicide in the last quarter century, according to a report in the January issue of Nature Medicine.
Although there is no single explanation for the failure of better psychotropic drugs to have an impact on suicide, there is strong evidence that a majority of suicidal individuals receive inadequate doses of antidepressant medication, according to the article’s author, J. John Mann, M.D., chief of the department of neuroscience at the New York State Psychiatric Institute in Manhattan.
Psychological autopsies of suicide victims reveal that only 10 percent to 14 percent of individuals who committed suicide in the course of an episode of major depression were being treated with adequate doses of antidepressant medication at the time they killed themselves, according to Mann. Most of the studies find that 50 percent to 80 percent of victims have seen a physician or health care professional within 30 days to 90 days of suicide. The implication, observes Mann, is that poor recognition and treatment of depression is a major factor in the undiminished suicide rate.
He notes that one Swedish study in which primary care physicians received enhanced training in the diagnosis and treatment of depression led to increased prescribing of antidepressants and a decreased suicide rate. Other studies have produced similar results. Unfortunately, Mann notes, the evidence is that the benefits of such training are transient, lasting for a few years and then fading. This suggests that refresher training at regular intervals could enhance the diagnosis and treatment of depression and decrease suicide rates.
"I think that suicide, which is responsible for over 30,000 deaths each year, is a complication of psychiatric illness," Mann told Psychiatric News. "Therefore, the responsibility for reducing that death toll rests on psychiatry and psychiatrists, and we haven’t done much to [reduce the] death toll over many years."
Patients, families, and doctors are missing signs of psychiatric illness, said Mann. When the signs are recognized, "the treatment is often inadequate," he added. Nonpsychiatrists, in particular, "tend to prescribe sedatives, and when they prescribe antidepressants, use doses too low to be therapeutic."
This view validates surveys of primary care training. One analysis of primary care residency programs at a sample of facilities in the United States, for example, found most of the programs sorely lacking in psychiatry training, former APA president Jerry Wiener, M.D., reported in a presentation at APA’s Institute on Psychiatric Services (Psychiatric News, December 5, 1997).
Clinical signs are often poor predictors of suicide risk, said Mann. Neurobiological markers provide a better means of predicting suicide, he contended. By measuring the level of serotonin metabolites in cerebrospinal fluid, it is possible to predict the odds of suicide, he said. If those metabolites are low, the risk of suicide over the next 12 months is four to six times higher than if those metabolites are at normal levels, he explained. "That is the sort of thing we’re talking about, and we would like to develop tests that are even more discriminating than that."
At present, neurobiological measures provide clues, but are not definitive, he observed. Both now and in the future, it will be necessary to refocus clinical attention on characteristics that reflect a propensity for suicide, said Mann. These factors include a history of suicidal behavior, family history of suicidal behavior, evidence of impulsive aggression, and suicidal ideation or hopelessness disproportionate to the severity of depression.
Not all suicide researchers agree with Mann’s assessment that there has been a lack of progress in suicide prevention. Charles Rich, M.D., chair of the department of psychiatry at the University of South Alabama, has studied suicide for many years.
Although depression is underdiagnosed and undertreated in the United States, Swedish and Hungarian data demonstrate dramatic reductions in suicide, largely as a result of adequate antidepressant drug treatment, Rich maintained.
There is "growing evidence from what are called pharmacoepidemiological studies that increased prescription of antidepressants, particularly in Sweden, has resulted in measurable decreases in suicide," Rich added. "The bottom line is [that] there is good evidence that antidepressant treatment does prevent suicide." Mann "should be more optimistic" in his assessment of progress in preventing suicide, Rich said.
"I’m very impressed with how incredibly complicated the brain is and how simplistic some of these [neurobiological] models are," Rich concluded.