All this back and forth between the pharmaceutical industry and its detractors about whether selective serotonin-reuptake inhibitor (SSRI) antidepressants (Prozac [fluoxetine], Zoloft [sertraline], Paxil [paroxetine], Celexa [citalopram], Luvox [fluvoxamine], etc.) cause or contribute to suicidal feelings misses the point. A potential side effect of these medications is an intense kind of restlessness called akathisia that makes people feel so unbearably frantic that some may be driven to take their lives. Every mental health professional prescribing these drugs knows that, and it is useless for the pharmaceutical industry to argue that it is merely the patients’ depression, and not a drug effect, that contributes to the SSRIs’ suicide statistics (which indeed, as critics charge, may have been “spun” by the manufacturers to preserve profits). But the point is that the makers of these drugs have for the past decade or more aggressively marketed them to primary care providers (PCPs) over and above psychiatrists. The drug companies’ strategy is to persuade non-psychiatrists that they are so easy to prescribe that patients’ depression can be managed without needing to refer to psychiatrists or psychotherapists. Do we hear inadequate care here?? Most PCPs do not have the time or the expertise to track a patient’s suicidality adequately, and they are not sophisticated enough psychopharmacologically to recognize and address akathisia. (I know; I teach both suicide assessment and psychopharmacology and, at various times, have been approached by pharmaceutical companies to train PCPs,) I’ll bet that the proper analysis would show that any excess suicide mortality over the last decade or so in patients on SSRIs has a correlation with the proportion of SSRI ‘scripts written by non-psychiatrist MDs. ( No offense to the primary care physicians among you; you are victims of the no-holds-barred marketing tactics of Eli Lilly et al as well!)

But maybe it isn’t SSRIs at all. If there were a different reason over the past ten or fifteen years that depressed patients were committing suicide more (like the adverse impact on quality of mental health treatment caused by the penetration of managed care), this might be misconstrued as an SSRI effect. Since SSRIs became the first-line medications for depression during that time period, totally supplanting older antidepressants, treatment with medication for depression during that time period has been virtually synonymous with treatment with an SSRI.