Wood s lot points to this essay from The Globe and Mail: When depression turns deadly, which asks “Can antidepressants transform despair into suicide?” Although there’s no love lost between me as a psychopharmacologist and the rapacious pharmaceutical manufacturers, the article is misleading. It’s no surprise that the manufacturer of Prozac, Eli Lilly, settles lawsuits out of court and tries to minimize negative evidence, but that doesn’t damn the drug, only the corporation. The research studies that purported to show a link between SSRIs and suicide are largely discredited, methodologically flawed and inconclusive. I’m familiar with several of the Boston-area psychiatrists featured prominently as critics of the SSRIs, and know them to be sensationalistic media hounds. Anecdotal reports of suicide on Prozac and other SSRIs come from a number of factors:

Early on, when these observations were first made, Prozac was being tried on the most desperately ill patients who had failed most existing antidepressant treatment. Many of us think the suicidal despair that arose in a subset of these early users was not due to a pharmacological effect of the drug but subjects’ added disappointment at its failure to live up to its miracle ‘hype’ in such recalcitrant cases. Many of the most chronically, treatment-resistant depressed cases do not represent classical ‘major depressive episodes’ which have a good prognosis for medication response, but rather the entrenched,lifelong and atypical depression of patients with personality disorders, especially borderline personality disorder. These patients are prone to both suggestibility and self-destructiveness. Suicidality is always a risk factor in unresponsive depression.

Suicidality is a risk factor in improving depression too. All antidepressants can promote suicidality in that, paradoxically, as depression responds, the first thing to change — before the despair and hopelessness that make the sufferer conclude she should end her life — may be her energy, motivation and confidence to carry out a suicide plan. It is an old chestnut in psychiatric training to watch for this problem, a skill that has fallen by the wayside with modern prescribing practices (see below).

Prozac and several other SSRIs can cause as a side effect a particularly uncomfortable kind of restlessness technically known as akathisia, which can make a person feel like jumping out of their skin — or jumping out of a window. But which can be managed and reversed.

The real culprit here regarding suicide risk is that the SSRIs were such a real advance over previous generations of antidepressants in ease of use (except for the akathisia and sexual dysfunction they cause, which were not appreciated at the outset) absence of severe side effects and nonlethality in overdose, that the prevalence of antidepressant treatment in the population exploded when they caught on. This was largely achieved by an as-yet-unheard-of marketing strategy — the manufacturers targeted not psychiatrists but internists and other primary practitioners to be their major prescribers. Very appealing to the target practitioners — they could handle their patients’ emotional complaints themselves without referrals to psychiatrists, and could offer these endlessly complaining patients (who some estimates suggest make up as much as 50% of the traffic in many primary care practices) something more than time-consuming talk in their office visits. The upshot, of course, was that depression — and, worse yet, difficult personality disorders — began to be treated without adequate time, sufficient skill in the subtle art of suicide assessment, or expertise in management of psychopharmacological side effects.

Finally, let us recall that the anti-Prozac movement was spearheaded by S*c*i*e*n*t*o*l*o*g*i*s*t*s, and that is not just an ad hominem argument! [The asterisks, of course, are because I am paranoid about persecutory lawsuits or denial-of-service attacks…]