Over the past 2 decades, more and more people have been treated with antidepressant medications. In the same period of time, suicide rates have gone up – not down. To those of us who treat patients, this fact is both surprising and perplexing. It seems that suicidal thoughts are a common feature of major depression, and when the depressive symptoms abate with treatment, the suicidal thoughts dissipate. Intuitively, it seems that treating depression on a larger scale should prevent suicides, but we still don’t know that conclusively.
According to the National Health and Nutrition Examination Survey (NHANES), 11% percent of Americans over the age of 12 are taking an antidepressant medication. In women aged 40-59, this number is 23%. Of those taking antidepressants, only one-third have seen a mental health professional in the past 12 months. What also is striking is that for people surveyed with symptoms of severe depression, only one-third were on medication.
In 2013, just over 40,000 Americans died of suicide. From 2000 to 2013, the suicide rate per 100,000 Americans has steadily increased from 10.4 to 12.6 per 100,000 people. While we know that people with psychiatric illnesses have higher rates of suicide compared with the general population, what we don’t know is whether the people dying are the same people who are getting treatment.
Thinking about this gets very difficult. It has been estimated that 90% of those who die of suicide have suffered from a mental illness. This figure includes those who were treated, untreated, and previously treated, but the studies have methodologic inconsistencies and that 90% estimate may not be accurate. Certainly, however, people die of suicide for reasons that have nothing to do with psychiatric illness, and we do know that impulsive responses to distressing circumstances are a factor, especially when a lethal method is easily available.
Several studies have shown that antidepressant use, particularly in older adults, may be associated with a decrease in suicidality. The studies often combine suicide attempts and completions. The issues with younger patients are more complicated, and in recent weeks, the reanalysis of the 2001 Paxil 329 study has again raised issues about the safety of certain antidepressants in children and adolescents. The data for all these studies are both confusing and contradictory, and are not easy to examine or interpret.
We also don’t know what role psychotherapy plays. A study done at Johns Hopkins Bloomberg School of Public Health looked at the follow-up for 65,000 people in Denmark who had attempted suicide and found that the rates for completed suicide dropped if the patient received a short course of psychosocial therapy at a suicide prevention center. But again, this study looked at a select group of people who had already attempted suicide.
I began to think it might help to ask these questions in a closed system where patients could be tallied with regard to requests for treatment, what type of treatment was provided, and even access to autopsy results. The U.S. Department of Veterans Affairs seemed to be a source where such answers might be found. It has been reported that 22 veterans a day die by suicide, and many veterans get their care in VA facilities, with VA pharmacy benefits, and treatment effects can, in theory, be studied.
Hoping to get a better sense of the relationship between treatment and suicide, I met with Robert Bossarte, Ph.D., director of the Epidemiology Program in the VA’s Office of Public Health. His career has been focused on suicide prevention.
The first thing Dr. Bossarte did was dissuade me of the idea that the VA is a closed system. Not all veterans receive lifelong benefits from the VA, and the formulas for determining who is entitled to what benefits, and for how long, is rather complicated. Dr. Bossarte also noted that some patients go outside of the system for their care.
“What we do know is that among those who have used VA services in the previous year, about 2,000 veterans a year die from suicide. It’s been hovering around that for the past decade,” Dr. Bossarte explained, again emphasizing that many veterans do not receive care at VA facilities. “We published a report in 2012 where we estimated 22 veterans a day die by suicide and that caught fire, but it is purely an estimate. The truth is we have no idea what the real count is, because until we began working on the Suicide Data Repository there was no national register of veteran mortality and there has been no way for us to know.”