US Preventive Services Task Force: No evidence that screening for suicide reduces suicide
Fri, 21 May 2004
The U.S. Preventive Services Task Force (USPSTF) issued its findings and recommendation against screening for suicide. The USPSTF findings corroborate those of the Canadian PSTF.
“USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. There is limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk. The USPSTF found insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality. The USPSTF found no studies that directly address the harms of screening and treatment for suicide risk. As a result, the USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting.” See: http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm#clinical See: Annals of Internal Medicine, May 18.
These authoritative findings contradict the recommendations of professional associations whose members have a financial interest in recommending screening for illness programs, and call for a reassessment of costly, federally funded screening for depression programs such as those that target school children and adolescents. Those funds can be put to better use for children’s healthcare needs.
A panel discussion at the NY Academy of Medicine (May 19), focused on Adolescents and Antidepressants in the News: Facts and Fears. The panel of speakers included two psychiatrists, two medical reporters, a child and adolescent screening center, and a parent trying to cope with troubled teens. The meeting was sponsored by NAMI (of NYC), an organization that promotes the use of psychotropic drugs–voluntarily or not. The drugs have been shown to induce severe adverse effects in a significant number of patients, in many cases, these adverse effects have proven worse than the condition for which the drugs had been prescribed-some have died as a result. See: revised (2004) label warning about drug-induced hyperglycemia and diabetes for patients taking Zyprexa (olanzapine) and other atypical antipsychotics: http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#zyprexa
It was apparent that those who have had a role in creating an inflated market for antidepressants are uneasy about the negative public perception of overprescribing drugs for children. The drug industry and their collaborators are turning to the media to protect them from critical news reports. The media, however, is dependent upon drug advertising. Thus, it is hardly biased against the drug industry.
It is fair to say, that collectively, our educational efforts and family testimonials, have brought about a demonstrable change in public perception–simply by bringing the facts about the drug controversy to the public arena.
A survey of 512 parents of children under 18 was commissioned by Columbia University “amidst the current controversy over anti-depressant safety.” The questions appear to have been designed to elicit responses favoring widespread school “screening for depression” to prevent suicide, and to elicit criticism of the media for bias against antidepressants. However, the most robust finding showed that: 68% (78% males, 57% females) of parents believe that antidepressants are overprescribed to teens compared to 8% who think the opposite! 67% (73 male, 60% female) believe antidepressants are usually, but not always safe for teenagers.
Half the parents believe that antidepressants pose an increased risk of suicide; 38% say they affect brain development; 37% believe they cause weight gain / loss; and 30% (46% female, 22% male) believe antidepressants worsened depression. See: http://www.teenscreen.org
Laurie Flynn, former executive director of NAMI, who now heads Carmel Hill Center for Early Diagnosis and Treatment, a federally funded, national teenage mental health screening program claimed that the recent MEDCO report documenting skyrocketing SSRI sales for children–particularly preschool children– demonstrates the importance of antidepressants: “just like antibiotics and anti-asthma drugs.” See: Medco’s Drug Trend Report and Symposium: http://www.drugtrend.com
The pitch is for “regular screening” of high school children for depression: “Teens need mental check-ups–just like heart and lung check-ups…” (Heart and lung check ups are conducted at medical facilities using objective, scientifically verifiable tests–whereas depression is diagnosed on the basis of flawed, subjective check lists). Ms. Flynn proclaimed: “schools should screen for mental health.”
In light of the negative findings by the U.S. Preventive Services Task Force, the costly Carmel Hill school screening project should be re-evaluated, inasmuch as such screening does nothing to prevent suicide in adolescents, and it may do much harm. Given the Medco finding about the inordinate, unsupportable escalating prescribing of SSRIs for children, the teen screening program will likely further increase the market for antidepressants, as additional children will be labeled “depressed” and will likely be prescribed antidepressants.
The two psychiatrists, Dr. Gabriella Carlson (Stony Brook) and Dr. Mark Olfson (Columbia University) were in a bind because they recognize that public opinion is critical of those who overprescribe SSRIs for children. And they are painfully aware that the published reports upon which they had relied when they claimed the drugs had been proven safe and effective for children, have been discredited.
The April 24 article in The Lancet was cited without clearly indicating what the devastating findings are. See: SSRIs in childhood depression: systematic review of published versus unpublished data. The Lancet. Volume 363, Number 9418. See also: Efficacy and safety of antidepressants for children and Adolescents. BMJ, online free at: http://bmj.bmjjournals.com/cgi/content/full/328/7444/879?
Drs. Carlson and Olfson acknowledged the uncertainties of diagnosing depression in children / adolescents; they acknowledged the weaknesses in clinical trial design and recruitment of subjects; they were critical about the uncertain outcome criteria; and they questioned the credibility of the claims made in clinical trial reports! They embraced the very arguments that have been made for years by critics who had been scoffed at.
Dr. Carlson dismissed the value of clinical trials which, she acknowledged, were flawed, rushed, and unrepresentative of the population for whom the drugs are prescribed. She acknowledged that:
*investigators rush to recruit children in order to fill quotas;
*methodology, such as the use of the HAM rating scale for determining diagnosis and recovery was flawed, if not meaningless;
*some children are enrolled by doctors who use the trials to provide treatment then let them drop out.
“We don’t have confidence in the information [obtained in clinical trials] or how successfully the drugs worked or how safe they are.”
It would appear that even mainstream child psychiatrists now lack confidence in the integrity of industry-sponsored trials, thereby validating the concerns expressed by critics. This shift is made somewhat in self-defense, with an implication that someone other than they was responsible for pulling the strings that control how clinical trials are conducted, and how information is selected, analyzed, and reported.
Dr. Olfson, who did not disclose his financial ties to drug companies, talked about a “collision of culture” referring to the media / internet and (presumably) medicine. He suggested a decline in suicide rates among adolescents since use of SSRIs. However, when he examined regional differences, he acknowledged that the areas that had highest SSRI consumption had highest suicide rate; and those with lowest SSRI consumption, had lower suicide rates.
Dr. Olfson claimed that no suicides had occurred in clinical trials–until reminded (by Lynn Michaels) that Traci Johnson, a teenager, had committed suicide at Eli Lilly’s laboratory. Understandably, Dr. Olfson appeared uncomfortable by the reminder, inasmuch as he claimed that the rate of suicide decreased since SSRIs.
Two media cheerleaders expressed no doubts whatever about the drugs’ benefit. Jamie Talan (NY Newsday) who has close ties to psychiatrists who promote drugs, suggested that the many patients who were helped by SSRIs, more than justified their use, even if a few suffered harm. Michael Rosen, MD (WCBS) was outright hostile toward critics of the medical establishment. Sounding more like a crusader than an objective, responsible journalist, Rosen railed against Public Citizen and those in the media who report critical findings about medical practice. He lashed out at a nameless NY Times reporter who had reported that studies showed that mammograms were of no benefit for women between 40 and 50 years (a controversial issue). Dr. Rosen stated that if a single woman didn’t have a mammogram and died of cancer, it would be that reporter’s fault. Curiously, he failed to apply the same standard to reporters who failed to report the controversy swirly around antidepressants and the suicidal risk. Will Dr. Rosen assume responsibility for every child who committed suicide because the risk of drug-induced suicide had not been disclosed on the drug label, and he had failed to report about the controversy so that parents would be better informed?
Neither of these reporters seem to appreciate the role of an independent press, and the necessity of airing controversial medical issues publicly–so that the public is informed that there is more than one point of view among experts, rather than being misled into believing that a consensus of scientific opinion exists.
Dr. Rosen’s journalism ethics seems to be entirely shaped by what’s good for the medical provider industry. That business ethic is at the root of current bad medical practices such as the medically unsupportable, hazardous prescribing of antidepressants for preschool children.
When opportunity for public comment presented, I informed those attending about two relevant news items: New warning labels (April 2004) issued by SSRI and SNRI manufacturers (except Lilly and Pfizer) acknowledging the drugs are linked to: “Clinical Worsening and Suicidal Risk” for children and adults. Among the psychiatric adverse drug effects listed: “anxiety, agitation, panic attacks, insomnia, irritability, hostility (aggressiveness), impulsivity, akathisia (psychomotor restlessness), hypomania, and mania have been reported in adult and pediatric patients being treated with antidepressants…”
The labels go on to warn: “Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, and the other symptoms described above, as well as the emergence of Suicidality, and to report such symptoms immediately to healthcare providers.” See, for example: http://www.lexapro.com/pdfs/lexapro_pi.pdf
This is an acknowledgement that the drugs, not the underlying depression are to blame, puting physicians and caregivers on notice that the drugs can produce these dangerous behavioral symptoms.
Lynn Michaels suggested that genetic testing be required PRIOR to the prescribing of SSRI’s to children. The tests determine an individual’s ability to metabolize an SSRI and are readily available [Genelex Labs –www.healthanddna.com]. If an individual does not have the necessary enzymes to metabolize an SSRI, the drug quickly builds up in the child’s system, causing the child to go into psychosis. This is the period when the drugs become lethal and suicide occurs. By requiring this simple blood test, the guess work would be eliminated as to whether or not the drugs are harmful. One of the doctors in the audience agreed and stated that the cost for each test was approximately $300/child.
Lynn referred to the research by Dr. Joseph Glenmullen at Harvard University and Dr. David Healy in the UK, who reported that suicides have increased by 750% since the introduction of Prozac over 10 years ago, noting that in legal testimony, Eli Lilly Scientists had acknowledged knowing that Prozac induced Suicidality. She also informed the audience that the wife of Randall Tobias – the former CEO of Eli Lilly – committed suicide while on Prozac.
It is difficult to understand, however, how physicians who are sworn to “do no harm” justify prescribing potentially harmful drugs even without the time or tools to make an adequate diagnostic evaluation.
Contact: Vera Hassner Sharav