Antidepressants and Increased Suicidality
The Media Portrayal of Controversy
Ian R. Sharp, Department of Psychiatry, University of Pennsylvania
Jason E. Chapman, Department of Psychiatry, University of Pennsylvania
The authors wish to thank Elizabeth L. Jeglic for her assistance in reviewing and rating the media articles.
The potential link between antidepressant use and the emergence of suicidality is currently an active topic not only in the scientific community but also in the popular media. Vivid stories of children, adolescents, and adults committing suicide while taking antidepressants have been widely featured on television and in the print media. It is beyond the scope (or ability) of this paper to present a comprehensive overview or definitive conclusion about whether antidepressant use contributes to suicidality. This is an extremely complex issue for which we believe the jury is still out. The focus of this paper instead is on the accuracy of recent media coverage of the topic. This is an especially relevant issue as most people (including those taking or who have children who are taking antidepressants) acquire information through newspapers, television, and the Internet.
Brief Overview of the Controversy
According to the Centers for Disease Control’s National Vital Statistics Report, 1,883 children and adolescents between the ages of 10 and 19 committed suicide in 2001. There is significant evidence that a majority of these individuals likely suffered from some form of psychopathology, often depression (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Shaffer & Craft, 1999). There is also evidence of an increase in the use of psychotropic medications for children and adolescents, with utilization rates approaching that of adults (Zito et al., 2003). On March 22, 2004, the U.S. Food and Drug Administration (FDA) released a Public Health Advisory warning of the potential risk of worsening depression and/or emergence of suicidality in both adult and pediatric patients taking several antidepressants. This story received significant media coverage.
The controversy over whether antidepressant use can increase suicidal behavior in some people began primarily in the early 1990s with a number of published reports on the emergence of suicidality in a minority of research participants taking fluoxetine (Prozac) (King et al., 1991; Teicher, Glod, & Cole, 1990). Much of the early evidence supporting the link has been limited to small numbers of research participants or clinical case reports. For example, Vorstman, Lahuis, and Buitelaar (2001) reported on the case of a 10-year-old boy whose mild suicidal ideation severely worsened following trials with two separate SSRIs. In contrast, there is seemingly conflicting evidence from large epidemiological studies suggesting that increases in antidepressant prescription are related to decreases in suicide among youth (Olfson, Shaffer, Marcus, & Greenberg, 2003).
In response to the initial reports of a purported link between antidepressant use and emergent suicidality, the American College of Neuropsychopharmacology (ACNP) issued a review of available data in 1993 and concluded that no link existed in studies of adults (ACNP, 1993). Similarly, in response to the recent controversy, the organization released another review concluding that there was no significant increase in suicidal behavior in clinical trials of youths, and noted that there were no deaths by suicide among more than 2,000 research participants (ACNP, 2004). However, others have argued that meta-analyses of randomized clinical trials reveal higher rates of suicide acts by those on active treatments as compared to placebo, leading to the conclusion that “it is difficult to sustain the null hypothesis that SSRIs do not cause problems in some individuals” (Healy & Whitaker, 2003, p. 331). Therefore, this debate continues to be a controversial topic with a number of significant unanswered questions. We next turn to a description and evaluation of the popular news media coverage of the debate.
To effectively describe the news media coverage of the antidepressant-suicide controversy, we believed that it would be informative to systematically evaluate the amount and type of coverage that has occurred. Lexis-Nexis (http://www.lexis-nexis.com), a searchable electronic database of major news sources, was used to identify occurrences of the keywords “antidepressant” and “suicide” in major newspapers beginning in the year 2000. The Figure depicts the findings of this search categorized by year. We note that search criteria were limited to variants of the keywords “antidepressant” and “suicide” (e.g., search results could include terms such as “antidepressants” and “suicidal”). Thus, the results may include articles that do not exclusively focus on the potential link between antidepressant use and suicide, and may include those that happen to contain each of the keywords. Bearing this limitation in mind, the figure illustrates a marked increase in the occurrence of these keywords in major newspapers beginning in the year 2003. More specifically, there was a 252% increase between 2002 and 2003. Additionally, between January 2004 and the end of March 2004 (a 3-month span), the keywords appeared approximately 165% more frequently than during the entire year of 2002 and nearly 66% of the entire year of 2003. Most notable for the results from January to March 2004 is that the number of headlines containing the keywords quadrupled from the entire year of 2003. Thus, the coverage of this debate in major newspapers increased substantially from 2002 to 2003 and signs of even greater increases between 2003 and 2004 may be anticipated if current trends continue.
Figure. Lexis-Nexis search results for “antidepressant” and “suicide” appearing in major newspaper articles and headlines.
Because the news media’s coverage of the antidepressant-suicide controversy has increased dramatically, serious concerns exist regarding the impact of this coverage on the perceptions and reactions of the general public. Specifically, questions arise regarding the content, quality, balance, and accuracy of these articles. Our primary goal was to specify criteria for evaluating these articles, evaluate a sample of relevant articles, and provide conclusions regarding the nature of the news coverage of this topic. We next briefly present the methodology we employed.
Our general review of the news media coverage (i.e., major newspaper articles containing the keywords “antidepressant” and “suicide”) assisted us in the specification of 6 criteria we believe are important, particularly from the public’s perspective, in an evaluation of the overall merit, strengths, and weaknesses of the news coverage. Consensus between the authors was reached on each criterion. We describe these criteria below. Following specification of the criteria for evaluation, we randomly selected 10 of the 21 (48%) major newspaper articles published during February and March 2004 with headlines containing the keywords “antidepressant” and “suicide” (see Appendix). We then reviewed these articles according to the 6 criteria (see Table). The reviews were conducted independently by two doctoral-level researchers, one of the authors (J.E.C.) and another psychologist engaged in suicide research. We reviewed the ratings and reached consensus on each of the independent ratings. We turn next to the description of and rationale for each criterion, as well as the findings from our review.
Criteria and Ratings of Newspaper Articles Covering the Antidepressant-Suicide Controversy
Does the article’s headline present a reasonably balanced description of the potential link between antidepressants and suicide? Our description of the news coverage began with the article’s headline, as headlines frequently serve as the “catch” or impetus for continuing to read a given piece. Ideally, headlines would provide a glimpse of each side of the debate. Our review of the 10 articles found that 2 of 10 headlines (20%) presented a balanced view of the controversy. For example, the headline “FDA’s suicide alert no reason to cut drugs, experts say: Researchers split on antidepressant risk” (Fidelman, 2004) acknowledges the lack of certainty around this topic; whereas the headline “US regulator acts on suicide risk of antidepressants” (Boseley, 2004) is more ambiguous and is thus viewed as less balanced.
Do articles that present vignettes of patients who committed suicide while taking antidepressants also present vignettes of patients who benefited from the use of antidepressant medications? We were concerned about the potential influence of using vignettes in which a study participant/patient tragically committed suicide. Although this appears to be a rare occurrence, the extreme seriousness of the outcome and the use of such emotional vignettes may contribute to a vividness bias or availability heuristic on the part of the general public. Of the articles reviewed, 2 of 10 (20%) presented vignettes of participants/patients who committed suicide, and of these, 1 (50%) presented vignettes of individuals/ patients who reported marked benefits from antidepressant medications.
Does the article include an adequate and balanced description of the antidepressant and suicide controversy, including limitations of findings and unanswered questions? This criterion was intended to evaluate the quality of the general coverage of the topic. We were again concerned that a one-sided presentation of the current data would adversely impact the decision making of patients, families, and professionals. Our review indicated that 5 of 10 articles (50%) provided a balanced discussion of the topic. For example, in what we consider a balanced description, Fidelman (2004) reported on the FDA warning and possible link between antidepressants and suicide in addition to a description of potential alternative explanations for this relationship, acknowledgment that suicide is a rare occurrence, and mention of the established efficacy of antidepressant medications. In contrast, Boseley’s (2004) coverage of the topic was limited to evidence supporting a causal link between antidepressant use and suicidal behavior.
Does the article address the potential risks associated with not treating depression or other psychological disorders? Our review of newspaper articles revealed numerous statements that clearly suggest that the use of antidepressant medications places patients at risk for suicide. However, given the potentially significant impact of these articles on the public’s willingness to consider medication as an intervention for depression, equal consideration should be accorded to the potentially serious risks associated with not treating depression. These risks also include suicide. Our review found that 5 of 10 articles (50%) discussed the potential risks and concerns associated with not treating depression as the result of concerns over antidepressant medications.
Does the article recommend that individuals taking antidepressant medications be closely monitored by parents or family members? If so, does it provide specific guidelines and warning signs? Given the increasing coverage of this issue, the media may represent an effective delivery method for disseminating information about potential warning signs to monitor in those taking antidepressants that would signal the need for immediate intervention. This would include specific, concrete guidelines for parents and patients regarding the warning signs of any potentially serious side effects of antidepressant use. Our review indicated that 5 of 10 (50%) of the articles made some general statement related to the need for increased monitoring by parents or patients. Nevertheless, only 1 of these 5 (20%) delineated specific signs and symptoms, such as worsening depressive symptoms or increasing suicidal ideation.
Does the article review or address the availability of alternative empirically supported interventions for depression? Because the public’s willingness to seek appropriate treatment for depression may be negatively affected by this controversy, this criterion is of great importance. That is, if a significant link exists between antidepressant use and suicide, the public should be well informed of alternative treatments for depression that are not associated with these negative outcomes. Although half of the articles reviewed cited the potentially negative and serious consequences of untreated depression, 0 of 10 (0%) provided information about alternative treatments for depression. Particularly striking was the lack of discussion of empirically supported psychological interventions (e.g., cognitive behavior therapy).
The antidepressant-suicide debate is highly controversial in the scientific community, and additional research is needed to clarify what causal relationship, if any, exists between antidepressants and suicidality. Media coverage of this topic helps to alert society to possible risks. However, there is also significant potential for harm. For example, overly alarmist coverage could lead some parents to withdraw their children from drug treatments without the appropriate guidance of a physician, inadvertently placing their children at increased risk for medical complications or suicide. Based upon our review, half of the articles provided a reasonably balanced view of the controversy, with the remaining articles focusing heavily on evidence of a link. Furthermore, only one of the reviewed articles provided specific guidelines and warning signs for individuals taking antidepressants, and none discussed alternate empirically supported interventions, such as cognitive behavior therapy. Fortunately, although the articles we reviewed often failed to meet our criteria for ideal coverage, they were largely free of sensationalism or extreme bias. Finally, it should be noted that our review was limited to newspaper articles. There may be important differences in television or Internet coverage of the topic.