Antidepressants are, by definition, supposed to improve mood. They are prescribed to lift people out of psychological depression. In theory, drugs like fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft) should prevent the dire consequences of depression. It seems absurd that antidepressants and suicide could be linked. What about if antidepressants like duloxetine (Cymbalta) are prescribed for pain? Do doctors warn pain patients that such a drug might increase the risk for sadness or suicidal thoughts?
Are Patients and Family Members Warned?
We suspect that many prescribers do not believe antidepressants can increase the risk of suicidal thoughts and actions. Perhaps that is why they do not warn patients or their families to be vigilant for signs of suicidality.
This parent shares a horrible story:
Q. For 20 years, my daughter struggled with schizoaffective disorder. Despite a caring family, she was simply referred from doctor to doctor, from hospital to hospital, with no continuity of care.
At one point, she was on multiple medications, some contraindicated. Therapy sessions turned into 15 minute “med checks.”
Tragically, she ended her own life. When she died, she had just been put on an antidepressant with a black-box FDA suicide warning.
A. We are so sorry to learn about this tragedy. Most antidepressants now come with a warning about an increased risk of suicidal thoughts and behaviors. We worry that some clinicians may not take this caution seriously enough.
Our mental health care system depends heavily on medications. While these can help reduce symptoms, they are no substitute for comprehensive care.
Duloxetine Prescribed for Nerve Pain Led to Symptoms of Depression:
Many doctors are convinced that if someone with depression develops thoughts of self harm, it is the underlying mental illness that is causing suicidal ideation. That is even with the FDA’s boxed warning regarding “Suicidality and Antidepressant Drugs.”
This reader was never told that duloxetine prescribed for back pain could cause depression:
Q. I have pain due to severe compressed discs in my lower back. My doctor prescribed duloxetine, which was very effective. After a short time, though, I felt fatigued, weak and listless, with low energy. Also, I was very sad. These are symptoms of depression.
After reading about duloxetine side effects, I told my doctor and stopped taking the drug. My mental state improved immediately.
Now that I know the probable side effects, can I start duloxetine again and monitor myself closely? Would the side effects eventually fade away as I continue the medication?
A. Duloxetine (Cymbalta) was originally approved to treat depression in 2004. Later, the FDA gave it the green light for nerve pain, fibromyalgia and musculoskeletal pain.
The official prescribing information warns that patients suffering from major depression:
“may experience worsening of their depression and/or the emergence of suicidal ideation and behavior.”
Other potential complications include fatigue, weakness and lack of energy.
It is hard to tell whether such adverse reactions would fade with time. You may want to ask your physician if there is another approach to ease your back pain.
What If?
What if you learned that your blood pressure medicine increased the risk of stroke? You would be outraged, right? After all, one of the key reasons to take a medication to lower blood pressure is to prevent strokes.
A diabetes drug is supposed to reduce the complications of diabetes, such as heart attack. Drug companies now test their new glucose-lowering meds to prove that they do not increase the likelihood of cardiovascular complications. (Some prior diabetes drugs seemed to up the odds of heart attacks and strokes and fell into disfavor for that reason.)
Antidepressants and Suicide?
When it comes to treatment of depression, though, many people seem OK with the concept that antidepressants and suicide might be connected. It’s almost as if we cannot conceive of the idea that a drug intended to prevent something as serious as suicide could actually contribute to its emergence.
Few drug side effects are as controversial as suicide. When antidepressants were linked to an increased risk of suicidal thoughts or actions in young people, many health professionals and patients were skeptical. Actually, scornful might be a better description.
green and white 10 packet of pills for depression and metal health
A Short History of Prozac:
It seems counterintuitive that a medication designed to protect people from depression or self-harm could actually push some over the edge. Many years ago, in our book, Graedons’ Best Medicine (1991), we wrote about the evolution of Prozac:
“When Prozac (fluoxetine) was introduced in 1987 it barely made a splash. The Eli Lilly Company had been badly battered by the Oraflex scandal of the early 1980s. This prescription arthritis drug had been aggressively promoted with a full-court publicity blitz, but was later found to cause potentially life-threatening kidney and liver damage. The drug was eventually outlawed, but only after thousands of adverse reactions and over a hundred deaths worldwide. It was one of the darkest moments in Lilly history, especially since there had been charges of a cover-up.
“Perhaps because of the Oraflex debacle Lilly planned the Prozac promotion carefully. Instead of launching the drug with great fanfare, the company initially introduced this entirely new antidepressant only to psychiatrists. There were no glitzy press kits and no dog and pony shows. But the drug took off like a shooting star!
“In 1988 Prozac chalked up sales of $125 million, a very respectable number in the pharmaceutical industry for a new drug. The next year sales had leaped to over $350 million.
“In less than two years the American public spent more on Prozac than it had spent previously on all of the other twenty antidepressants combined. The drug was projected to top $1 billion by 1995, if not sooner. (Only six other medications have reached such rarified atmosphere, and few so fast.) At the time of this writing, 650,000 prescriptions are being filled each month and that number is quickly expected to reach one million a month.
A Tragic Suicide Story Not Long After Prozac’s Launch:
“Several years ago we received a troubling letter from a physician who told a tragic story about the death of his forty-year-old daughter:
“During the time when she found she was going through a difficult emotional period, her counsellor recommended that she see a physician who, because Jeanne was not eating properly, started her in a program for eating disorders.
“He prescribed the medication Prozac. One month later, after taking this medication, she committed suicide by hanging herself. What was so strange about this unsuspected action was that she was not behaving like a person who was depressed or suicidal.”
“At first we discounted the significance of this story. Unfortunately, emotionally disturbed people sometime commit suicide whether they are taking an antidepressant or not.
“But in February 1990 an article appeared in the American Journal of Psychiatry (Feb. 1990) that shed a new light on this case history. Physicians associated with the Department of Psychiatry at Harvard Medical School reported on six patients who suddenly developed an:
“intense violent suicidal preoccupation after 2-7 weeks of fluoxetine [Prozac] treatment.”
“It would be disastrous if an antidepressant medication actually produced “obsessive, recurrent, persistent and intrusive” thoughts of suicide. This may be a rare occurrence, but the Harvard psychiatrists warn that people who feel fatigued and restless or sleep much more than usual may be at higher risk. Anyone who starts to feel in the least suicidal on this medicine should contact a psychiatrist immediately! The company believes that Prozac is no more likely to cause this type of problem than any other form of therapy, but for the moment this is a small cloud on Prozac’s otherwise bright horizon.”
Keep in mind that section in our book, Graedons’ Best Medicine, was written in 1990, just a couple of years after Prozac was approved. We had many conversations with representatives from Lilly and the FDA about our concerns regarding Prozac and suicidal thoughts. We kept being reassured that there was nothing to worry about. We continued to alert our readers, however, that there might be a connection between antidepressants and suicide.
The FDA on Antidepressants and Suicide:
The FDA eventually required drug makers to include a black box warning on most antidepressants.
Here, for example, is what appears in the prescribing information for paroxetine (Paxil):
“Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of paroxetine or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need.”
Adults, Antidepressants and Suicide?
The FDA warning suggests that adults are not affected:
“Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24…”
Visitors Continue to Share Tragic Stories:
We have heard from readers who might dispute that assessment, however. One person wrote about her son:
“He was a 35-year-old young man with everything to live for, good job, happily married, no financial problems. He was experiencing some anxiety and chest pains and saw a doctor who prescribed Paxil. Three days later my son committed suicide. Something needs to be done to stop this from happening to others.”
Another reader related her own experience:
“After having experienced 11 deaths in my immediate family in less than 36 months, I sought help from a therapist who subsequently referred me to a psychiatrist. After one session I was diagnosed as being clinically depressed and placed on Wellbutrin XL and Lexapro. Within two months of starting the medications, I began to experience very, very strong impulses to harm myself. The psychiatrist assured me that this could not be a side effect of the medication and suggested that I take a vacation.
“I took her advice and went to Hawaii. When I checked into the hotel, I had a strong desire to jump out of the elevator somehow. When we were walking down the hallway to our rooms, I happened to glance over the balcony and envisioned myself climbing over and jumping. Once in the room, I contacted the psychiatrist again and was told that these thoughts would go away.
“We had a patio on our room and everything in me wanted to fling myself from the patio. I sat on the floor because I feared that if I stood up, I would walk out and jump over, falling 32 floors to the ground.
“I IMMEDIATELY discontinued both medications and I have never ever experienced any thoughts or feelings like those again. Prior to starting those meds I never had any suicidal thoughts. I am a successful business owner, mother and grandmother with no history of mental illness.”
We have received many similar stories from adults. We suspect that young people are not the only ones who are vulnerable to this complication, despite the FDA’s reluctance to warn about such a link. There is, however, some science to support an association.
Research Linking Antidepressants and Suicide:
Swedish investigators wanted to know whether antidepressants reduced or increased the risk of suicide (International Journal of Risk & Safety in Medicine, 2017). Their objective:
“To establish whether the young women (15-24 year old) who committed suicide in Sweden (1999-2013) received antidepressant treatment or not, and to what extent, prior to and/or at the time of suicide. To investigate the belief that increased prescription of antidepressants would drastically reduce the number of suicides.”
Their Conclusion:
“An increasingly larger proportion of young women who later committed suicide, had in the last few years been treated with antidepressants, prior to and at the time of the suicide. The previous assumptions that treatment with antidepressants would lead to a drastic reduction in suicide rates, are incorrect for the population of young women. On the contrary, it was found that an increasing tendency of completed suicides follow the increased prescription of antidepressants.”
The New York Times and a “Lawsuit Over a Suicide”
An article by Roni Caryn Rabin in the New York Times (Sept. 11, 2017) discusses the connection between antidepressants and suicide. In particular, it describes the case of Stewart Dolin, a 57-year-old lawyer who “threw himself in front of an oncoming train” after taking paroxetine.
The FDA-sanctioned label on Paxil and paroxetine notes that like other antidepressants, any risk of suicidal thinking or behavior is limited to children, adolescents or people under the age of 25.
As reported in the NYT though:
“Ms. Dolin’s lawsuit, however, has lifted the curtain on data from early clinical trials of Paxil, renewing concerns that older adults, who use antidepressants in far greater numbers than young people, may also be at greater risk of self-harm when taking the drugs.”
The People’s Pharmacy Perspective:
We have been writing about this controversial topic for almost three decades. We are still surprised by the amount of push back there is from health professionals, patients and the Food and Drug Administration. That said, the FDA has added this caution:
“Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.”
That’s not nothing. But we think it falls short of a true warning about antidepressants and suicide in adults.
We know that many people benefit from such drugs. For that we are truly grateful. And patients should never stop antidepressants suddenly or on their own. Withdrawal symptoms from stopping antidepressants can be brutal. Here are links to articles on this topic:
Antidepressant Withdrawal Feels Like Circles of Hell
How To Stop Duloxetine (Cymbalta) Without Withdrawal Symptoms
Share your own thoughts on antidepressants and suicide below in the comment section. Have you found drugs like fluoxetine, duloxetine or sertraline helpful? If so, we would like to hear from you. Have you had significant side effects from antidepressants? We’d like to read your story too.
