By By Jackie Jadrnak /
Journal Staff Writer
Warnings against possible dangers of suicide among people using antidepressants have multiplied in recent years, even as new evidence is arising to contradict that concern.
What’s a depressed person or a prescribing physician supposed to do?
The answer from medical organizations and a couple of local psychiatrists boils down to this: Be careful, be vigilant, but don’t be afraid to get treatment for the problem.
The New Mexico Health Policy Commission is going to take a crack at some of these questions this summer with a task force created through passage of Senate Memorial 9 in the last legislative session.
Commission director Liz Stefanics said the task force won’t tackle every question raised about antidepressants, which the U.S. Food and Drug Administration has been looking at for years. The memorial specifically asks whether physicians should be required to get continuing medical education on how to monitor risks associated with antidepressants.
The legislative action was spurred by an Albuquerque mother, Camille Milke, who has become an activist against antidepressants since the suicide of her 21-year-old daughter Sarina on Oct. 28.
Milke said her daughter was being treated for anxiety by a nurse practitioner and got prescriptions for six drugs — two antidepressants, two anti-anxiety drugs, an anti-convulsive drug and a painkiller — within a nine-day period about a month before her suicide.
She died of carbon monoxide poisoning, sitting in her running car in a closed garage. Milke said an autopsy showed alprazolam, an anti-anxiety drug, and Lexapro, used to treat both depression and anxiety, in Sarina’s blood.
Milke said she believes a side effect of the drugs led to her daughter’s suicide.
“She was not suicidal,” Milke said. “She went to a Halloween party that night ... Friends who saw her that night said she was laughing, she was having a blast. She was making plans for the next day.”
Milke said she has gathered between 1,200 and 1,300 signatures on a petition to abolish antidepressants through her Web site, www.copesfoundation.com. The foundation Milke formed — Coalition of Parents Enduring Suicide — solicits contributions for an eco-retreat Milke said she hopes to create to offer nondrug, natural treatments to people suffering from emotional and addictive disorders.
Milke believes SSRIs — selective serotonin reuptake inhibitors, a type of antidepressant that is thought to delay the breakdown in the brain of the chemical seratonin — are dangerous.
The U.S. Food and Drug Administration has enough concern about the drugs that it has included a “black box” warning that says, in part, “Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior... Pooled analyses ... have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants.”
The FDA initially called for the warning in 2004 on 10 SSRIs when they were used in people younger than 18. It later expanded the warning up to age 24 and applied it to all antidepressants.
Now there’s a move to expand the warnings to anti-convulsive drugs, used to treat epilepsy and other seizure disorders, according to Dr. Jan Fawcett, professor of psychiatry at the University of New Mexico.
There’s one important thing to realize, though, he said.
“The studies do not show there are more suicides, but a higher rate of threats or behaviors” after people start taking antidepressants, he said.
Some analyses published in the last couple of years show suicide attempts actually peak right before a person goes on treatment and decline afterward — and that’s true for all types of treatment, Fawcett said.
Other studies across populations have shown suicides decreasing after the advent of SSRIs, then rising after the “black box” warnings appeared and prescriptions declined among youths.
It’s possible that certain individuals may be more susceptible to agitation and anxiety that arise occasionally as side effects, leading to threats or attempts of suicide, Fawcett said.
Some research suggests that people with a certain genetic trait may be more sensitive to the effects of serotonin, which increases with antidepressants, he said. Also, 7 percent of Caucasians lack an enzyme used to metabolize serotonin, which can lead to high blood levels if they are taking antidepressants, he said.
Dr. Stephen Adelsheim, a pediatric psychiatrist who serves as a consultant to the state’s Behavioral Health Purchasing Collaborative and as director of UNM’s Center for Rural and Community Behavioral Health, said only one of his patients has displayed the warned-against side effects to these drugs.
“I take prescribing medication very seriously,” he said. “At this point, my years of clinical experience indicate that, when monitored appropriately, the medications are really helpful and they really do save lives.
“The risk-benefit analysis seems really clear that treating people with antidepressants seems to decrease the risk of suicide and improves mental health status,” Adelsheim said. “What seems important is early and close monitoring.”
It’s not clear how closely patients are followed by their prescribers, especially when the drugs are prescribed by primary care doctors and other nonpsychiatrists.
“I think they’re used a little too casually,” Fawcett said.
Accurate diagnosis also is key, Adelsheim said, noting that bipolar patients, who might appear to be suffering from depression if they seek help in that phase of their cycle, can become manic when they take antidepressants.
The standard of care also calls for depressed patients to receive nondrug therapy to help change their thinking patterns and behavior, he said.
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