[swores]

> When they trialed Prozac on people with no history of mental illness, someone committed suicide out of the blue.

I hadn't heard about this before, and while I'm sure it is possible for any drug that messes with brain chemicals to cause someone to decide to kill themselves, I've always been told & read a different explanation for the suicide warning that comes with most (or all?) antidepressants:

Which is that a depressed person while at their lowest might think about suicide but not have the energy or willpower to do anything, but if they start taking a drug that partially fixes it, so they start having energy again, but doesn't fix their root problems so they still think that suicide would be preferable to life, and suddenly have energy to make that happen.

Which is also the reason that modern guidance is for antidepressants to be co-prescribed with talk therapy, to try to use drugs to let the person be able to work on their issues, rather than just hoping the drug can fix all issues.

[skissane]

That may be a factor, but it is likely more complex than just that.

SSRIs can cause some individuals to become disinhibited, impulsive. It is a particularly common symptom in children and adolescents (which is why many paediatricians and child psychiatrists hesitate to prescribe them), but more rarely can happen in adults too. Probably some people have a genetic susceptibility to it. It isn’t purely about ameliorating depression, since the same side effect has been observed in non-depressed children administered SSRIs (which aren’t solely used to treat depression, sometimes they are used to treat anxiety too, plus some children can end up being prescribed them when they have neither, due to misprescribing or off-label use.)

Disinhibition and increased impulsivity can increase the risks of suicidality/homicidality/etc

[cupcake-unicorn]

I honestly wonder if it isn't less rare in adults or if adults just are more likely to fall through the cracks and to have whatever underlying disorder blamed on the behavior. Children are a more vulnerable group who has a parent who is witness to the obvious behavior changes and can staunchly advocate for their child. Many adults starting SSRIs are isolated, don't have great support networks or friends looking out for them and are meeting with their doctors for the first time. For all the doctors know, behavioral issues were underlying, things just got worse, etc.

Anecdotal, but I've never once met a doctor who adequately described the risks of an SSRI to me as a patient, and even some who have pushed back when I've told them of my own dangerous reactions and other risk factors the drugs have. They really should, as should the risks of new psychedelic based drugs hitting the market. I don't have a problem with the study that's posted. What I do have a problem with is that I feel as if this information is going to be disproportionately used to deny access to RX psychedelics, when existing RXs with similar or worse risk factors aren't discussed in this manner at all.

[skissane]

> Anecdotal, but I've never once met a doctor who adequately described the risks of an SSRI to me as a patient,

I've tried SSRIs several times, more than one (and an SNRI and MAOI too). They never did anything for me other than cause unpleasant side effects.

The best cure for depression I've ever found is Vyvanse/lisdexamfetamine. Is that because I was never actually depressed and my real problem all along was ADHD? Maybe... but, on the other hand, I'm pretty sure sometimes my depression has been an independent problem from my ADHD and sometimes a much bigger one. The fact is, psychostimulants have an antidepressant effect, and are sometimes even prescribed off-label to non-ADHD patients in order to treat depression (generally only for "treatment-resistant depression", i.e. "we've tried all the antidepressants and none of them work"). I think it could possibly benefit more people with depression (at least they should try it), but psychiatrists are discouraged from prescribing it for them (here in Australia, psychiatrists actually need per-patient government approval to legally prescribe stimulants off-label). In practice, it is easier to convince a psychiatrist that you have ADHD, than it is to convince a psychiatrist to prescribe you stimulants for something other than ADHD.

[cupcake-unicorn]

I can understand why you would have that reasoning, but SSRIs are commonly prescribed off label to populations for non-mental health related reasons, for example ED or urinary incontinence, and in these populations the relationship holds, leading to some governments and regulatory bodies to recommend or warn against use for these conditions.

"Although duloxetine reduced the symptoms of stress urinary incontinence and improved women’s quality of life, the harms related to suicidality and violence were 4 to 5 times more common with duloxetine than with a placebo, a meta analysis using patient level data by researchers from the Nordic Cochrane Centre showed." https://www.bmj.com/content/355/bmj.i6103

[swores]

Wow, TIL, thanks!

Any idea if the logic I wrote about is also true? Or is it the same as how many doctors will talk about SSRIs working because depressed people "have too little serotonin", a myth that remains commonly believed despite research not backing it up?

[skissane]

It is possible multiple processes are at work-it is possible that SSRIs increase violence risks independently of their antidepressant effect, and simultaneously their antidepressant effect also increases it. The two explanations aren’t necessarily mutually exclusive

[cupcake-unicorn]

Sure, but if that's what's going on, it should be researched further and taken seriously during prescribing. 100% guarantee that when psychedelics hit the market, doctors will fall prey to overstating the harms from studies like this while turning a blind eye to the wealth of evidence of greater likelihood of harms in prescriptions they churn out without blinking an eye.

I'm not anti medication, and I'm not saying that there are cases where the benefit doesn't outweigh the harm, but I do think the potential harms of each medication should be thoroughly investigated equally. Large companies with the ability to withhold damaging trials, sway the public opinion, and have a giant PR team and legal team at their disposal shouldn't be impacting our understanding of the real risks and science.

[skissane]

> Sure, but if that's what's going on, it should be researched further and taken seriously during prescribing.

Well I mean, it is, at least to some extent. The FDA has officially put a "black box" warning on antidepressants that they can increase the risk of suicide, especially in the young, and so have its counterpart agencies in several other countries. All doctors know about it – whether they all take that risk seriously enough is a matter of opinion, some are much more hesitant about prescribing them than others are. And it remains an active area of research.

> 100% guarantee that when psychedelics hit the market,

Here in Australia, they only let psychiatrists prescribe them (started in July last year for psilocybin and MDMA), and only for individually approved psychiatrists who have completed a training programme in psychedelic treatment. This is similar to our existing restrictions on prescribing psychostimulants–which most Australian states only permit psychiatrists and paediatricians to prescribe absent special approval–albeit even stricter. They'll likely relax the rules over time, but very unlikely non-psychiatrists will ever be legally allowed to prescribe them (outside of exceptional circumstances).

From what I understand, the approach in the US is different, as far as the DEA is concerned, theoretically, any doctor can get a DEA number which lets them prescribe any Schedule II/III/IV controlled substance. However, in practice, there are a number of drugs which very few US doctors would dare write a script for, even though by the letter of the law they are allowed to do it, because they don't want the "extra attention" the DEA will give them if they do – methamphetamine is a good example. (Technically, any Australian doctor can legally write a script for methamphetamine, but it is almost impossible to fill, because unlike the US, it isn't approved for sale in Australia–not because it is a controlled substance, rather because it lacks our equivalent of FDA-approval–the only way to actually fill the script would be to get a government permit to import it for an individual patient, and there is zero chance they'd approve such a permit unless the prescriber was a senior psychiatrist.)

[PedroBatista]

Seems like a pretty good system as letting doctors prescribe “psychedelics” can mean everything under the Sun.

Also the training and approval is paramount, they are doctors not magicians and many don’t even have a good understanding of nutrition let alone this type of drugs.

[cupcake-unicorn]

No problem, I like to spread awareness of this stuff! BTW here are a few more RCTs about the relationship https://www.madinamerica.com/2021/03/antidepressants-still-l...

Honestly it's hard to say and I'm not even sure if you'd be able to study this empirically in this population. I do think that's why doctors fall prey to this bias, and especially so in a stigmatized population. "Ah, they were likely to have these symptoms anyway". It would be interesting to do a wider study, but there already was a history of these companies withholding damaging trials and results so I doubt it would be done, especially given that suicides have occurred in these trials.

I really do believe that these classes of medications are treated differently due to the great power the industry has on this issue. If you look up the background of NAMI it's quite suspect and reminds me about how doctors were getting textbooks that were written by the opioid prescribing company. NAMI goes on to inform public opinion and then this stuff becomes "fact". I'm glad the "too little serotonin" thing is being examined but it was crazy to see how many weirdly defensive memos and articles there were out when it first came out. I see I'm getting downvotes on my original comment but I do think it's extremely important to examine these intuitions and where they came from, because as we've seen some of this stuff has been based on profits/trial P-hacking/junk science.

[mtlmtlmtlmtl]

SSRIs are never used for ED. If anything they may cause it. They are sometimes used to treat premature ejaculation though because they tend to cause genital numbing or anorgasmia.