Psychiatrists, antidepressants and suicide

David Healy (who I have mentioned before, see eg. previous post and a review of one of his books) has published a blog post on his website, which he provocatively entitles a 'Royal College of Psychiatrists' suicide note'. His post was in response to a letter written by the President of the Royal College about newspaper articles citing a study by John Read (2023) that David reviewed for the Ethical Human Psychology and Psychiatry journal, which also published an accompanying paper from David. 

John's study examined a data set summarizing 7,829 media reports of Coroners’ inquests in England and Wales between 2003 and 2020 that mentioned antidepressants (ADs). This information was collected on the AntiDepAware website. Overdose of antidepressants was not always the cause of death. John concludes:-

The data set we have summarized here confirms the findings of drug trials showing that ADs are ineffective for many people. The reports document the deaths of several thousand people who killed themselves despite being on ADs, and more than a thousand who actually used the drugs that were supposed to alleviate their depression to kill themselves.

As John also says, the paper has "few firm conclusions". Not many people will be surprised to learn that antidepressants do not necessarily prevent suicide; nor that some people take overdoses of their prescribed medication. I'm not sure that this information really reinforces questioning about whether antidepressants are effective, although I agree this is a major issue (see eg. previous post).

Not that whether antidepressants cause suicide is not also a major issue (see previous post). It's just that I don't think John's study adds too much to this debate either, despite the hype. Nor do I think David's accompanying paper really takes the issue forward. David describes two clinical scenarios, one of for which he was an expert witness at the inquest. As he says, "Coroners have actively steered" him to blame mental illness rather than medication for the cause of death. He is convinced these two cases were antidepressant-induced deaths. 

How to determine causality in such cases is not easy. What worries me about David's position is that he tends to take a physicalist approach to medication and not necessarily consider how people react to the taking of medication (see previous post). How people react to the act of prescribing in itself when they are feeling desperate does need to be taken into account. Antidepressant prescribing may well be a factor in suicide, but it is not necessarily due to the effect of the medication on the brain.

Cultural-ecosocial approach to psychiatry

Gómez-Carrillo et al (2023) argue for the value of a cultural–ecosocial approach to integrating neuroscience in psychiatric theory and practice. I’ve mentioned before (eg. see previous post) that relational psychiatry brings together a cultural-ecosocial psychiatry with developments from anti-cognitivist phenomenological and enactive accounts of psychopathology. Gómez-Carrillo et al also make this link in their article by explicitly recognising the importance of 4E cognition, which examines how cognition is embodied, embedded, enacted, and extended. As they say, "training in systems thinking and social science needs to be a key feature of psychiatric education”.