Could antidepressants have caused Robin William's suicide?

Could antidepressants have caused Robin William's suicide?:

This article I’ve linked to has a very provocative premise: that comedian Robin Wiliams was taking antidepressants and that the media is ignoring the possibility that those medications may have, at least in part, led him to become suicidal. In fairness, the article does not claim that this is definitely what happened, only that it is a possibility that must be considered, no less than if he was under the influence of illegal drugs.

The premise may seem reasonable, but the article, in my opinion, creates the impression that these drugs are more dangerous than they are. One of the article’s main arguments is that the drug mirtazapine, which was apparently found in Mr. Williams’ system, carries an FDA “black box warning” that the drugs causes suicidal ideation. This is true of all antidepressants and has been since 2004, but the reality is that most psychologists and psychiatrists believe the black box warning grossly exaggerates the risks associated with the drugs. This article, published in a well-known and peer-reviewed professional journal, (sorry I can’t post the whole thing–you know, permissions and whatnot):

“What every psychologist should know about the Food and Drug Administration’s black box warning label for antidepressants.

Rudd, M. David; Cordero, Liliana; Bryan, Craig J.

Professional Psychology: Research and Practice, Vol 40(4), Aug 2009, 321-326. ”

presents a cogent set of arguments that have been repeated by many others since the black box warning took effect. To summarize, there are several reasons to believe that the FDA’s decision was based on little evidence and has led to more harm than good. The decision was not made on evidence that antidepressants CAUSED suicides, rather that a relatively small number of people who happened to be taking antidepressants committed suicide, and that number was so small that it was not meaningfully higher than the rate seen in a group receiving placebo treatment. In the data the FDA reviewed, NO children or teens on antidepressants committed suicide. Another factor apparently ignored by the FDA is that people who are very depressed often have very low energy. When those people start taking antidepressants, for many there is a gradual increase in energy–for some people there is a very rapid increase in energy and agitation (typically only for a few days or a couple of week). A severely depressed person may be thinking about suicide, but not have the energy to act on the thought. An increase in activation may lead the person to feel like they have the energy to follow through on the thought. This is why severely depressed people should never be started on antidepressants without close follow up particularly early on, and medications generally should be combined with psychotherapy. With these supports in place, the chances of suicide while taking the medications (already very low) become lower yet.

The FDA surely meant well, but a consequence of the black box warning has been that fewer people take antidepressants, and the rates of suicide increased following the introduction of the black box warning and correlate with a decline in prescriptions for antidepressants.

I am not arguing that pills are the best way to combat depression, as a psychologist I employ a far wider range of treatments, though medications can be a valuable tool to use. And more to the point, I think this article does a disservice by assuming (not the author’s fault, to be sure), that the FDA warning means that antidepressants are more dangerous than people realize, which I would argue is not the case and the facts do not support it.

Robin Williams’s suicide was tragic, and I have no way of knowing whether he was receiving adequate care for his depression at the time of his death, and we should not jump to any conclusions about the care he was receiving. In my experience, these stories are often very complicated. I suspect blaming the medications he was taking, even as partly responsible for his suicide, greatly oversimplifies what happened that led him to that decision, and the evidence simply does not support the fear that some people have about antidepressants and suicide. It is a perfectly fair point to observe a lack of attention in the media to what prescription medications were present in his body, as that indeed may be important information. But speaking generally, antidepressants are relatively safe medications and are much more likely to prevent suicide than to cause it (and they may not even do that.)