Barry Blackwell: The Baby and the Bathwater
Leonardo Tondo’s comment on Barry Blackwell’s essay and Edward Shorter’s comment

          I would like to start my comment on Barry Blackwell’s essay and Edward Shorter’s comment on it concerning the relationship between babies and muddy water with consideration that the initial epistemological comment should establish if there is indeed a baby in the muddied water.

          More specifically, I would like to refer to the association of the use of antidepressants and suicide risk. First, it should be pointed out that when we speak of suicide risk we need to separate ideation from behavior. Although the former almost invariably (there are some rare impulsive suicide behaviors) precedes a suicidal act, the passage to an attempt is quite rare and even less frequent ideation is the first step to a death. Fortunately, most of the time ideation is a passive idea that life may not be worth living.

          Moreover, we know that almost all suicides occur during a depressive or mixed depressive episode of a bipolar (more likely) or major depressive disorder. These episodes are treated quite successfully with, among other agents, antidepressant medicines. We also know that these agents are effective in about two thirds of the patients leaving the remaining third with only their side effects and probably mulling over their suicidal ideation and behavior initiated before the treatment. It has been proposed that suicidality (short for suicide ideation and behavior) may be caused by the antidepressants, but a multitude of studies supported by the industry or the academy are unable to confirm or contrast this proposal.

          In my not so modest clinical experience (more than 6,000 patients treated and carefully recorded) the occurrence of suicidality during antidepressant treatment has been quite rare, probably less than 1% of the treated patients (I recorded the data but it would take a very long time to dig it out). Yes, there is the possibility that some unfortunate patients committed suicide and I was not informed, but given the type of my practice I would consider that event extremely rare.

          So, the main point is to establish the rate of this occurrence before sentencing antidepressants to a therapeutic death. In economic terms we should first consider a cost-benefit analysis based on the attributable risk (how many events occurred compared to the prevention of others). Or to go back to the beginning of this discussion: first, look carefully for the baby in the warm water.

November 8, 2018