A Bridge to Cross

The Golden Gate Bridge has been approved for a $76 million suicide safety net. As I recall, installing a protective structure has been in discussion for a lot of years. Families of people who have jumped off the bridge are understandably happy about it. I can certainly see how they'd want to do something proactive to prevent the kind of suffering they and their loved ones have experienced.

But I have a problem with it, and I hope this isn't interpreted as a lack of empathy towards those families, or towards Kevin Hines, who jumped off the bridge in 2000, at age 19, and miraculously survived.

The statistic in the linked article, which is consistent with my understanding, is that 1400 people have died jumping off the "bridge of death" since it opened in 1937. That's roughly 18 people per year. Again, I don't want to minimize the suffering involved, but to put it in perspective, according to the American Suicidology Association, 39, 518 people killed themselves in 2011, the most recent year for which statistics were available on the site. In other words, 0.05% of all suicides in 2011 were committed by jumping off the Golden Gate Bridge.

What I'm curious about is how much money the federal government devotes to suicide prevention. I poked around online, and I found out the the NIH spent $21 million on suicide prevention in 2013, with a projected spending of the same amount for each of 2014 and 2015.

In 2012, the National Strategy for Suicide Prevention Plan devoted $55 million dollars in federal funds to state, tribal and community prevention efforts.

I found a document, I believe from 2001, with some relevant financial figures:

In 2002, the NIMH offered $2.5 million for stigma-related research.

"SAMHSA provide(d) $5.4 million for a three-year collaborative effort with states to develop and evaluate public education approaches for overcoming barriers to mental health treatment and encouraging community participation for persons with psychiatric disabilities."

"SAMHSA provides funding support to Signs of Suicide (SOS), a peer program that teaches students to recognize depression in peers..." (no figure provided)

"By providing $3.0 million in funding annually over three years, SAMHSA sponsors the Hotline Evaluation and Linkage Project (HELP)."

"SAMHSA is overseeing the launch of the National Suicide Prevention Technical Resource Center in late 2002. Funded at $7.5 million over its first three years, the Center will be dedicated exclusively to suicide prevention..."

"Several HHS operating divisions fund technical assistance efforts aimed at suicide prevention." (no figure)

It was hard to find more information about funding. When I googled, the main link was to the Golden Gate Bridge story.

A few more stats:

At the upper end, there were 19,990 suicides by firearms in 2011. At the lower end, 354 suicides by drowning. And a total of 3996 suicides in California.

And in 2011, there were 987,950 non-fatal suicide attempts in the US.

So this is my problem. The federal government is handing over $76 million to build a net that will prevent roughly 18 people per year, NOT from committing suicide, but from committing suicide by jumping off the Golden Gate Bridge.

I think a lot has to do with the iconic nature of the bridge. As it turns out, about 6 people per year jump off the George Washington Bridge. But no one cares about the GW because it's a rubbish bridge.

A jump from the Golden Gate is dramatic, no doubt. I don't quite understand how people get there on foot. There's Golden Gate Park on one side, and Sausalito on the other, and it's been a while since I've been in the Bay Area, but I think you pretty much have to drive to get close. What I'm trying to say is that it takes some planning.

I just think they're building the wrong kind of net. It's a dramatic gesture for a dramatic structure, but I doubt it'll accomplish much. I think the money would be better spent on catching people before they purchase guns, or down a bottle of pills, or set foot on the Golden Gate, or any other bridge.

Book Review, Sort Of

I just finished reading David Healy's Let Them Eat Prozac.

In it, he takes a passionate position on the adverse effects of SSRI's, particularly with respect to suicidality. While initially convinced that prozac did not induce suicidality, Dr. Healy was subsequently an expert witness on several suicide/homicide lawsuits related to SSRI use. While researching those cases, he had more data made available to him, and was then convinced that SSRIs significantly increase suicidality. The supporting data include:

*Re-evaluations of results from SSRI studies

*Cases in which patients were started on an SSRI, became akathetic and agitated, stopped the SSRI, improved, then were subsequently restarted on the SSRI (or other serotonergic drug) and deteriorated once more (challenge/dechallenge/rechallenge, which is how causality can be established)

*Internal Memos from Lilly, which stated things like, "We know prozac causes a 5.6 times greater risk of suicidality than placebo, so we need to figure out how to deal with it, and specifically, how to figure out which patients will benefit from Prozac."

*His own trial of and SSRI in healthy volunteers, in which suicidality emerged

*Early studies in which subjects who developed akathisia and agitation on Prozac were either removed from the study, or given benzos for those side effects, essentially demonstrating that benefits in the study may have been from benzos, rather than Prozac.

*The fact that the BGA (the German equivalent of the FDA) did not approve fluoxetine, claiming that it was not sufficiently effective, and that it induced akathisia and agitation in patients, and ran the risk of inducing suicidality. Fluoxetine was approved in Germany a number of years later, under what appears to be powerful political pressure.

What I liked about the book is the fact that, despite how strongly Dr. Healy feels about this subject, and despite the fact that he lost a job because of his opinions, he still doesn't assume a conspiracy took place. Rather, he makes a case for a series of bad decisions, bad luck, predictable greed, overall good intentions, and selective blindness.

I also liked the fact that he is not advocating a complete moratorium on SSRI use. He believes, and this confirms my clinical impression, that there are subgroups of patients, some of whom do well on SSRIs, and others who don't. He advocates for research to figure out how to predict which group a given patient will fall into. He also advocates for research to specifically examine suicidality in SSRI use, and points out that, remarkably, no such study has been undertaken.

What I didn't like about the book was that his arguments are sometimes difficult to follow, causing me to question his conclusions, My impression, in general, though, is that the dude knows his stuff.

This is only "sort of" a book review because I'm including a link to his paper, Antidepressants and Suicide: Risk-Benefit Conundrums, as part of the online journal club The link is from his site, and another thing I like about his work is that he encourages open sources, and provides links to publications.

He's written more recent papers on this topic, but this one, in particular, summarizes what he covered in Let Them Eat Prozac, although the paper is for a professional audience, while the book is more for a lay population.

This is a table from the paper:

Note that on Placebo, there were 2 completed suicides, and 21 suicide attempts, on Active Comparators (e.g. TCAs), there were 5 completed suicides, and 24 attempts, and on All SSRIs, there were 23 completed suicides, and 186 attempts.

I'm very curious to hear people's evaluations of his statistical methods, so please comment.