M. David Rudd, Ph.D., ABPP
Chairman Filner, Ranking Member Buyer, and Members of the Committee, I want to express my appreciation for the opportunity to testify on behalf of the 152,000 members and affiliates of the American Psychological Association (APA) regarding the relationship between medication and veteran suicide. Attention to this issue is particularly timely given the considerable confusion about medications and suicide risk since the 2004 Food and Drug Administration (FDA) black box warning label was placed on certain antidepressants being prescribed for children and adolescents. As you know, the label was subsequently updated in 2007 and expanded to include young adults up to 24 years of age. Since then, there has been a “spillover effect” for adults beyond this age. In 2008, the FDA also issued an alert that antiepileptic drugs include a warning in their labeling to inform patients about the possible risk for suicidality.
Given the confusion that has followed the warning label and more recent FDA alert, along with its potential impact on direct clinical care, the field of psychology can make a significant difference in helping to inform the discussion regarding the actual nature of risk, the role of medications in the treatment of suicidality, and the utility of psychotherapeutic treatment approaches as a primary treatment option or in combination with medications. While the vast majority of the data are not specific to the veteran population there is no reason to believe the observable trends for adults in the general population would be different.
Confusion following the warning label has been shared among both practitioners and the general public. Among the facts frequently overlooked are the following: 1) there were no suicides in the original pediatric and adolescent trials (a total of 4,400 patients), 2) although there were suicides in the adult trials, the “number was not sufficient to reach any conclusion about drug effect on suicide” with comparable numbers across the placebo and clinical components of the studies, 3) given the failure to demonstrate any clear relationship between medications and death by suicide, the warning label focuses on “suicidality” defined as “suicidal thoughts” of unknown frequency, severity and duration and “suicidal behaviors” of unknown lethality, 4) the rates of suicidality in the clinical trials were low and in terms of actual numbers, very small differences were significant and resulted in a warning label, 5) the follow-up periods for the various drug trials were quite short (i.e., several months), and we do not have much needed data to understand potential recovery curves and treatment effectiveness after the initial 4-8 week window of the trials, 6) neither the warning label nor the medication guide provides any age-related data regarding suicide risk, with little context to understand the implications of the findings (particularly since suicide risk increases with age), and 7) practicing general and family physicians have demonstrated error rates as high as 91 percent in terms of an accurate understanding of the nature of the risk for suicidality communicated in the FDA warning label, with most believing the warning label communicates a risk for death by suicide.
Given that as high as 75 percent of depressed adult patients looking for treatment receive medications and that an estimated 50 percent receive both psychotherapy and medications, this is a very critical issue for our veterans. Not only have there been unintended consequences of the warning label and widespread media coverage of the link between medications and suicidality, but also the effectiveness of behavioral treatments has often not been considered.
Acute and chronic suicidality is a particularly difficult clinical problem. It is one that requires an accurate understanding of the role and effectiveness of medications, along with behavioral treatments. There is evidence available to suggest that not only have practitioners been hesitant to diagnose and treat problems like depression since the FDA warning label, but also that patients have been less willing to pursue treatment, with both groups inappropriately believing medications raise the risk for death by suicide. It is not surprising that our efforts to reach veterans in serious need of care are hampered when death by suicide is inappropriately considered a significant risk of treatment. This concern extends to the family members of veterans as well.
The reality is that the efficacy of treatment (both psychotherapy and medications) far outweighs the observed risk for suicidal thoughts and behaviors. There have been a number of well designed, rigorous studies demonstrating a marked reduction in suicide risk associated with selective serotonin reuptake inhibitor (SSRI) use, cutting across the full spectrum from early to late adulthood. For high-risk suicidal individuals, medications can be very effective in managing symptom severity (e.g., sleep disturbance, agitation, anxiety) during periods of imminent risk and prove an important complement to behavioral treatments. During periods of acute risk, patients often experience difficulty fully participating in psychotherapy because symptoms limit their ability to concentrate, engage, and most importantly, learn.
Since many, arguably all, suicidal patients consider suicide as an option in an effort to reduce or eliminate their emotional suffering; medications can play an important and strategic role. They provide a treatment option that can more quickly target symptoms facilitating a patient’s feeling of hopelessness. Behavioral treatments take time, with patients gradually building critical skills and resolving traumas. Until adequate skills are established and refined, medications can help fill the gap, buying what is often times lifesaving time.
Despite the concerns about medications and suicide, we now know scientifically that a number of behavioral treatments help reduce the risk of death by suicide. There are a number of reviews of psychotherapies that have proven effective in the treatment of suicidal behavior. I completed a recent review driven by a simple question, what are the common elements of treatments that work? There are a handful of treatments proven to be effective at reducing suicide attempts after treatment, with considerable overlap in the nature and type of treatment. In the case of behavioral treatment, simple interventions can help save lives.
First, all of the effective treatments have simple and understandable models that are shared with patients. Patients need to understand why they have become suicidal and the benefits of the treatment in order to fully invest in care. When a patient understands why they have been suicidal and how treatment will help, the net result is hope, improved motivation, less shame, better compliance and more effective care. This is a simple step and can be carried out in any setting and by a range of health professionals. Second, effective treatments target identified skill deficits. Patients that consider suicide evidence skill deficits that can be identified, targeted and improved. Third, effective treatments emphasize self-reliance, self-awareness and personal responsibility in a number of concrete ways. Patients are encouraged to assume a considerable degree of personal responsibility for their own care by use of commitment to treatment agreements and safety plans. As might be apparent, the ability to take personal responsibility for one’s care is very much an identified skill. Fourth, effective treatments emphasize the importance of crisis management, removal of available lethal methods, and access to care during and after treatment, with written and accessible treatment plans. This includes the involvement of family and friends. Finally, effective treatments incorporate compliance protocols. When a patient drops out of treatment, specific steps are taken to try to engage the patient in care, with a concerted effort to identify and target the reasons the patient withdrew. It is critical to keep at-risk patients engaged in treatment.
These are very simple actions that can save the lives of our veterans who are experiencing thoughts of suicide. They can be accomplished across the full range of settings and by a variety of providers. Especially for those hesitant to consider medications as an alternative, behavioral treatments have much to offer, either as an independent treatment or in combination with medications. We owe it to our veterans to ensure that they have the mental and behavioral health care that they need and deserve and the psychology community remains committed to assisting in this effort.
Thank you. I appreciate the opportunity to speak with you today and welcome the chance to respond to questions.