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According to the Morbidity and Mortality Weekly Report of the Centers for Disease Control, the number of suicides in the United States has now surpassed the number of deaths from car accidents. In 2010 there were almost 34,000 deaths from collisions, and 38,000 suicides.
Even more alarmingly, the suicide rate for Americans in mid-life, ages 35-64, increased between 1999 and 2010 by nearly 30 per cent. This is huge.
Keep in mind that the use of the Prozac-style antidepressants increased steadily over these years as well, so that according to the National Center for Health Statistics, 11 per cent of all Americans over age 12 were taking antidepressant medications by 2005-8. That is one in ten! What more stunning testimony could there be for the lack of effectiveness of this drug class in serious depression, people on the verge of suicide.
And this is the problem: Over the last 30 years, the drug classes prescribed for depression have been increasingly less effective. If you were diagnosed with serious (melancholic) depression in 1980, what would you be on? The tricyclic antidepressants (TCAs) were the agents of choice. Imipramine (Tofranil) hit the American market in 1959, the first drug advertised specifically as an "antidepressant." And with good cause. The TCAs were quite effective in patients with what was then called "endogenous depression" "Vital depression" and melancholia are approximate synonyms, though at the heart of despair there is melancholia is a way that was never quite true for the milder-sounding endogenous depression.
Or in 1980 you might be given a monoamine oxidase inhibitor (MAOI). These drugs arrest the action of the enzymes that break down neurotransmitters such as serotonin, although that might not be their main mechanism of action. In any event, they are quite effective, and older clinicians still swear by Parnate (tranylcypromine) in the treatment of patients who are suicidally depressed.
How about shock therapy (electroconvulsive therapy, ECT)? It's the most effective treatment psychiatry has on offer for suicidal depression. Yet here we nuance the story a bit. ECT was introduced in 1938. But in the years after 1960 it experienced a setback because the flower children didn't like it. Nor did the pharmaceutical industry (given that no drug possesses such great effectiveness in the treatment of severe depression). So between 1960 and around 1990 ECT underwent a near-terminal decline.
But then in the 1990s it experienced a revival, because many psychiatrists began to understand that ECT beat the pants off pharmacotherapy. The problem is that, recently, the use of ECT has once again begun to decline in psychiatry departments based in community hospitals, where many depressed patients are seen—and put on Prozac-style agents instead. It is unknown what has happened to ECT in specialized psychiatric facilities, but almost certainly its use has continued to increase, because within psychiatry there is now a worldwide revival of interest in convulsive therapy.
So in 1980 you, as a suicidal patient, would have received two out of the three best remedies for melancholic depression, which is not bad.
Today, by contrast, there is a good chance that you will receive none of them. The TCAs have vastly receded in importance in the face of Prozac and its cousins (now all available as generics, as the patents of the brand-name SSRIs have largely expired and they are no longer advertised.)
The MAOIs have almost vanished. I recently talked to a group of bright young psychiatry residents (specialists in training), and only a couple of them had even heard of Parnate.
If you're lucky enough to find a physician willing to prescibe ECT, you'll be saved. It's marvellously effective in suicidality.
But so many of the depressed, despairing Americans at midlife haven't been lucky. Quality health care should not depend on luck. The statistics are tragic, and point to a national crisis.
