Thursday, February 23, 2012

Study questions antidepressant-suicide link

I have always thought this is a problem of taxonomy. Drugs that perk up true depressives may perk up anxious depressives far too much, worsening rather than alleviating their symptoms. So Prozac etc should be given to true depressives only. That it is sometimes foolishly given to anxious depressives as well therefore explains the conflicting findings about suicide etc. A study that made sure that only true (sluggish) depressives got Prozac (etc) would likely show benefit at all ages

The Food and Drug Administration has a blanket warning on antidepressant medications stating they increase the risk of suicidal thoughts and behaviors among kids and young adults, but a new review of clinical data finds no link between suicide and at least two of the medications.

The new analysis, based in part on previously unpublished data, also concludes that treatment with antidepressants decreases the risk of suicide among adults of all ages.

“These results have to instill some additional confidence that prescribing these medications is not necessarily going to lead to suicidal thoughts or behavior,” said Robert Gibbons, a professor at the University of Chicago and lead author of the study, published in Archives of General Psychiatry.

The findings — based on data for kids and adults using fluoxetine (Prozac) and for adults on venlafaxine (Effexor) — are not enough to change everyone’s view of the risks of antidepressants, especially to kids.

“The authors in this study examined the risk of suicidal thinking or behavior associated with one drug, fluoxetine,” said Jeff Bridge, a researcher at Nationwide Children’s Hospital in Columbus, Ohio. “My view is that the weight of evidence shows a small but significant increased risk of suicidal ideation/suicidal behavior in pediatric patients treated with antidepressants.”

Bridge’s position is in line with the FDA’s current stance on suicide risk for children taking antidepressants.

In 2004, the agency asked manufacturers of antidepressants to include what’s called a “black box” warning on its packaging for the medications, alerting physicians, patients and parents to an increased risk of suicide among children taking the drugs. Three years later, the FDA expanded that warning to include young people up to age 25.

Gibbons has long been opposed to the labeling. As an advisory board member to the FDA, he voted against adding the warning to antidepressant packaging. “I didn’t think the data were very convincing, and I was concerned physicians would stop prescribing antidepressants,” he told Reuters Health.

The FDA had looked for any reports of suicidal thinking or action among 4,400 children who were in clinical trials comparing an antidepressant drug to a fake drug called a placebo.

They found that suicidal thoughts or attempts were twice as common among the kids taking an antidepressant, although none of the children had committed suicide.

To get a better handle on the risk of suicide over the course of treatment, Gibbons’ team gathered data from experiments that compared the antidepressants to placebo and that had measured suicide risk from the get-go.

Some results came from a study of adolescents by the National Institute of Mental Health and the rest came from two drug makers, Eli Lilly, which markets Prozac, and Wyeth, whose parent company markets Effexor.

The authors have served as consultants or have received research money from drug makers in the past, but Gibbons said neither company had access to this study — which was funded by the federal government — before it was published.

The analysis found that among the 708 children in the reviewed studies, the risk of having suicidal thoughts or attempts after eight weeks was no different between the kids who took Prozac and the kids who took the placebo.

Although fluoxetine is the only antidepressant drug approved for use in children, doctors can prescribe other drugs “off-label” to treat depression in kids.

“I think it’s premature to extrapolate these findings to other antidepressants,” Bridge told Reuters Health in an email.

The studies in the FDA review that found an increased risk of suicide looked at fluoxetine and eight other drugs.

In Gibbons’ review, treatment with fluoxetine or venlafaxine resulted in a 90 percent decreased risk of suicidal thoughts or behaviors after eight weeks among adults and the elderly, compared to a 79 percent decrease after eight weeks of taking a placebo.

Gibbons said the drop in suicide risk seen in adults was tightly linked to the improvement in depression symptoms. “What that means — and it’s not a surprising result – is if you don’t treat depressive severity, you continue to have a high rate of suicide,” he said.

At the beginning of the studies, children had higher rates of suicidal thoughts and behaviors overall than adults; about 20 percent of kids and three to five percent of adults started out thinking about or attempting suicide.

Gibbons said it was interesting that the kids’ suicide risk didn’t fall like the adults’ did, even though the results indicated the antidepressants did work to relieve the kids’ depression symptoms too. “Suicide and depression are very strongly linked in adults and the elderly, and apparently not so strongly linked in children,” he said.

Bridge said he’d like to see future studies examine whether antidepressants are tied to behavioral problems, such as hostility and agitation, and if an increased risk of those behaviors is related to more suicidal thoughts and behaviors.

As for the black box warning, Gibbons said he would support the FDA in gathering more data to better evaluate whether the warning is warranted, but he would not say whether it should be removed.

The FDA did not respond to requests for comment.

Keri McGrath-Happe, a communications manager at Eli Lilly and Company, wrote in a statement to Reuters Health that “at this time, we do not plan to discuss this matter further with the FDA.”

She added that “some depressed individuals, on treatment and off, have worsening suicidal ideas and acts. It is prudent for clinicians and patients to remain vigilant for this possibility.”


When it comes to food, think global

Becoming a ‘locavore’ won’t save the planet, make you healthier, revive communities or improve food security

Earlier this month, spiked’s deputy editor Rob Lyons took part in a debate at the Canadian Food Summit on the motion ‘The local food movement: good for us and good for the environment’. The other panelists were New York Times columnist Mark Bittman, author and food blogger Sarah Elton, and business journalist Andrea Mandel-Campbell. This is an edited version of Rob’s opening comments.

Let me state my position baldly: there is no problem to which local food - or at least buying your food within some predetermined distance of home - is a good solution. Despite the claims of some campaigners, local food won’t save the planet, it won’t make us healthier, it won’t restore traditional communities and it doesn’t offer greater food security.

The big claim usually made in terms of the environment and local food is that we should be trying to reduce our ‘food miles’. It seems to make sense that the shorter the distance between fork and fork - between the one in the soil and the one on our plate - the better. The trouble with that theory is that transport from field to warehouse to shop is just one small part of the total environmental impact of our food.

Insisting on local food could actually increase the environmental impact of what we eat. Frequently, less energy is used when producing a food crop under ideal growing conditions and then transporting it long distances rather than using extra energy to produce it locally. The classic example is New Zealand lamb, which is produced in that country’s plentiful pasture and then shipped to the UK. Lamb produced in the UK often needs to be fed with grain when pasture is inaccessible, which adds to the cost and environmental impact. On the other hand, filling a huge container ship with frozen lamb and shipping it round the world means the fuel costs for each unit of lamb are actually small. As a result, New Zealand lamb probably has a lower environmental impact than the UK variety and is cheaper, too. Another example would be tomatoes that are grown in hot countries and then shipped to countries with temperate climates. The energy required to grow tomatoes in the UK is often greater than the energy required to ship them from Spain, for example.

Some locavores respond by giving up food that doesn’t grow well in their neck of the woods. Fine, but if you live in a big city like London, for example, you need a pretty broad definition of what ‘local’ means in order to feed yourself. If you come from a region with great agricultural variety that might not be too bad, but the truth is that any local diet must forgo some kinds of food or simply not be terribly local. I’m not aware that Canada or the UK are big producers of tea, coffee, bananas, spices and a whole variety of other foods.

Would people who really care about food, who revel in the joy of discovering new foods from around the world, really now turn their noses up at food products because those foods come from too far away? That seems mad.

This speaks to a major problem with environmentalism, which approaches environmental problems by simply insisting we stop doing certain things, whatever the advantages. In this case, because food that has been transported a long way is seen as a problem, we should just stop importing it. A far better approach is to find ways of getting the advantages without the side effects. If greenhouse gas emissions really are going to become a major problem in the future – and my feeling is that the problem has been overstated – we need to find ways of transporting goods with fewer emissions or adapting to rising temperatures. Sadly, greens seem more intent on finding problems caused by humanity than in finding solutions.

One more thing on this point: if we don’t have specialisation of production, then a return to localised food production would mean using more land to grow food. If we’re not growing food in the most ideal conditions, then to get the same amount of food would mean using more land. That’s particularly true if we also have a return to organic farming methods and crop rotations, as many environmentalists and local-food advocates call for. Where would that land come from? Bringing uncultivated land into production seems to fly in the face of allowing nature to flourish. What’s so ‘green’ about that?

But isn’t local food healthier? Some claim that if you buy direct from the farmer, for example, then perhaps the food is fresher and that may have benefits in terms of retaining nutrients. However, the fact is that those of us who live in countries with cold (or coldish) winters cannot eat fresh food all year round if we restrict ourselves to what can be produced locally. Most of the food we eat is harvested and stored in one way or another for at least three months per year when little food production is possible.

As it happens, freshness is the least significant factor in nutrition. Most people in the developed world have no problem getting all the vitamins and minerals they need, even from that ‘industrialised’ food some people seem to hate. Nutrition is not an issue if people get enough to eat and have some reasonable variety in their diet. It really doesn’t matter how far the food travelled or whether it came from the supermarket or the farm shop. The question of whether food is local or not is a side issue when it comes to health.

Of course, it would clearly be difficult to eat a lot of processed foods if you only did your shopping at the farm gate or the farmer’s market, so you could cut out a lot of sugary, stodgy food in favour of more fruit and vegetables. But if that was a concern for you, it would still be easier and cheaper to cook from scratch using supermarket food. There’s mountains of fruit, vegetables, meat and other ingredients in every store. There’s nothing that is inherently healthier about local food.

But what about local food as a way of reviving community? It just sounds so great: you get together with your neighbours to grow food or to develop relationships with food suppliers and producers and in the process gain a sense of belonging. No more would you be dependent on The Man. Working together with other people towards common goals can be a very liberating thing. But do we really need to get together around food, a problem most people would see as solved by a weekly and relatively inexpensive trip to the supermarket? Why would you spend more money or devote more time and energy to something that already works well?

Moreover, this reveals a narrow conception of community, which ties it to a particular geographical area rather than around sharing ideas and common interests. While many people would like to feel a stronger connection with other people in society, simply rehashing old forms of community seems like a backward step to me.

A good example of this is The People’s Supermarket. This is a store near where I work in London which was set up with great fanfare and a four-part TV series. The idea was to try a different model of shopping. People who live in the local area staff the shop and get discounts in return for their work. It’s modelled on the Park Slope Co-op in New York. The trouble is that people can get those low prices and a wider selection of foods at the branches of mainstream supermarket chains like Tesco, Sainsburys and Waitrose that already operate nearby. Where is the material incentive for people to work to get what is, to all intents and purposes, a poorer service?

Despite the fact that The People’s Supermarket has received not inconsiderable public subsidy, it is struggling to survive because it can’t staff itself from the local community it claims to represent. On the other hand, there are people who hate the supermarkets and Big Food who are prepared to travel from further afield to work there or to support The People’s Supermarket in different ways. In other words, they share a common interest in changing the way we buy food that can’t be reduced to a particular geographical area. Once again, ‘local’ is a side issue.

But what about food security? If we can grow all our own food, then why wouldn’t we? That would make us secure, no matter what else went on in the world, right? Yet we have far more food security now than we did in the past precisely because we trade with the rest of the world. In recent years in the UK, we’ve had summers with low rainfall, so crops were parched and harvests reduced. In years with floods, crops have rotted in the fields under water. In those circumstances, it’s rather a good thing to be able to buy food from places that had better harvests. It is poverty and a lack of access to markets that really create food insecurity.

There’s another important question underlying the debate motion: who, exactly, is ‘us’? Does ‘us’ include, for example, the Kenyan farmer producing green beans for export to the UK or a Caribbean banana grower sending fruit to Canada? If those people do count as ‘us’, then banning imports of their products won’t be very good for ‘us’ at all. In the long run, it is better for farmers in poorer countries to produce valuable food crops for export, and use the money to help develop their own farms and their societies, than to demand that they go back simply to feeding themselves.

To me, locavorism is like survivalism for eco-warriors, though at least you avoid the hassle of learning to use a crossbow or hiding in the woods. Locavorism seems to me to be a backward idea, a way of running away from the world rather than embracing the best aspects of globalisation and trying to solve the teething troubles that arise. Going local certainly won’t ‘save the planet’ and it definitely isn’t good for anyone.


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