1. Comment #74335 by oxytocin on September 28, 2007 at 7:16 am

The hysteria surrounding the use of antidepressants is similar to the hysteria surrounding vaccinations. Sadly, state of the science medical interventions come with risks. If these risks aren't properly communicated to the public, misunderstandings prevail, and decisions based on faulty premises are made.

It is common knowledge within mental health that people with depression are at greater risk for suicide when one starts to experience an alleviation of symptoms. If someone is severely depressed, cognitive slowing and lack of energy often prevent people from commiting [or even thinking about] suicide. When they start to become more energized and cognitively activated, suddenly they have the capacity to consider other options and even act on them. This has explanatory power when considering why some people who take meds [and engage in therapy] might become more suicidal rather than less, in the early stages of treatment.

Also, most people don't act on suicidal thoughts. The single largest predictor, unsurprisingly, is a previous suicide attempt. This is followed by having a concrete plan and the means to carry it out.

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2. Comment #74380 by robotaholic on September 28, 2007 at 10:55 am

this was on NPR today and I found it interesting - hopefully this type of research will aid in other fields...

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3. Comment #74381 by BAEOZ on September 28, 2007 at 11:06 am

Great post oxytcyn. Very informative. I wonder if the good Dr. has some thoughts on this as well....

It is common knowledge within mental health that people with depression are at greater risk for suicide when one starts to experience an alleviation of symptoms.

It's a quirk of history that revolutions occur when times start getting better. As conditions alleviate, people start to demand more, if they don't get it, they revolt. Weird species humans. (That parallel strangely popped into my sleep deprived brain at 4:05 am AEST :)


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4. Comment #74395 by A. Person on September 28, 2007 at 2:17 pm

Antidepressants aren't the subject of "hysteria", it's a serious and well-established concern. The FDA isn't subject to hysteria, they're a serious organization. In clinical trials with most SSRIs, those getting the drug are roughly twice as likely to think of killing themselves or develop psychotic symptons (hallucinations, delusions, etc) as those getting placebo. The simple explanation is that the drugs make people want to kill themselves. Anywhere outside of a drug trial, if someone thinks of killing themselves, it is considered more likely that they will then kill themselves.

However, in the interest of making the drug sound safe, they insist that suicidal ideas from a drug in no way contribute to suicidal actions. This is basically the same as asserting that, if I have two friends, and one says he's thinking of blowing his brains out, and the other one says he's feeling depressed, I should worry equally about the likelihood that they will kill themselves. It is, in other words, stupid.

The reason suicides almost never occur during drug trials are that they screen patients looking for relatively mild cases, and that the patients are monitored very closely. Most drug trials have checkins weekly, if that infrequently, whereas a real psychiatrist who has given a suicidal-ideation-inducing dose of medication will likely not see that patient again for months to years unless the patient wants to come in. When you consider that the patients are already ill, medicated, and often children, it's not surprising they often fail to take this initiative.

If those doing research want to assert that it's simply "extra energy" that causes extra suicidal ideation, and the drugs are really safe, they can try to produce evidence to support that theory. Given that it's a fairly unsupported hypothesis in antidepressants and that it is far more likely that suicidal thought leads to suicidal actions, it ought to require special effort on the part of those making the assertion. This is something that has not been done.

It's worth remembering that psychiatry proper is an extremely young science, fifty years removed from the era of lobotomies, which oodles of anecdotal reports insisted worked great, thanks to how nonscientific observations can and do work. Psychiatry is also a little over a hundred years from Freud promoting cocaine and radical nose surgery as cure-alls, though he was part of the cure for that problem as well. It's also worth remembering that drug companies, apart from much idiot vaccine hysteria, really have quashed drug trials in many other classifications regarding the potential dangers of their products.

... also, hi. I made an account to say this.

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5. Comment #74404 by Ashley1319 on September 28, 2007 at 2:59 pm

I'm interested to see the outcome of this. I had a friend who took anti depressant medication, and she was constantly having mood swings and bouts of manic depression. She was actually better after she quit using it.

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6. Comment #74434 by notsobad on September 28, 2007 at 8:19 pm

They need to make better drugs then. Or people can do something so they are not depressed.

But since the latter requires personal responsibility and other things people do not know any more, it's up to science to produce better drugs.

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7. Comment #74437 by oxytocin on September 28, 2007 at 9:40 pm

A. Person, I just wrote a retort to your post but lost it upon attempted submission. I'm most aggravated. I will re-construct it tomorrow. What is your line of work, if I might inquire?

Ashley1319: there is research suggesting that antidepressants can sometimes switch people over into a manic phase of bipolar disorder if that is their diagnosis. However, I sincerely hope you don't use one case to make generalizations about this class of medications.

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8. Comment #74441 by nother person on September 28, 2007 at 10:15 pm

Thank you A. Person for a nicely considered response to this issue. It is great to read the many thoughtful comments on this board about the weaknesses in the standard arguments put forward by people who one must assume are generally reasonable but who seem to have blinkers on when it comes to religion, or at least, to their own religion. But there are also from time to time posted some science cheerleading type remarks made by individuals who seem to be equally blind to the weaknesses of certain aspects of science. There's nothing wrong with being a technophile, but I find it disturbing that an attitude is sometimes expressed here that technology can and will solve all problems, that everything science currently says is correct, that the science-industrial complex is an irreproachable boon that creates no problems only solves them or, as was hinted above, that the best way to solve problems of human suffering is to medicate people.

I have been lurking for some time now, and mostly enjoy the remarks and am impressed with the thinking expressed. I have also noticed that in almost every case where someone makes one of those cheerleading type statements, someone else posts a caution or a correction. I guess that fell to you this time around. I also felt that this was a good time to register in order to appreciate you doing that and so that I could more fully participate in the future. I don't think that reigning in zealots is the most important thing to do here, but it is significant and worthy work.

I would like to emphasize that what we are reading here is a report in the NYT, not a peer reviewed journal article. The authors of the original work called it preliminary. What they apparently reported was a duel correlation in about 1% of the depressed population from which the study sample was drawn. Even if their results prove to be robust, they are not likely to mean much to the majority of clinically depressed people. On top of all that, hard evidence of a genetic link to a psychiatric disorder is the holy grail in some sociobiology circles. Given all that, it seems just a tad premature to be hashing out the subtitles of the differences between expressing a feeling state, expressing an intention and taking an action. But one can understand why the NYT would spin it this way...

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9. Comment #74450 by irate_atheist on September 28, 2007 at 11:33 pm

Having had first-hand, insider, experience of recurrent, severe, unipolar depression I can attest how debilitating the condition can be. As there are strong genetic links to a pre-dispostion to such mental health problems (in my case on the maternal side), it would not be a huge surprise to me that genetics may also play a part in response to the treatment.

As regards a correlation between incidences of suicide, and attempted suicide, once taking certain anti-depressants, a large number of factors may come into play.

The patient may well be at their most depressed anyway when they start taking the drugs. Many people do not seek professional help until the situation is extremely serious, and in many cases, until the illness has recurred several time. The subject may therefore be at their most vulnerable state in their life to date. If the patient does not percieve the medication is working, may this not depress their mood even more and make them feel there really is no way they can carry on?

Some of the side-effects of anti-depressants can be quite unpleasant themselves. My experience was a fairly rapid loss of the ability to sleep properly. Fortunately, the (real or placebo effect) of the drugs I was taking, and the knowledge I was taking a step to help myself - save my life, in fact - rendered this a minor inconvenience. However, in another patient, loss of sleep and the resulting extreme tiredness, short term memory problems and the effect on mood, may not be so manageable...

I would, however, wager more people have been helped by the modern variesties of anti-depressants, especially SSRI's, than have been killed by them.

All anectodatal evidence and opinion, I know, but it's just a few thoughts from someone who's been round the block a few times already in life.

If people are interested to learn more about the subject of mood disorders, may I recommend Lewis Wolpert's excellent book 'Malignent Sadness: An Anatomy of Depression' and Peter C. Whybrow's 'A Mood Apart'.

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10. Comment #74456 by A. Person on September 29, 2007 at 12:12 am

irate_atheist: The increase in suicidal thoughts is from double-blind clinical trials compared with placebo, not normal case histories. It's only observed in a fraction compared with the number that improve (IIRC), and all antidepressants have a number of very real miracle stories associated with them, which is why they're in such wide use.

Oxytocin: I look forward to it. I'm going to hold off further commentary of my own until I've heard more of your side. It's a very interesting issue, and certainly deserves (even requires) the extra depth debate can add to it. I'm a student.

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11. Comment #74465 by Solarium Solaris on September 29, 2007 at 2:13 am

Like another poster above I also have first hand experience with anti-depressants. I've been taking Paxil for 4 months and my only regret is that I didn't start taking it far earlier. I haven't had any noticeable side-effects and the drug has worked like a miracle for my anxiety and depression.

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12. Comment #74512 by L.Minnik on September 29, 2007 at 7:50 am

For those interested in the adverse effects of psychiatric drugs:
http://www.breggin.com/

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13. Comment #74546 by oxytocin on September 29, 2007 at 12:41 pm

Wow, what is it with people and psychiatry? It sounds to me as though the scientologists have succeeded in their plot to discredit the field…it's like the Rodney Dangerfield of the science world.

Nother Person, I'm taking a wild guess that your comment was directed at me; if this is true then you're making unwarranted assumptions. I can assure you that I have no desire to toe the line of the "science industrial complex", as you say…as a scientist and clinician, I care about the data and the welfare of my patients. As a psychologist, I neither prescribe medications, nor do I have any ties with pharmaceutical companies. What I stated above is based on what I've read in the research, not blind adherence to the status quo. I am a "cheerleader" for the scientific method. Further, science, by definition, does not claim to have final answers; it is inherently tentative, and I have no idea how you derived the contrary from what I wrote above. We strive for technology to help us solve problems, but we do not know if it will ever be complete in this regard. I am stunned that you would suggest [if you have indeed] that I used psychiatry in a "religious" manner…this is the very antithesis of my worldview. By your reasoning, if I were to defend evolution against the pestilence of intelligent design, I would be mindlessly defending without cause.

A. Person,
1-What I've said previously about people misunderstanding the risks involved in taking an antidepressant medication does not negate the risks in their entirety, only that people are making a bigger deal out of them than is warranted by the data; I deal with the fallout of such pronouncements very frequently. In order for us to accurately assess the nature of the risk, we must examine the data that have been gathered on this important issue. For the present purposes, I have linked to brief statements that everyone can access, since I assume the majority of people won't be able to access academic journals.

For adults:
[http://tinyurl.com/yovbwu],[http://tinyurl.com/yvqgad],[http://tinyurl.com/2utbyv]

For children & adolescents:
[http://tinyurl.com/2yjjdb],[http://tinyurl.com/ywyn44],[http://tinyurl.com/yqfgv8],
[http://tinyurl.com/26m86l]

If more references are deemed necessary, I will provide them. I will be unable to do so, however, until Monday when I return to my workplace.

2-To make the statement that "the drugs make people want to kill themselves" represents a misunderstanding of experimental design and the idea of causation. You've simply created an unjustified sound byte. You worsen things by commenting on "suicide-inducing doses", as if psychiatrists are twirling their moustaches and plotting the demise of patients. If you have evidence for this statement, please present it. What are the alleged doses by drug that induce suicide? Further, although I can't comment on the practice of all psychiatrists, the ones I know do not cut people loose upon prescription of medication. If it's a relatively simple case, they may re-direct them to the care of their family physician, but I've not observed patients cast aside without follow up since that would be unethical. I have no doubt that people fall between the cracks, but I don't know why you'd accuse physicians of callousness and apathy.

3-That the risk for suicide increases in the initial stage of psychopharmacological treatment, perhaps due to a reduction in psychomotor retardation coupled with an increase in motivation and cognitive ability, is a well-known phenomenon. This isn't wild speculation on my part; research supports the notion, which is why I stated it. The thing that you need to understand is that this relatively rare phenomenon has been observed in the initial stages of psychotherapy as well, so it's not even unique to antidepressant medications, suggesting that it may be a natural sequelae of the upward trajectory of the illness. With regard to children, they have fewer coping skills, they are more impulsive [particularly if they have co-morbid ADHD, Conduct Disorder, or substance abuse, which are also risk factors for suicide], and they are less cognitively complex [depending on developmental stage] when compared to adults, making it extremely important to observe them throughout the course of any psychopathology.

4-I'm uncertain why you assume that drug trials are limited to "minor" depression; are you aware of what that actually means? In fact many of the findings we discuss in my profession are related to severity of depression and its interaction with psychotherapy.

Also, in a subsequent comment, you state that "all antidepressants have a number of very real miracle stories associated with them, which is why they're in such wide use". This couldn't be more wrong. They're in use because RCTs have shown them to be effective in large numbers of people [60-70%], not based on miraculous cases. That would be horrifically unscientific.

5-Yes, while people are more likely to commit suicide when they experience suicidal ideation, only a relative minority of people who consider suicide [~15%] will take action on such thoughts [e.g., Kovacs et al., 1993]. Thoughts and attitudes are actually notoriously poor predictors of behavior [Glasman & Albarracin, 2006]. Now, that is not to suggest that clinicians take suicidal ideation lightly…we take great precautions whenever someone presents with these thoughts.


Glasman, L. R., & Albarracin, D. (2006). Forming attitudes that predict future behavior: A meta-analysis of the attitude-behavior relation. Psychological Bulletin, 132, 778-882.

Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors and childhood onset depressive disorders: A longitudinal investigation. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 8-20.

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14. Comment #74587 by A. Person on September 29, 2007 at 4:03 pm

Alright.

From the start, I'm going to have to boggle at the Scientology reference. The FDA aren't scientologists, I don't think, and it's their double-blinded studies and warnings that largely cause the concern over SSRIs. Wariness regarding SSRIs does not require or even correlate with a conspiracy theory. The worst I could say for those reliant on medications is that they overuse them because when all you have is a hammer, everything looks like a nail. Drug companies I'm less kind to, out of the belief that they suppress unfavorable information in the name of the bottom line- which is a well-documented phenomenon. But that's all. Beyond that lies madness and Scientology.

But even the father of the ice-pick lobotomy was deathly convinced to his grave he'd done wonderful work for mankind. Intent doesn't prove that you're correct, nor does being hated by Scientologists.

Regarding the studies, you'll note placebo works 35% of the time in double-blind studies compared with 60-70% with prozac, resulting in a 25-35% increase in improvement on the drug, compared with a 2% increase in suicidality, which is about what I remembered- a fraction of the number. For the simple reason of the huge placebo effect, however, all the population studies- those without double blinds- are more or less useless. They don't do much but look good on paper and make for a nice sound byte. Several of them even have disclaimers to this effect towards their end- "Gibbons and colleagues also point out that their aggregate data do not prove a causal relationship.", and similar. In the social sciences, those kinds of studies are known to use the exact same sets of information to argue exactly opposite conclusions, usually (in my experience, anyway) in keeping with the political leanings of those doing the analysis.

... before you leap on this, I still don't believe it's a conspiracy. I just think people expect their point of view to be correct, which is understandable, but results in confirmation bias. The studies are, regardless, still not double-blinded, still horrifically unscientific, and still useless.

One of your articles also highlights one of the problems; "In contrast, toxic side effects are rare in SSRIs. Physicians often prescribe the drugs in larger doses and may not see the patient again for up to two months. This scenario, Licinio warns, can set the stage for suicide risk."

It's not uncommon, it's done, and it means that the 2% of patients that get much, much worse on SSRIs within the first few weeks are much more likely to kill themselves than a closely-monitored clinical trial would indicate. If you're a psychotherapist (I took this from context and may be wrong), you see your patients often enough that they're at much lower risk, which is great but says little about common practice. Suicide is measured as a few per hundred thousand, it only takes a small fraction of patients to spike the rate considerably.

If you want a textbook example, one of the Columbine shooters was on Luvox for a year. It was entirely insane and stupid to pull the drug simply because he was on it, because Columbine was a one in a million occurrence. This is the same public outcry that targeted all kinds of media at half-random, after all. That said, it illustrates nicely that when teenagers are going off the deep end, they will not necessarily tell people, even though it's generally 'just' a suicide at the end instead of a shooting spree, and it's completely impossible to directly point to antidepressants as the cause of anything.

Regarding drug trials, it's my understanding that they screen out either suicidal or previously suicidal patients fairly frequently as a matter of course. It's not going to skew the results terribly, it's true, but completed suicide almost never happens. I'm sorry if "miracle stories" seems like hyperbole, but personally I think being twice as effective as placebo is miracle drug territory. I know it was when Prozac came out, has this changed? Noone's ever doubted that doubling the number of people who improve is a wonderful result- it's just that it also doubles suicidal ideation, which is a much smaller group and smaller effect but very worriesome. Suppose (completely hypothetically) that the drug saves or even just cheers up two or ten teenagers, but kills one. Isn't that a serious problem that needs to be addressed? The ethical dilemma gets harder the worse the ratio between people saved and harmed gets and the milder the help is compared with the harm- suicide compared against wellbeing. The dilemma becomes nearly impossible (back in reality) when it becomes difficult to actually quantify help versus harm and total effects meaningfully. The default scientific position is ignorance, and if you have evidence for both help and harm clinically, with largely unmeasurable practical effects, it's far saner to back off and be cautious.

The only set of statistics there that's actually worrying about the black box warning is the well-documented spike in 2004 suicides, especially among young girls and by hanging. If I remember (and I'm sorry, but I'm not going to source this) prescription numbers didn't drop until a year later; if the 2004 suicide hop isn't a fluke and really is related to the black box warnings, it's probably (IMO) because patients got spooked at the black box warning and stopped taking their medication against their physicians' advice, which results in withdrawal and is a rather different problem than fewer prescriptions. This is a problem with the patients and the media, though, not the scientific studies and concerns about SSRIs.

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15. Comment #74610 by oxytocin on September 29, 2007 at 5:22 pm

A. Person,
First, perhaps I wasn't clear, but I wasn't referring to the FDA as scientologists...in fact, I didn't refer to anyone as a scientologist. I was referring to actual scientologists. Second, I said in my post that I'm a psychologist, and I will further specify that I work on an inpatient unit alongside many psychiatrists. Please don't presume to tell me what's done. You've still failed to provide references for any of your assertions.

Hold on there professor. Although RCTs are the gold standard, it is not always possible to conduct them since they take a tremendous amount of work. I suspect, since you are a student in an as yet unidentified field, that you are unaware of the intricacies of this type of research [a friend of mine is conducting an RCT right now in fact]. It most certainly does NOT make other designs useless...we have several different types of research designs that ask different questions and are limited in different ways. If they were useless, they wouldn't be funded and they wouldn't be done. This is the economy of science. Again, it sounds as though you have only passing familiarity with what you're attempting to proclaim with great authority.

If there are psychiatrists who don't see their patients for 2 months after prescription, this is a patient care issue and not a drug issue. This isn't how the colleagues that I work with operate.

I have no idea what you're talking about with regard to Columbine. What point are you trying to make? You seem to be supporting my assertions.

Yes, they often screen out suicidal people for drug trials. You are confounding this with depression severity [from your last post], since suicidality and depression are two separate entities, with the former potentially being a symptom of the latter, even at low levels of dysphoria. But then it might not be present at the severe end of the spectrum, even if the patient has psychotic features. They're separate but related.

Let's not use words like "miracle" with modern science...it's nothing of the sort. Of course the suicides are a problem that need to be addressed. No one has said anything to the contrary. I stated that in my last post [which you apparently didn't read]. Again, though, this same phenomenon appears in psychotherapy. This is a bit of a problem for your hypothesis.

Just so we're crystal clear, let's review some of the findings I cited in my previous post.

1-The number of suicides reduced by 60% in the 1st month of drug use and fell even further thereafter.
2-Suicide rates following treatment is higher for adolescents than adults, but still have lowered rates of suicidal ideation [it appears to be vulnerable individuals who are most at risk, and scientists are now attempting to identify who they are] overall.
3-For adults, suicidality was highest before treatment began and declines sharply subsequently.
4-Rates of adolescent suicide were lower in counties in the US where more SSRIs were prescribed [even after controlling for income and availability of psychiatrists]; it's not double blind, and it's retrospective, but it still has value, whether you want to admit it or not. Sorry, but it IS a valid research method. It has limited power [as do all methods], but not in the way that is damaging to the present case!
5-Rates of suicide fall when using SSRIs and older meds [e.g., tricyclics] with veterans and young people.
6-Untreated depression places people at risk for suicide; antidepressants protect them from it.
7-After a steady decline in suicide rates from 1988 onwards [after Prozac was introduced], there was an increase in suicide rates following the "black box" labeling of SSRIs by the FDA.
8-"Several large-scale studies in the United States and Europe also screened blood samples from suicide victims and found no association between antidepressant use and suicide. "Researchers found blood antidepressant levels in less than 20 percent of suicide cases," said Licinio. "This implies that the vast majority of suicide victims never received treatment for their depression. Our findings strongly suggest that these individuals who committed suicide were not reacting to their SSRI medication," he added. "They actually killed themselves due to untreated depression. This was particularly true in men and in people under 30". "Licinio and Wong fear that overzealous regulatory and medical reaction, public confusion and widespread media coverage may persuade people to stop taking antidepressants altogether. They warn that this would result in a far worse situation by causing a drop in treatment for people who actually need it." [Then they go on to talk about the effect of increasing energy and so forth that I mentioned in my last post.]

These are ALL important findings. As always, the data speaks for itself.

In conclusion, the benefits of antidepressants outweigh the costs. But the costs need to be considered seriously, in research and with vigilant treatment.

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16. Comment #74639 by A. Person on September 29, 2007 at 7:06 pm

I'd like to note that saying that "scientologists have succeeded in their plot" in response to my issues, which the FDA backs up, is in fact tarring me (and the FDA) unreasonably with the same brush as scientology. Arguing from authority because I'm a student who you assume is "unaware of the intricacies of this type of research", along with the sarcastic "professor", is simply stupid and an ad hominem attack. I'm certainly not going to bother with undoing my anonymity any further than that if you're immediately eager to argue ad hominem at the tiniest hint that I don't have your high authority when it comes to medications.

Seeing as you're willfully applying ad hominem attacks, though, I can happily list off mindless counters to your bullet points, which I nevertheless already addressed. It's going to get repetitious here, but I don't feel like being accused of not arguing against your points again.

1-6 Correlation does not imply causation. Since we're being mean, anyone who took a week of statistics 101 should know these studies prove nothing. Those doing the studies mostly know it, too. Studies with inconclusive results are done to suggest further, more conclusive research before anything is done. Suicide rates have trends up and down regardless of drugs. Clinical trials demonstrate 35% efficacy for depression in placebo, which is extremely high. These results do not demonstrate that suicide rate drops because of antidepressants rather than during the course of the illness during which people can and do seek help, and the more scientifically sound double-blind research that prompted the black box warnings seems to disagree with conclusions of safety. Additionally, the segments applying to adults are not as relevent, as the black box warning was initially and primarily for children and adolescents.

7- One year does not establish a trend. Suicide rates are measured in a few per hundred thousand, it's not necessarily the warnings doing it. More importantly, the "black box warning" could be prompting people to stop taking the medication abruptly, leading to severe withdrawal- which is a problem with the patients and the media and the warnings, not a lack of problem with the drug. Even if the black box warnings are doing damage, it isn't necessarily because SSRIs are good so much as that abrupt, unsupervised termination is bad. And, lest we forget: Correlation does not imply causation.

8- Correlation does not imply causation, again. Those who killed themselves never sought SSRIs, but also probably never sought ANY kind of help. This doesn't necessarily mean SSRIs would have saved them, since if they didn't even have SSRIs they probably weren't doing anything at all. Remember there's a massive placebo effect, and it's not like they were chosen in a trial not to get SSRIs- they had to be people who chose not to get help, which is very possibly - even probably - a bigger indicator of being a suicide risk than SSRIs could be. It's known as a self-selecting sample, it's completely unscientific to rely on it, and it's why we have double blinds.

You have yet to 'prove' in any meaningful way that the benefits of antidepressants outweigh the costs, especially given the complicated nature of antidepressants and suicide. The double blind reseach is not there, I know it, the FDA knows it, and a majority of your sources know it. Non-double blind research has limits, and those limits are, specifically, that it can't actually 'prove' anything, only suggest it, because self-selecting samples are extremely unreliable and lurking variables- causes you aren't looking and adjusting for- are abundant. Ignoring these facts results in incorrect conclusions about cause and effect, and is the result of wishful thinking and confirmation bias.

Back outside of the very basics and repeating myself for your bullet-points, inpatient facilities are much, much safer and closer-monitored than elsewhere. I shouldn't even need to source that many millions of those receiving treatment aren't in inpatient, and I'm going to add that they aren't monitored very well. I'm not even going to cite any research besides the study you linked that gives two months as a standard period of neglect. Insisting that antidepressants are safe because they're safe in inpatient or in clinical trials is poor logic. That guns are safe in gun ranges does not make guns safe in reality. Proving they're safe enough to be used in the setting they're actually used in should be placed at the feet of those who say they are, especially when a lot of data suggests that they aren't.

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17. Comment #74672 by irate_atheist on September 29, 2007 at 11:57 pm

A. Person -

You can't try to hype-up the validity of clinical trials (in a thinly veiled ad-hom attack on myself) and then try to run them down a couple of posts later in the thread. Well, OK, you can, but you'll get no credit here for doing it. (I've certainly been pulled up for faulty arguments here before now :-) )

I have no formal education in the subject area - and have not claimed I have.

Having added: 'All anectodatal evidence and opinion, I know...' to the end of my original post, perhaps you would give me a bit more credit for recognising the position I am in. Like yourself, I get pissed off when opinions replace facts, and assertion stands in for evidence. The key to an honest debate is to recongnise when oneself is in danger of doing so and add the required caveat. (A lot of the time I don't, but I think I've gotten away with it...)

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18. Comment #74676 by A. Person on September 30, 2007 at 12:19 am

Oh, sorry. The comment on clinical trials against placebo was in response to your third paragraph (or thereabouts) where you were speculating (or it seemed) about whether the suicidality link could be correlation rather than causation. Should've been clearer, it wasn't about your story, which was properly noted as such and informative. Anecdotes are good. If you've got enough good anecdotes and thinking you're well on your way to understanding things.

I'm still hyping up clinical trials, it's population studies (without a placebo group) that I hate. Clinical trials are considered the gold standard of testing in medication, the problem is that they don't show antidepressants to be safe. They are, in fact, what convinced the FDA they were dangerous.

I think I slipped much closer (in retrospect) to ad hominem when bringing up ice pick lobotomies and Freud's love of cocaine. They're a fairly, ah, dramatic selection for examples of unblinded observations gone haywire, to say the least. I should have picked something more neutral, probably, but I'm not sure anything else in the same vein would be quite as fitting and I was already thinking of psychiatrists.

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19. Comment #74678 by irate_atheist on September 30, 2007 at 12:33 am

Luckily I never had anthing to do with psychiatrists, per se, just normal general practitionors & counsellors.

One problem with the treatment of all mental health issues is sitgma, misconception and prejudice. One can but hope the zeitgeist moves forwards so that those who need help feel more able to ask for it and the provision improves. To be honest, a change in lifestyle and dramatic reduction in stress were, in restrospect, probably the most important factors in my long term recovery.
It is one reason I consistently rail against too much pressure being put on children to 'perform' in any arena - academic or otherwise. It is neither healthy nor wise. This doesn't of course prevent me from educating my son about the importance of compound interest. After all, it's the only thing that will give him a decent pension in 65yrs time. Hey, are you listening boy? Pay attention when your old man's talking. And stop crapping your pants - it's not big, and it's not clever. At 8 weeks old you should at least be able to use the facilities here...

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20. Comment #74682 by nother person on September 30, 2007 at 1:05 am

—Nother Person, I'm taking a wild guess that your comment was directed at me;

I thought it was pretty clear that my comment was directed to A. Person.

—if this is true then you're making unwarranted assumptions.

I try not to make assumptions where I don't have too, but I'm sure I make many unwarranted assumptions nevertheless. But in particular I make no assumptions about your feelings or beliefs other than that you are human like all the rest of us.

—I can assure you that I have no desire to toe the line of the "science industrial complex", as you say…as a scientist and clinician, I care about the data and the welfare of my patients. As a psychologist, I neither prescribe medications, nor do I have any ties with pharmaceutical companies.

I never doubted your good intentions... or am I missing the point here?

—What I stated above is based on what I've read in the research, not blind adherence to the status quo.

Excuse me but you stated a number of things, some of which probably is supported by research you have read. But you must be more specific. Your very first statement concerned "The hysteria surrounding the use of antidepressants." Is it your contention that this 'hysteria' is documented fact? Or your hypothesis that "people with depression are at greater risk for suicide when one starts to experience an alleviation of symptoms"? Or your hypothesis of this hypothesis that it is explained by an increase in psychic energy? Or your assertion that this has explanatory power? All the above? Your statements may be based on research but they consist of opinion and conjecture, not data, and they do represent a very common, one might say institutionalized, point of view. That doesn't mean you are wrong, of course. But it doesn't mean you are right either.

—I am a "cheerleader" for the scientific method.

That's great! Can you explain then why you argue from the authority of 'common knowledge?' "It is common knowledge within mental health that people with depression are at greater risk for suicide when one starts to experience an alleviation of symptoms."

—Further, science, by definition, does not claim to have final answers; it is inherently tentative, and I have no idea how you derived the contrary from what I wrote above.

I am perfectly well aware that science is tentative and iterative. Which of my statements told you that I had derived the contrary from what you wrote, for I must tell you I am not aware of making any such derivation? Have you made an unwarranted assumption that everything I said had something to do with what you wrote?

—We strive for technology to help us solve problems, but we do not know if it will ever be complete in this regard.

I'm having a little trouble with the concept of 'complete technology.' Technology is tools. Tools are useful or ill-suited, but not 'complete.' Some tools may be beyond improving, but I know of no way to demonstrate that. Whether the tools of Psychiatry ever achieve completeness or not is, in my opinion, entirely irrelevant. It is not their completeness but their usefulness that is at issue.

—I am stunned that you would suggest [if you have indeed] that I used psychiatry in a "religious" manner…this is the very antithesis of my worldview.

I made no suggestion that you use psychiatry in a religious manner. I will suggest, however, that you demonstrate a certain contextual unawareness that is analogous to the voluntary self-deception of the faithful. You show great faith in the medical model of 'mental health,' which faith perhaps serves you clinically. You perhaps forget that it is just a model, and you perhaps are not aware that it has been eloquently criticized, and I don't mean by scientologists.

—By your reasoning, if I were to defend evolution against the pestilence of intelligent design, I would be mindlessly defending without cause.

This is not my reasoning at all. This is your own reasoning which I'm afraid I can't follow. I would be very happy to hear you defend evolution against intelligent design, and I would not at all be insensitive to the many good reasons to do so. If I make the perhaps warranted assumption that your post had something to do with the NYTs article on genetic links to suicidal ideation in patients taking a particular antidepressant, your defense of antidepressants would seem to pit evolution (antidepressants) against intelligent design (genetic link). But I'll bet that's not what you have in mind, is it? I'll bet that you are reacting to this line of the article: "regulators and some former patients are locked in a furious debate about the risks of antidepressant drugs." And your defense of evolution (antidepressants) is against intelligent design (former patients and anyone else who dares to question, not the efficacy, but the appropriateness of antidepressant drug therapy). Am I right? If so I think the reasons for your defense are fairly transparent, yes, but not without cause certainly.

If I am wrong, as I know I might well be, then I'm afraid I don't really understand your post, neither your purpose in posting it, which may go a long way toward explaining why I did not address any remarks to you about it.

In sum, I am perfectly happy to concede that you are a good guy doing your best to be thoughtful and helpful. I am delighted to know you value the scientific method; I never thought otherwise. I think your use of the word 'hysteria' was ill advised, and I'm betting you think so too by this point. I am happy to admit that I am riddled with ignorance and blind spots. I am very sorry if my compliment to A. Person was an affront to you, I did not mean it that way. In truth I really was making a general observation not directed to you particularly. In the back of my mind was another comment made by notsobad ("But since the latter requires personal responsibility and other things people do not know any more, it's up to science to produce better drugs.") as well as a previous discussion in which someone mentioned PETA with an attitude (not your attitude, I accept) that only the lunatic fringe would ever dare to criticize Science, and another post from days ago where an environmental issue was raised which someone took as an opportunity to rattle on about the benefits of modern industry with, again an attitude of, 'anyone who disagrees with me is a fool because, I... am a Scientist.'

I believe we could learn from each other. What do you think?

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21. Comment #74776 by oxytocin on September 30, 2007 at 11:50 am

Nother Person,
My apologies for thinking your comment was directed at me...it seemed like a passive-aggressive attack. This is the challenge of this type of communication. I have no doubt that we can learn from each other.

I will need to disagree with your use of "faith" in my endorsement of the medical model. I would say "trust" instead since what I think about medicine is based on evidence and is falsifiable. The irony is that in here I'm defending medicine when in my life "out there" I'm actually quite critical of it [and vocally so]. How much fun would these boards be if we all sat around and patted each other on the back for being right?

A.Person,
Oh bother. My scientology comment was a poor attempt at humor. All of the psychiatry articles on this website are lambs to the slaughter. I was "joking" about the efficacy of the scientologists' methods in convincing the public to abandon support of psychiatry. That's all.

1-It's not ad hominem to surmise that someone doesn't have much experience with research. I don't have any authority with regard to medications…I'm not a physician. But I do know research, that is, how to read it, and the practicalities of carrying it out. My sincerest apologies if you felt attacked…it wasn't my intent. I have students of my own, and the last thing that I ever want to do is attempt to quash dissent. Again, the folly of the written word alone…

2-I would caution against the word "proven". As we know, inferential statistics do not "prove" anything. They "reject" or "fail to reject". The best we can say is that we often value the evidence from RCTs more than other types of trials…

…but why might scientists employ other research designs when they are clearly and self-evidently useless? Well, because many researchers don't take such a black and white approach to the issue. They recognize the unique validity of other approaches. For example, have you noticed the number of participants in the retrospective studies? They are often far larger than an RCT would permit. With an increase in N comes an increase in statistical power. Now…RCTs are often substantially smaller and astronomically more expensive. Not every researcher has the coin or the infrastructure in place to carry out this Herculean task. Because RCTs are often small[er], they have the disadvantage of potentially failing to document rare events, such as suicide. One benefit of observational research is that you're far closer to population parameters, and the probability of capturing rare events in the data is much higher. Patients can also be reluctant to join an RCT. Why might that be? Well, because ethically, we have to tell them that they may not get the active treatment. [Note: many argue it is unethical to deny treatment to people, especially when the utility of a medication is well-established; the control then becomes the well-established medicine]. Might people who self-select out have something in common that is pertinent to the question at hand? Perhaps, perhaps not. Another issue is what we call external validity or generalizability. Sometimes people are taken out of studies with the goal of making the sample homogeneous, but it may "backfire" when attempting to say something about the population as a whole. Quasi-experimental designs attack the problem from a completely different angle by including all sorts of folks in their data sets and using huge numbers of people. Typically, RCTs are great at identifying a desired effect [called "efficacy"], while observational studies are better at demonstrating the ability to bring about an effect [called "effectiveness"]. Finally, RCTs are often limited to short term outcomes while observational research can cover much longer periods of time. Although we can make less specific and concrete conclusions with observational research, we are on more solid ground in our application of [conservative] blanket statements across a population. These are but a small sampling of the considerations.

I will also say with regard to the RCT that it is becoming a political issue. What I have noted, both in comments by researchers in the literature, and in my experience, is that people use "RCT" and "evidence based medicine" as a catchphrases without knowing what they really entail. We are increasingly being required to carry them out by people who don't understand the issues. This is a problem.

If we don't value quasi-experimental research, we are losing a lot of very interesting and valid data. What scientists need to do is to ensure that their studies of this sort are rigorously designed for maximal benefit. But this is what makes science challenging. We have to put together various sources of sometimes disparate information and hopefully paint a picture that appears somewhat coherent. Sometimes this happens, and sometimes it doesn't.

With regard to the medications: My goal was never to "prove" anything. This is not a black and white issue and it isn't how science works. Although you have raised some very important concerns with observational data [and which researchers constantly flog themselves for without the need for us to do it for them], you are failing to recognize that most scientists who work in this field do indeed value the data generated by quasi-experimental research. So, if you negate all the data from those studies, then we may never agree on anything. Each have their strengths, and both need to be considered to achieve a more complete picture.

Let's find common cause here. Clearly, it sounds as if we both care about what happens to people who are depressed, which is important to recognize. Ultimately, we're disagreeing over the interpretation of complicated data sets that are tough to pin down. What concerns me is that in the litigious US, regulatory bodies may be so concerned over law suits that they may become overly conservative in the application of their power, which has the very real potential to lead to harm. We need more research of all sorts, because one tool doesn't solve all problems. This will continue to be the state of affairs until our methodological technology is catapulted forward by the successor to the RCT. What form that will take is beyond me.

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22. Comment #74793 by Bonzai on September 30, 2007 at 1:12 pm

Oxytochin wrote:

I would say "trust" instead since what I think about medicine is based on evidence and is falsifiable..

Without getting into your debate with the two "persons" I would just like to caution you on one thing.

IMHO an important consideration of the medical model should be whether it is appropriate in a given context, not just whether it produces falsifiable statements. As I am sure you know that some questions are easier to be casted in the form of hypothesis testing than the others even though these questions may not be appropriate or relevant for the issue at hand.

To use an analogy, you can easily come up with some numerical scales to measure a variety of things, but just having a bunch of numbers doesn't make something "scientific", the numbers may be measuring completely irrelevant or inappropriate things. Contrary to modern superstition, being able to quantify something in and of itself doesn't make science.

Many thoughtful people have suggested that perhaps health and well being are not just a biological issues, rather, they are tied to a myriad of social and economical factors that we understand intuitively and can explain logically and qualitatively yet because of their complex and intertwining nature it may be impossible to formulate them in the clean format for hypothesis testing (I happen to think qualitative research does have its place in the social sciences) If they are right then the medical model would not be appropriate at least in some context. It is not in keeping with the scientific spirit to only deal with a class of questions even if they may be the "wrong questions" to ask just because we can apply certain sets of "scientific" tools to them.

On a somewhat unrelated note,I should also point out that our statistical tools may not be as reliable as many think. Clinicians typically treat statistics as a black box and take certain things for granted. But unlike in the physical sciences, the mathematical assumptions behind these statistical models are difficult or impossible to verify in the social and health sciences. They are very likely to be seriously violated. "Robustness" to my understanding simply means that the tools of measurement in these areas are so crude that they are not able to detect serious inconsistencies and internal contradictions even when the assumptions behind the statistical models are violated, so you can get away by using your statistics to build more complicated models until something seriously wrong turns up, at that point you return to the drawing board and start all over again. I don't know how serious an issue it is but I think in the interest of prudence one should keep that in mind while trying to make "everyday statements" based on statistical research.When results are communicated to the public the usual qualifications in journal papers go out to the wind. To your credit I think you do understand these kinds of problems based on our correspondence on the other thread, you are quite correct that in the life sciences one can only make very tentative and probabilistic assertions about the truth value of certain statements


Aside: This is not the modus operandi of more mature sciences such as physics. First in the physical sciences we deal with samples of identical units typically of the size of the Avogrado number and we have complete control over experiments so statistical inferences are a lot more reliable and we can measure things very accurately. Secondly our theory building is not just based on statistics, but precise mathematics.We also have much more in depth causal models which statistical method cannot produce, but must go back to first principles.This "cultural difference" may explain our slight disagreement on the other thread on the nature of scientifically provable/disprovable statements.

Other Comments by Bonzai

23. Comment #74826 by kardde1492 on September 30, 2007 at 5:16 pm

My friend takes a huge dose of an anti-depression medication for OCD, and he has never told me about suicidal thoughts. He does sharpen his pocket knife for fun, but he doesnt seem depressed or suicidal at all. and he takes a HUGE dose of medication. I think it was a weeks worth of medication a day.

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24. Comment #74827 by oxytocin on September 30, 2007 at 5:30 pm

Bonzai,
I think you've raised some very important issues.

I for one see tremendous value in qualitative research [my honors thesis, in part, used this type of analysis], and I very much agree that the issues we are discussing above [and indeed much about the field of health in general] goes beyond the biological. This is why many of use bio-psycho-social models. And yes, reducing this to hypothesis testing is often not at all what we do; other times it's extremely difficult to do without being overly reductionistic.

I think many of us who use stats are wary of them and see them with a particularly skeptical eye. Perhaps even ambivalence. Many of the things we do, such as the Bonferroni correction, leave many of us scratching our heads and wondering if it makes sense to do it.

Robustness refers to the ability of a statistical test to withstand violations of the underlying assumptions. For example, as a class, parametric stats are generally sensitive to violations of the assumptions, while non-parametrics are less sensitive [since they're not based on parameters]. For example, if we know that we are going violate the assumption of normalcy in the distribution, we would select a non-parametric stat. Some assumptions are easier to identify than others.

Psychology very much aspires to measure as the physical sciences do, but we're not there in almost any way. Being a young science, we don't yet have the technology to accomplish this task, but I think the striving to do so will will eventually get us there. [with multiples missteps along the way!]

kardde1492: I hope your friend is taking the PRESCRIBED dose.

Other Comments by oxytocin

25. Comment #74829 by A. Person on September 30, 2007 at 6:12 pm

Sure. Statistical studies are worth a lot when more precise research can't be done, I agree, but especially with anything as intricate as suicide and depression it's very nearly impossible to pin down all the roving variables in population studies.

The problem is that, statistically, the apparent effect of SSRIs on suicide could likely be duplicated by sugar pills. If you gave out sugar pills to everyone seeking psychiatric help, 80% of suicides would not have sugar pills in their system because the people who kill themselves are not the ones acknowledging they have problems and seeking help. It's fairly basic statistics.

That's my objection to the population research across the board. It's hairy and difficult enough to control for even the basics like social class in population studies, when you get into such intangibles as tendency towards suicide it's very nearly completely outside of the ability for statistical models to explain or comment on meaningfully. Looking at trends is very useful to suggest information, as are anecdotes, but to really quantify what any actual program is doing or not doing meaningfully requires the mind-bogglingly expensive and time-consuming years spent in clinical trials.

The thing is, those trials have already been done, and they're the reason for the initial concern. If anything, the genetics research the initial article here is on seems to support the thesis that there's a component outside of simple "extra energy" increasing suicidality in reaction to SSRIs, which is very troublesome. Supposing the people with 15x the likelihood of a violently bad reaction to the medication are given it and then cut loose for months, doesn't this seem like a serious and severe problem? It's an extremely common practice, and it's, well, bad shit. Genetics research to figure out who is at risk is a good stopgap measure, but the perpetual optimist in me sees this as an avoidable problem brought on by a lack of realistic evaluation for how the medication is given out and affects people, in line with many past blunders.

Other Comments by A. Person

26. Comment #74841 by oxytocin on September 30, 2007 at 8:21 pm

A. Person, RCTs are "statistical" studies...you may have used the wrong word there. In addition, we don't actually do "population" studies since that would be a near impossibility. They're still samples...just really large ones that require inferential stats just the same.

With your conjecture about placebos preventing suicide: it's an empirical question. If it hasn't been done already, go, formulate a testable hypothesis, and do the research [and have fun trying to appease the ethics committees]. Be the iconoclast that the best scientists are. But I assure you, there's nothing "simple" about what you just said. Stats or otherwise. Nevertheless, I would be there cheering you on. Above anything else, I want the facts uncovered for all to see. If the issue was settled with the RCTs, this would be a dead issue. It's not even been diagnosed with a terminal illness.

I think all the suicide researchers would likely disagree with you on the meaningfulness of their research, but never mind that. Statistical trends and personal anecdotes are far from equivalent. I see that you'll never give quasi-experimental designs the props they deserve. Okeedokey.

Yes, where death is concerned, it's always a serious issue. Again, suicide subsequent to the consumption of an SSRI is a rare event. Although you will disagree, I find the research that says that not only are these meds useful, but they prevent suicide as well, valid. Yes, it's terrible that a subset of people exhibit paradoxical reactions to the medications. We need to work our asses off to prevent it from happening. I will state again, if this is a patient care issue, we need to make certain that psychiatrists properly monitor their patients for adverse reactions and take appropriate actions. Although only tangentially related, as someone who uses CBT for major depression, I see my patients weekly and monitor levels of suicidality with great regularity and seriousness.

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27. Comment #74842 by Bonzai on September 30, 2007 at 9:01 pm

oxytocin wrote:

Robustness refers to the ability of a statistical test to withstand violations of the underlying assumptions. For example, as a class, parametric stats are generally sensitive to violations of the assumptions, while non-parametrics are less sensitive [since they're not based on parameters]. For example, if we know that we are going violate the assumption of normalcy in the distribution, we would select a non-parametric stat. Some assumptions are easier to identify than others.

I understand that, this is the text book definition of robustness. But to my knowledge,-- which may not be much,-- none of the robustness claims made in the social sciences are based on rigorous mathematical proof ( say, establishing some kind of error bounds based on the degree of violation of a particular assumption like it is commonly done in numerical analysis). They are just heuristics developed by end users of statistics in their areas of expertise. Sometimes asymptotic results in mathematical statistics such as the central limit theorem are cited to justify such heuristics, but the mathematical statements of such results typically require N --> infinity, which certainly is not the case with a sample of a couple of hundreds. To my mind the ultimate justification of using such models is the apparent consistency when they are applied in a given context. Now it is tricky to try to establish consistency empirically rather logically because things may appear to fit together consistently simply because we don't have instrument powerful enough to detect the discrepancies,--or you may say the discrepancies are unimportant in the scale we are interested in.

I am not trying to diminish the importance of heuristics, especially when there is no realistic alternatives. But perhaps it is still somewhat useful to keep this in mind if we want to have a, should I say, philosophical discussion on the foundational aspects of methodology. That was what I meant in post#22.

I apologize for going off a tangent which really doesn't specifically deal with the topic at hand.

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28. Comment #74845 by A. Person on September 30, 2007 at 9:56 pm

When I say "statistical" and "population" I'm thinking of any study that doesn't collect its own data but instead relies upon (for instance) the CDCs nationwide statistics. It's true that's not a very precise usage of the term.

It's not about placebos preventing suicide, it's about the course of treatment during which SSRIs are administered preventing suicide, which is different. The continued mantra is that correlation does not imply causation. The burden of proof ought to be heavily on those asserting it does, especially when suicidality has been shown to actually increase in experiments that are properly blinded.

I've got my own thoughts about experimental models regarding SSRIs and psychiatric meds in general, but I'm really not inclined to write them out on a weekend. It's depressingly negative to do nothing but point towards the inadequacies of existing statistics, but it also consumes far less energy. :P

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29. Comment #74924 by oxytocin on October 1, 2007 at 6:30 am

Bonzai,
wrt robustness and mathematics: although I know that I learned about this issue at some point, it is lost in the recesses of my mind.

A.Person,
Yes, the burdon of proof does lie on the party making the positive assertion. The problem becomes when one party thinks they've provided the evidence and the other does not.

Well, maybe one day you'll contribute to the literature with rigorous studies using interesting new methodology. And you're very right, tearing a hole in something is far easier than the reverse!

Other Comments by oxytocin

30. Comment #74942 by A. Person on October 1, 2007 at 7:33 am

In the interest of continuing to be contentious, I'm going to re-re-re-iterate that I think clinical trials have many times greater explanatory power than all the evidence in favor of SSRIs combined.

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31. Comment #74946 by oxytocin on October 1, 2007 at 7:41 am

And I think you're incorrect [RCTs demonstrate the efficacy of SSRIs above and beyond placebo; this is a separate issue from the observed suicides]. I guess we'll have to leave it at that so we can avoid adding another "re" on to the iterations, lest the word collapse under its own weight.

Let's get on with debunking the god-botherers.

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32. Comment #75095 by USA_Limey on October 1, 2007 at 7:17 pm

Comment #74946 by oxytocin wrote:

Let's get on with debunking the god-botherers.

I've been lurking on this thread and have learnt a lot so thanks to all, especially you oxytocin and A. Pearson.

Yes, debunking the god botherers is mostly what we are here for but I think we all enjoy the off topic debates generated by some articles. Learning from people with a specialist interest / knowledge on a whole myriad of subjects is a great facet of this site.

So, what I am trying to say is; don't be so hasty to get back to the debunking; some of us are taking notes!

:-)


__________________________________________________
Carousel is a lie! There is no renewal!

~ Logan

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33. Comment #75204 by logical on October 2, 2007 at 3:33 am

Beyond going into details of clinical trials and their statistics, can anyone here explain to me why faithheads, mainstram press and the people writing here are so unified against suicide?

To my plain thinking it should be considered as a part of self-determination, just like abortion and euthanasia.

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34. Comment #75206 by Russell Blackford on October 2, 2007 at 3:49 am

^Yes, but if it's a matter of self-determination surely we want anyone making such a decision to do so in a frame of mind where they're thinking clearly and rationally about the alternatives. To believe that is not to believe that someone who makes an open-eyed, clear-headed decision to commit suicide is thereby "sinning".

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35. Comment #75263 by oxytocin on October 2, 2007 at 7:12 am

logical, as Russell alluded to, it is important that someone has the "capacity" to make decisions of this magnitude. Thus, in the hospital system, we have neuropsychologists who are trained to assess for this. The presumption is that if someone is unable to think in a logical and coherent manner, they should be deemed incapable of giving informed consent or making other important decisions. This is particularly relevant when someone has been diagnosed with dementia. It can also be relevant when someone is severely depressed or psychotic, amongst other diagnoses. These capacity decisions are considered by a committee, and they are temporary statements to protect the rights of individuals. Re-assessment is required.

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