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Alarmist claim 1 in 6 with untreated depression suicide wins RACGP President Disease Monger Award

RACGP President Dr Harry Nespolon's alarming but inaccurate claim that “about 1 in 6 people with untreated depression commit suicide" wins Dr Nespolon PsychWatch Australia’s Disease-Monger of the Month Award for October 2019.

By Dr Martin Whitely

During an interview on ABC Radio 720 Perth in April, Royal Australian College of General Practitioners (RACGP) President, Dr Harry Nespolon, said "You’re looking at about 1 in 6 people with untreated depression committing suicide".[1]

Dr Nespolon's statement was alarmist and misleading for two reasons.

Firstly, any claim that 1 in 6 people with depression (either treated or untreated) die from suicide is just wrong.

Irrespective of the relative risks of medication, other treatments, or no treatment, the risk of suicide associated with depression is much lower than 1 in 6.[2] It appears that Dr Nespolon may have been simply parroting an old, discredited, but often-repeated 'zombie' claim.[3] However, making such an alarming and inaccurate claim is not acceptable from any GP, let alone from the elected leader of the RACGP.

Secondly, there is a growing body of evidence that antidepressants, the dominant treatment for depression in Australia, increase the risk of suicide, particularly among young people.

Perhaps Dr Nespolon could be forgiven for assuming that increasing rates of treatment reduces the risk of suicide. Despite the FDA and TGA suicide warnings about antidepressant use by patients aged under 25, most people, and far too many doctors, simply assume that drug treatments save lives. However, as detailed in two recent PsychWatch Australia blogs, one about youth suicide and antidepressant use, and the other on a recent review of FDA evidence on the relationship between antidepressant use and suicide, data indicates that treatment with medications presents a greater suicide risk than no treatment, particularly for children, adolescents and young adults.

I emailed Dr Nespolon with details of this evidence on 19 August 2019 (my email is copied below). In the email, I identified a possible source of Dr Nespolon's mistaken belief in the '1 in 6' statistic, and provided him with detailed information about the risks of treatment and non-treatment. I also invited Dr Nespolon to "either provide evidence supporting his assertion, or retract the comment and work with PsychWatch Australia to accurately portray the relationship between depression, treatment (especially antidepressant use) and suicide". After repeated follow-up requests, Dr Nespolon eventually responded briefly by email on 2 October 2019 (his response is copied far below).

Unfortunately, Dr Nespolon's response was as evidence-free as his original statement. He simply asserted that "untreated depression does lead to an increased number of people with completed suicides. This I hope that you can accept". It appears that regardless of the evidence I presented to him, I (and the public at large) are expected to accept as a matter of faith that treatment reduces suicides.  

Dr Nespolon's response also stated: "While we can argue about the numbers, I have heard much higher numbers [than 1 in 6]". This left me wondering where he heard "much higher numbers" . Was it in a peer reviewed journal? At a conference? From a drug rep in his surgery? Or down the pub? Without any evidence being provided, it is impossible to know.

Yes, Dr Nespolon was correct in his response that "treating depression includes both pharmacological and non-pharmacological treatment". However, the ABC interview was conducted in response to newspaper coverage of a PsychWatch Australia blog that revealed that roughly 1 in 8 (over 3 million) Australians were prescribed a PBS-subsidised antidepressant from July 2017 to June 2018 and that about 90% of antidepressant prescribing in Australia is done by GPs.[4] Given this context, Dr Nespolon's comments about "untreated depression" in the minds of many listeners, would be interpreted as "unmedicated depression".

It is little wonder that Australians are among the highest users of antidepressants on the planet when leaders like Dr Nespolon are making alarmist claims about the risks of "untreated depression" and are unwilling to engage with evidence that is presented to them.

Dr Nespolon's claim reinforces concerns that, far from being "specialists in life", many GPs don't have the time needed to keep up with the evidence, or the skills needed to treat individuals distressed by grief, family breakup, unemployment, or any other of life's inevitable trials. In reality, most Australian GPs are experts in 15 minute consultations with at least one medication as the likely outcome.[5] Too often, their only tools are antidepressants; and, if all you have is a hammer, everything looks like a nail.

As the chief spokesperson for GPs in Australia, Dr Nespolon should not have made the original misleading claim. But worse than this, when he was presented with relevant evidence, and the opportunity to either refute this evidence and justify his statement, or correct his error and help inform the public accurately, he did neither. This is the main reason Dr Nespolon is Disease-Monger of the Month for October 2019.

References

[1] ABC Radio 720 Perth - Breakfast with Nadia Mitsopolous 24 April 2019. Interviews with Dr Martin Whitely from PsychWatch Australia and Dr Harry Nespolon President Royal Australian College of GPs and talback callers. It was previously available at https://www.abc.net.au/radio/perth/programs/breakfast/breakfast/11027626 (Note this was a recording of the whole program. The interview began at 2:44:28 and ended at 3:16:00. Dr Nespolon made his comment at 3:02:18).

[2] Gregory E. Simon and Michael VonKorff, Suicide Mortality among Patients Treated for Depression in an Insured Population American Journal of Epidemiology 1998 Vol. 147, No. 2. Available at https://pdfs.semanticscholar.org/65e8/c5a4298167106fea861b7bc4c9ff76cab304.pdf

[3] A detailed analysis and refutation of previous similar '1 in 6' claims is available on pages 147-155 of the PhD thesis 'Depression and antidepressants in Australia and beyond - a critical public health analysis' of PsychWatch Australia Deputy Editor Dr Melissa Raven.

[4] In 2014/15, the vast majority (90.4%) of antidepressant prescribing was done by general practitioners. Psychiatrists were directly responsible for only 6.5%. Australian Institute of Health and Welfare 2016. Mental health services—in brief 2016. Cat. no. HSE 180 Canberra: AIHW. pp. 24-25 Available at https://www.aihw.gov.au/getmedia/681f0689-8360-4116-b1cc-9d2276b65703/20299.pdf.aspx?inline=true (accessed 13 August 2018)

[5] "For an ‘average’ 100 GP-patient encounters, GPs provided 102 medications and 39 clinical treatments (such as advice and counselling), undertook 18 procedures, made 10 referrals to medical specialists and 6 to allied health services, and placed 48 pathology test orders and 11 imaging test orders (Table 5.1)." Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Pan Y, Charles J, Pollack AJ, Wong C, Gordon J. General practice activity in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press, 2016, p.34

Email from PsychWatch Australia to RACGP President Dr Harry Nespolon sent on 19 August 2019

Dear Dr Nespolon,

Re: Your statement "You’re looking at about 1 in 6 people with untreated depression committing suicide" (ABC Radio 720 Perth Breakfast - 24 April 2019).[A]

My apologies for the delay in raising this important issue with you. I had intended to contact you earlier in relation to your statement; however other priorities prevented me.

I believe your assertion that approximately 1 in 6 people with untreated depression commit suicide is a grossly inaccurate and dangerously misleading statement. I invite you to either provide evidence supporting your assertion, or retract the comment and work with PsychWatch Australia to accurately portray the relationship between depression, treatment (especially antidepressant use) and suicide.

I understand why you may have believed the statement to be true. You are not the first prominent Australian doctor to make a similar claim. In 2001 the then head of Beyondblue, Professor Ian Hickie, claimed "people with depression have a one in six chance of being dead by suicide”.[B] This false but persistent claim comes from studies from the 1970s and earlier of people with treated depression, many of who had received long-term intensive treatment had a 15% suicide rate.

Diagnostic criteria were much stricter when these studies were conducted, so these patients are not representative of the broader spectrum of people currently diagnosed with depression. A detailed analysis and refutation of the claim is available on pages 147-155 of the PhD thesis 'Depression and antidepressants in Australia and beyond - a critical public health analysis' of PsychWatch Australia Deputy Editor Dr Melissa Raven.

In 1998 US research by Simon and VonKorff (Suicide Mortality among Patients Treated for Depression in an Insured Population) used a Washington State insurance database to examine the 15% suicide rate claim. The study found that the suicide “risk per 100,000 person-years” for those treated with depression “declined from 224 among patients who received any inpatient psychiatric treatment to 64 among those who received outpatient specialty mental health treatment to 43 among those treated with antidepressant medications in primary care to 0 among those treated in primary care without antidepressants”.

The authors concluded that this indicates that “overall suicide risk among patients treated for depression is considerably lower” than the 15% claimed. Given your leadership role the difference between suicide rates in primary care between those treated with antidepressants and those treated without antidepressants is I am sure of great interest.

Your interview with radio ABC720 Perth was in response to media coverage of an earlier PsychWatch Australia blog written by Dr Melissa Raven and I titled, 1 in 8 (over 3 million) Australians are on antidepressants - Why is the Lucky Country so miserable? In this blog we highlighted that most antidepressant prescribing in Australia is done by time-poor GPs with limited mental health training and few other options.[C]

A subsequent blog, that also received extensive media coverage, More young Australians suicide/self-harm and use antidepressants while experts dismiss FDA warning highlighted that Australian suicide rates, particularly among those aged under 25, have risen significantly in recent years.

It detailed how beginning in 2008-09, an increase of approximately 60% in per-capita antidepressant use rates by young Australians (aged 0 to 27) has been associated with a 40% increase in per-capita suicide rates by young Australians (aged 0 to 24). Prior to these rises, from 2002-03 to 2008-09, per-capita antidepressant use rates for young Australians (aged 0 to 27), fell by 27%. During this period under-25-year-olds' per-capita suicide rates were volatile, but trended downwards, falling by 17%.[D] This experience is consistent with the 2004 FDA and 2005 TGA warnings of an increased risk of suicidality associated with using antidepressants to treat depression in people aged under 25.

While our concerns primarily relate to young Australians, our latest blog (23 July 2019) outlines how a recent review of drug trials found that the rate of suicide attempts and completed suicides among adults was about 2.5 times higher in those using antidepressants compared to placebo.[E] This raises concerns that the positive correlation between antidepressant use and suicide rates may extend into older age groups.

Given the extraordinarily high rates of prescribing of antidepressants in Australia, including the off-label prescription of antidepressants to over 100,000 children, and the key role of GPs in prescribing, I am sure you agree it is important to get this right.

I raise these issues in the hope that we can work collaboratively to ensure improved mental health outcomes.

Dr Martin Whitely

Publisher/Editor

PsychWatch Australia

psychwatchaustralia@gmail.com

References

[A] ABC Radio 720 Perth - Breakfast with Nadia Mitsopolous 24 April 2019. Interviews with Dr Martin Whitely from PsychWatch Australia and Dr Harry Nespolon, President of the Royal Australian College of GPs and talkback callers. It was previously available at https://www.abc.net.au/radio/perth/programs/breakfast/breakfast/11027626 (Note this was a recording of the whole program. The interview began at 2:44:28 and ended at 3:16:00. Dr Nespolon made his comment at 3:02:18).

[B] In 2014/15, the vast majority (90.4%) of antidepressant prescribing was done by general practitioners. Psychiatrists were directly responsible for only 6.5% of prescriptions. Australian Institute of Health and Welfare 2016. Mental health services—in brief 2016. Cat. no. HSE 180 Canberra: AIHW. pp. 24-25 Available at https://www.aihw.gov.au/getmedia/681f0689-8360-4116-b1cc-9d2276b65703/20299.pdf.aspx?inline=true (accessed 13 August 2018)

[C] Harvey C. & Videnieks M. The new abuse excuse, The Australian May 25 2001, p. 14

[D] Calculated using ABS population data and 3309.0 - Suicides, Australia, 2010. Suicide Summary Statistics, Australia, 2001-2010. Available at http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3309.02010?OpenDocument

[E] Hengartner M.P. Plöderl M. (24 June 2019) Newer-Generation Antidepressants and Suicide Risk in Randomized Controlled Trials: A Re-Analysis of the FDA Database. Psychotherapy Psychosomatics. Available at https://www.karger.com/Article/Pdf/501215 (accessed 17 July 2019)

Dr Nespolon's response on 2 October 2019

Dear Dr Whitely

Thank you for your email and apologies for the delay in responding.

The issue that I was trying to raise was that untreated depression does lead to an increased number of people with completed suicides.   This I hope that you can accept.  While we can argue about the numbers, I have heard much higher numbers, the point remains the same. 

To be clear, treating depression includes both pharmacological and non-pharmacological treatment.

Dr Harry Nespolon President

The Royal Australian College of General Practitioners

Note: PsychWatch Australia believes that people we criticise deserve a right of reply. Dr Nespolon was provided with a draft of this blog two weeks before publication and offered a right of reply. To date, no response has been received.

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