How correlations can sometimes mislead about causation


Suppose you saw data that showed that people tended to commit suicide just after they started taking anti-depressants. What would you conclude?

The alleged suicide of Chris Cornell of the music group Soundgarden came with the news that he suffered from depression and was on anti-depressant medication. I was listening to a radio program Here and Now where they were interviewing Kelly Posner Gerstenhaber of the Columbia Lighthouse Project at Columbia University about other reports that suggested that anti-depressants could trigger suicidal thoughts and, as a result, some physicians were refraining from prescribing these medications for their patients with depression and some people with depression were afraid to take them.

Posner Gerstenhaber said that she led a team that had been asked by the FDA to look into whether anti-depressants could cause people to attempt suicide and she said that they found no such relationship and that in fact this medication was the best way to prevent suicides.

So how did this belief that these drugs could causes suicides arise? She said that it is due to an unfortunate combination of facts. One is that it is undoubtedly the case that depression is the main factor that causes people to attempt suicide. The second is that people are likely to seek treatment when they are feeling at their lowest and at the greatest risk. The third is that the medication takes some time to produce improvement.

As a result, many people start taking anti-depressants at the very time when they are most likely to attempt suicide and may attempt it (and sadly succeed) before the medication has had time to produce improvement. Thus you end up with correlational data of suicides that spike just after people begin to take the drugs that suggests a false causal relationship.

Comments

  1. Jenora Feuer says

    The other thought on this that I heard was that the time people were most likely to attempt suicide was when they were starting to come out of the deepest parts of the depression, because they still had the suicidal thoughts but now finally had the energy to do something with them.

  2. naturalcynic says

    Or, perhaps, the antidepressants are only starting to work and that slight elevation of mood is enough to a person into a cognitive state where suicidal plans might become more coherent and successful.
    Duloxitene takes away the troughs.

  3. naturalcynic says

    Jenora: same thought at the same time. At its worst, my depression seemed to cause a total lack of motivation to do anything. Before treatment, I was blankly staring at my computer for hours with my mind spinning out futile thoughts. In hospital while starting treatment I felt that I could make better plans.

  4. says

    “The third is that the medication takes some time to produce improvement.”

    And four, as others have pointed out, when the fog first starts to lift, the first thing to come back is energy. Meaning you’re still fucking depressed and suicidal (because the drugs have only started to work), but now you got the motivation to follow through on the idea.

    Those times are when I take all the sharp objects and put them somewhere hard to get to.

    I’ve been there, done that, didn’t even get a t-shirt for my lousy-ass trip through my personal hell.

  5. says

    What would you conclude?

    Well…I perhaps have the advantage of being someone who has struggled with depression in the past, so I would hypothesize what was #2 in your list that people are going to seek treatment when they’re already at a low point.

    I was actually getting to a low point those two days prior to Cornell’s suicide (would it still be “alleged” given that the official cause of death was determined to be suicide?) to where I was thinking about alerting friends and coworkers that I was going downhill and then hearing the news about Cornell helped shake me out of things…at least for a week. Today has actually been a bit of a struggle. But don’t no body worry too much…I’m more struggling to find a reason to keep going with life, but haven’t gotten to the point of even thinking about ending my life. On the other hand, I don’t really have a reason to end my life…I guess I’m in some sort of “limbo,” or maybe the best way to describe my situation is I am tired of feeling sad and sad that things that used to make me happy now make me both happy and sad at the same time.

    But then I look at WMDKitty’s blog…I haven’t been through anything anywhere near what she has. So if she can pull through, I have no excuse not to pull through as well. (I actually did get a shirt, so there’s that?)

    That all said, I’ll repeat that I don’t want anyone to worry about me. Really, it feels good just to speak out about things. If anything, I guess I would like to ask others who have on occasion struggled with depression if you’ve ever felt, much like I am now, that you want to be able to tell people how you are feeling, but simultaneously feel that you can’t actually do so because there is the concern they’ll overreact?

  6. Mano Singham says

    I never know what to say when someone confides that they have depression. You want to help but feel helpless. Everything you think of saying sounds so banal and unhelpful, and yet silence seems uncaring.

  7. says

    Leo

    Er… I’m a “they”, actually. But yeah. Thanks. It’s been a long, strange trip.

    The depression pretty much takes a backseat to the anxiety and the PTSD these days.

    “If anything, I guess I would like to ask others who have on occasion struggled with depression if you’ve ever felt, much like I am now, that you want to be able to tell people how you are feeling, but simultaneously feel that you can’t actually do so because there is the concern they’ll overreact?”

    All. The. Time.

    Mostly because it’s been my experience that people will act like I’m about to take a header off a bridge when I mention I’m on a downswing or already in the depression groove. Or, you know, go the complete opposite route and ask what I could possibly have to be depressed about (where do I even start…)

    Mano — Anything you say is going to be unhelpful, but the thought is appreciated! Offering hugs or a cup of tea and an open ear (if you’ve the time and inclination) can help.

  8. Timothy says

    A couple of thoughts:

    1. I’ve always struggled with the tautology in mental health: that everyone who suicides is depressed. And that depression causes all suicides.

    I’m not entirely convinced this is the case.

    2. While not specific to anti-depressants, I think this article is relevant:

    https://www.madinamerica.com/2017/05/psychiatry-defends-its-antipsychoticscase-study-of-institutional-corruption/

    I think there is more going on with psychiatric meds than many realize.

    3. Finally, the FDA recognized years ago that certain classes of anti-depressants cause increased suicidal thoughts in teens and young adults:

    https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/antidepressant-medications-for-children-and-adolescents-information-for-parents-and-caregivers.shtml

    “Recently, there has been some concern that the use of antidepressant medications themselves may induce suicidal behavior in youths. Following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. In 2006, an advisory committee to the FDA recommended that the agency extend the warning to include young adults up to age 25.”

    I don’t think it’s a logical stretch to conclude that these meds may effect some people over 25 in the same way.

  9. Heidi Nemeth says

    The National Alliance on Mental Illness (NAMI) is training people to be direct and ask the question “Are you suicidal?” Apparently, just asking the question leads to better outcomes. People who say yes, they are suicidal, are more likely to get/be gotten the help they need.

  10. Mano Singham says

    Heidi @#12,

    Really? It seems such an intensely personal and intrusive question that I would never have thought of doing so. Is it an action that is recommended only for professionals or is it something that even friends should ask if someone says that they are suffering from depression?

  11. Holms says

    #9
    It isn’t a tautology at all. Depression does not cause all suicides: people with no mental ill health can consider suicide, on the entirely rational basis that they are e.g. showing signs of early onset dementia, and prefer exit while they still have their minds. It therefore follows that not all people that do so are depressed.

    For an example of the above, see Terry Pratchett.

  12. Timothy says

    WMDKitty — Survivor:

    So sorry. I can’t tell whether you are being serious or sarcastic.

    Please let me know and I’ll respond accordingly.

    Thanks,

  13. Timothy says

    Please be respectful. No diminutives, please.

    An informed critique of psychiatry is not woo. There is significant scientific research to back up concerns around financial conflicts of interest in the sciences, particularly psychiatry.

    These are not ‘anti-psychiatry’ positions. These are people raising legitimate concerns.

    Please inform yourself before attempting to gate-keep someone.

  14. says

    Timmy, don’t tone troll me.

    There are no “informed critiques” of psychiatry. There are unhinged rantings and ravings, yes, all by people who are quite ill and in need of treatment, who are rejecting psychiatry because they are in denial about their illnesses.

    Trust me, I’ve seen far too many “critics” pushing lies about “dangerous addictive neuroleptic drugs” while providing “sources” that amount to nothing more than self-published books by known crackpots, and linking to Mercola.com.

    Now kindly fuck off to wherever you came from.

  15. Timothy says

    Kitty –

    You sound very angry. I’m sad for whatever happened to you that created such anger.

    Why would I trust you? You’ve done nothing but attack my words. Name-calling doesn’t change the fact that there are serious issues with psychiatry.

    I wish you peace. And I’m ending my part in this conversation.

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