Letters to the Editor
Reply: Suicide: The Persisting Challenge
Dear Editor:
I was pleased that our recent In Review articles on suicide in young people (1–3) caught the interest of Dr Myre Sim, whose textbook on psychiatry I recall reading with enjoyment years ago. I found his reminiscences on a half- century of psychiatry practised in Birmingham and Ottawa most interesting, but as always, some of his opinions are controversial and require an answer. Healthy controversy can spur scientific research, and I am glad to see that none of Dr Sim’s fires have been dimmed. Unlike Dr Sim, however, some of your readers—like myself—will be unable to attribute causal effect to “upsurges in suicide” that may have occurred following the introduction of monoamine oxidase inhibitors and selective serotonin reuptake inhibitors (SSRIs). Indeed, the reverse is postulated in Scandinavia and some other countries, as stated in my editorial (1); the issue currently debated is whether this is indeed so or whether the decline is the result of other influences (4).
Dr Sim refers to the release of aggressive tendencies by the SSRIs; however, there is only anecdotal and putative evidence of this in a very small number of patients. In most depression patients, the SSRIs appear to modulate aggressive impulses, as one would anticipate on theoretical grounds. With regard to replacement of tricyclic antidepressants by “pep pills,” the literature does not show superiority of tricyclic antidepressants over SSRIs in large samples of depression patients (5,6), although there may be subtypes of depression that respond differentially.
Concerning Dr Sim’s references to the therapeutic team, I would not myself agree with statements such as “psychiatrists have to resist the interference of the team.” However, I agree strongly with his implicit message that communication among members of the team caring for suicidal people should be effective, the team should be highly trained, and a clear, detailed care plan should be put into operation by all team members. The psychiatrist carries the medical responsibility and should play a major role in determining the care plan and in training the team in the care of suicidal patients. It should not be forgotten, however, that nurses also carry nursing responsibility, as do the other disciplines.
Dr Sim has made a long and important contribution to psychiatry, and I hope he will continue to do so. He showed admirable courage in shouldering full clinical responsibility for suicidal patients on his wards and protecting his nurses. I was glad to be reminded of his presentation on gun control in Canada at the 1979 IASP meeting in Ottawa (7), which I also attended. Groundwork like his laid the foundations for successive waves of gun control legislation in Canada that, however controversial, carry the possibility of some suicide prevention, particularly among men.
References
1. Sakinofsky I. Suicide: the persisting challenge. Can J Psychiatry 2003;48:289–91.
2. Van Heeringen K. The neurobiology of suicide and suicidality. Can J Psychiatry 2003;48:292–300.
3. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry 2003;48:301–10.
4. Hall WD, Mant A, Mitchell PB. Antidepressant prescribing and suicide: authors’ reply. BMJ 2003;327:289.
5. Steffens DC, Krishnan RR, Helms MJ. Are SSRIs better than TCAs? Comparison of SSRIs and TCAs: a meta-analysis. Depress Anxiety 1997;6:10–8.
6. MacGillivray S, Arroll B, Hatcher S, Ogston S, Reid I, Sullivan F, and others. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ 2003;326:1014–9.
7. Sim M. Gun control and suicide. Proceedings of the 10th International Congress for Suicide Prevention and Crime Intervention. Ottawa (ON): International Association for Suicide Prevention; 1979. p 187–9.
Isaac Sakinofsky, MD, FRCPC
Toronto, Ontario
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