Saturday, January 05, 2013

Annette Beautrais and the New Zealand Suicide Problem


Suicide
Annette Beautrais - 'Expert' in Suicidology

A report released in New Zealand last week has shown that almost 25,000 children have been diagnosed with behavioural and emotional problems. The percentage of children with diagnosed mental health conditions jumped from 1.8 per cent to 3.2 per cent since 2007-08. See Number of 'anxious' kids skyrockets

The NZ government have, like most governments, been duped.






For sometime now I've been writing about the suicide problem out here in New Zealand and how government officials, coroners, psychiatrists and self-proclaimed 'suicide experts' have not been able to fix the skyrocketing rate of child and youth suicides... despite, in some cases, 20 years of trying.


This particular blog post will feature Annette Beautrais who has a Ph.D, although nobody seems to know what specific subject she mastered completely.


Beautrais has authored and co-authored many studies centering around suicide, I covered one of them in my last post [Suicide Prevention and Ketamine - Larkin & Beautrais] where she, along with other authors, claimed that giving the horse tranquilizer, ketamine, to patients admitted into Emergency Departments for suicidality caused depression and suicidal thoughts to miraculously disappear within 40 minutes. The study ran for just 4 hours, featured just 14 subjects, had no comparator, no placebo, had the subjects on a range of other drugs and involved in therapy but did not assess the role these played in the results and was open label [patients and doctors knew what the drug was].


The conclusion?


Administering ketamine to depressed patients in a busy ED setting is feasible, safe and potentially effective in inducing a rapid remission of depression and Suicidal Ideation. Despite small numbers, the antidepressant effects seen herein started within minutes. Indeed, our study is the first to show the feasibility and utility of ketamine as a rapidly acting antidepressant in a busy ED setting.


How's that for a new standard of care - someone nearly kills themselves and Beautrais would have us respond, not by finding out what had triggered their desire to die and altering their circumstances but by shooting them up with a horse tranquiliser and asking them every 40 minutes if they still want to kill themselves. Given that ketamine is a psychotomimetic which causes delusions, delerium and hallucinations and that answering 'yes' to the question do you want to kill yourself is likely to see you locked up in a psych ward, its not surprising people said "I'm all good now, can I go home?"


So, who is Annette Beautrais and what is her interest in the New Zealand suicide problem?


Her biography page states that for 20 years she was Principal Investigator with the Canterbury Suicide Project at the University of Otago, Christchurch. The project, established in 1991, ended when Beautrais took umbrage, it appears. because she had been turned down for funding from the NZ government. Hardly surprising given the lack of results she was achieving as the government's key adviser on suicide prevention but something she decided was a personal attack on her. Beautrais, an American, left New Zealand and headed back home. Boo hoo.


Long-time co-worker and, probably safe to assume, friend, Professor David Fergusson, also of Otago University, stood firmly by the side of Beautrais claiming, "The whole area of suicide research in Canterbury has ceased largely because her [Beautrais]work was not supported or recognised by the Ministry of Health." Adding, "She became extremely disillusioned." [1]


It appears Beautrais couldn't keep away from New Zealand for long as her biog page shows that she has now returned, this time to Auckland, my new neck of the woods.


So, what was the Canterbury Suicide Project?


When Beautrais disappeared the Canterbury Suicide Project website also vanished but with the wonderful research tool, The Wayback Machine, one can still access some of its content... at least from 2003 upwards.


Whatever else it may have been, the Canterbury Suicide Project was a gravy train for Annette Beautrais. One can see from the Research Projects [2] that an initial 5 year study, Multiple Group Case Control Study of Suicide and Medically Serious Suicide Attempts, ended up being a 10 year study. This was funded by the Health Research Council of New Zealand, an agency responsible for managing government investment in health research.


Another study, The Impact of Suicide on Families Bereaved by Suicide, was also funded by the Health Research Council of New Zealand and Lottery Health.


Another study funded by the Health Research Council of New Zealand was, The impact of the reinstallation of safety barriers to prevent suicide at Grafton Bridge, the specific aim of which were for:



i. the removal and re-installation of safety barriers at Grafton Bridge influence rates of suicide by jumping from the Bridge,


and


i. the removal and reinstallation of barriers are associated with changes in rates of suicide by jumping in the population at large.


I'm not trying to be flippant here but any novice gardener would protect their strawberries from birds pecking at the seeds with a wire mesh. Why did it take funding for a study to show a barrier placed on a bridge would make it safer for those with suicidal thoughts? I mean, c'mon, it's hardly rocket science is it?


That's some funding going the way of the Canterbury Suicide Project. Beaturais received huge amounts of taxpayer money for her work on the project but did not report to the public about what she did with that money on the grounds that being accountable would compromise public safety because, in the gospel according to Beautrais, talking about suicide incites suicide. How convenient.


Delving deeper into the website and you will find a 2008 paper regarding teen and youth suicide. Teen and youth suicide are, according to the paper, distinguishable.


"Youth suicide includes suicides in the age range 15 to 24 years; Teen suicide is 13-19 years." [3]


The paper, drafted by the Canterbury Suicide Project, makes many claims and scrolling through the 24 pages you eventually get to the nitty-gritty.



Psychiatric illness is the strongest risk factor for suicidal behaviour. The clear majority (approximately 90%) of young people who die by suicide or make serious suicide attempts have at least one recognisable psychiatric disorder at the time of their attempt.
The most common disorders are mood disorders (including depression and bipolar disorder), substance use disorders (including alcohol abuse and dependence, cannabis abuse and dependence, and other drug abuse and dependence) and antisocial behaviours (including conduct disorder and antisocial personality disorder). Of these disorders, mood disorders are the type of disorder most commonly associated with suicidal behaviour.
On the strength of her work on suicide in New Zealand, Beautrais has participated in many suicide research projects conducted by the World Health Organisation. Projects funded by, amongst others, the Pfizer Foundation, Eli Lilly, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb, whose drugs include:

Lorazepam [Ativan] - a drug for, amongst other things, used for the short-term treatment of anxiety - Pfizer

Ziprasidone [Geodon] - a drug for schizophrenia, also prescribed off-label for  depression, bipolar maintenance, mood disorders, anxiety, aggression, dementia, attention deficit hyperactivity disorder, obsessive compulsive disorder, autism, and post-traumatic stress disorder - Pfizer
Alprazolam [Xanax] - a drug for  panic disorder, and anxiety disorders, such as generalized anxiety disorder or social anxiety disorder - Pfizer
Sertraline [Zoloft/Lustral] - a drug for major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder and social anxiety disorder - Pfizer
Duloxetine [Cymbalta] - a drug for major depressive disorder and generalized anxiety disorder - Eli Lilly
Fluoxetine [Prozac] - a drug for, amongst other things, major depression and obsessive-compulsive disorder- Eli Lilly
Atomoxetine [Strattera] - a drug for ADHD - Eli Lilly
Olanzapine [Zyprexa ] - a drug for  schizophrenia and bipolar disorder - Eli Lilly
Dextroamphetamine [Dexedrine] - a drug for ADHD - GlaxoSmithKline
Lamotrigine [Lamictal] - a drug for bipolar disorder, also used off-label as an adjunct in treating depression - Ketamine - GlaxoSmithKline
Paroxetine [Paxil/Seroxat/Aropax] - a drug for major depression, obsessive-compulsive disorder, panic disorder, social anxiety, posttraumatic stress disorder and generalized anxiety disorder - GlaxoSmithKline
Bupropion [Wellbutrin] - a drug for, amongst other things, clinical depression - GlaxoSmithKline
Aripiprazole [Abilify] - a drug for schizophrenia, bipolar disorder, and clinical depression - Bristol-Myers Squibb
Methylphenidate [Concerta] - a drug for ADHD -  Ortho-McNeil Pharmaceutical

Given that Beautrais claims that 90% of those who die from suicide are mentally ill then the above companies who funded research would be only too pleased to agree with her... and help bring down that 90% figure, right? Her promotion of this claim and of the anti-suicidal properties of a range of psychiatric drugs is a huge gift to the marketing departments of the world's largest pharmaceutical companies.


One would have to be from the planet Zog to not know the link between the above medications and suicide. Beautrais, however, seems to disagree. In 2007 she co-authored a paper that appeared in the New Zealand Medical Journal entitled, Effective strategies for suicide prevention in New Zealand, [5] on reviewing the 'evidence' the study authors claimed, "Some treatments for specific mental illnesses have been shown to reduce suicidal behaviour. These include long-term therapy with lithium for people with bipolar disorder or severe depression, and the use of the antipsychotic medications clozapine and olanzapine by people with psychotic illnesses, including schizophrenia."


When reading the study and references one can only assume that Beautrais hasn't really done her homework. The lithium study quoted by Beautrais et al showing psychiatric drugs 'have been shown to reduce suicidal behaviour' is actually not quite correct. While Beautrais claims this study shows lithium has anti-suicidal effects, the authors of the study she quoted state:

Evidence pertaining to potential anti- suicidal effects of various psychotropic drugs on suicide risk has been strikingly limited as well as inconsistent and inconclusive. Despite the large number of patients in these studies and the remarkably consistent results, a direct role of lithium treatment in decreasing suicide risk has not been definitively demonstrated. [6]


Authors
Tondo and Baldessarini rightly comment that the absence of controls on placebo, the high drop out rates of study participants, the fact that the vast majority were not designed to test the effect of the drugs on suicide, failure to control for social factors and a host of other methodological issues, limit the extent to which the studies Beautrais relies on demonstrate any of the conclusions she reaches. 

In relation to Clozapine and Olanzapine protecting against suicide, the study quoted by Beautrais et al and conducted by Meltzer and colleagues compared the two drugs with each other and not with placebo, other treatment or no treatment.



Enter Novartis Pharmaceuticals

The Clozapine vs Olanzapine study was not only funded by Novartis Pharmaceuticals but the drug company nominated the members of the expert group who determined which behaviours by the subjects should be coded as suicide attempts. Not surprisingly they found fewer suicidal behaviours on their drug than on their competitor Eli Lilly's drug.

For Beautrais to claim that both clozapine and olanzapine are anti-suicide drugs seems rather bizarre when you run the numbers from the study.


Here's a breakdown of the actual findings, findings which Beautrais seems to have oddly overlooked:





Adverse drug reactions to psychiatric drugs are, in many instances, known precursors to suicidal thoughts and suicide completion
The above table shows actual figures from study. Beautrais, after apparently reading the study, later went on to use it as a reference and cited that both clozapine and olanzapine are anti-suicide drugs. The figures show that they clearly aren't.






Remarkably, for a study aimed at identifying whether a drug prevents suicide, the authors comment "Although the total number of suicide-related deaths was greater in the clozapine-treated group, this was not significant "

I would have assumed that any suicide related events in any type of clinical study were relevant.

The study seems to be nothing more than a marketing ploy by Novartis, an attempt to claim that their drug, clozapine, was better than Lilly's, olanzapine. The authors mention that rates of suicidality are far lower on placebo than antipsychotics but also dismiss this as irrelevant. 


Quite how these drugs can prevent suicide when the figures from the study show the complete opposite begs the question why Beautrais et al made the claims that clozapine and olanzapine are anti-suicide drugs.


Back to Beautrais' Canterbury Suicide Project 2008 paper regarding teen and youth suicide



On genetics they write:
There is evidence that suicidal behaviour runs in families, suggesting a possible role of genetic factors in risk of suicidal behaviour.
On Media reporting the paper claims:
There is generally consistent evidence to suggest that particular types of media depiction and coverage of suicide are associated with increased rates of suicide and suicide attempt.

NZ is one such country where the media are not allowed to report on suspected suicides. They can be fined $5,000 for reporting that someone's death was a suicide until after a Coroner's verdict and then are allowed to report nothing but the name, age, occupation of the victim and that their death was a suicide. Reporting for  example that psychiatric drugs were linked with the suicide would be an offense under New Zealand law.


Why then does NZ have the highest rate of youth suicide in OECD?


Surely the Canterbury Suicide Project's claim on media reporting is a contradiction in terms?


I have to give it to Beautrais, she's a tryer. She once tried to prevent self harm... or at least thought she could try by sending postcards to 6 patients that had been admitted to an Emergency Department. That particular study was government funded and... failed. It's unknown how much funding was plowed into that particular project [7], in fact it's unknown how much funding Beautrais has received over the years via the NZ government.


So, with all of the above, with all the funding from the NZ government, footed by the NZ public, what has Beautrais contributed to suicide prevention?


I'll try to break it down.



  • 90% of youth who attempt suicide have a mental disorder
  • Erecting safety barriers on one bridge in NZ has deterred possible self-harmers from jumping
  • Long term use of Lithium, clozapine and olanzapine and ECT reduces suicidal beahvior
  • Suicidal behaviour runs in families
  • Media depiction and coverage of suicide are associated with increased rates of suicide and suicide attempt.
  • The horse tranquilizer, ketamine, reduces suicidal thoughts and depression within minutes
  • Kids who kill themselves come from bad families

Beautrais has been an 'expert' on suicide prevention for at least 20 years. She has advised the NZ government and, some would suggest in return, been given funding for studies.


Last year suicides of 15-19 year olds in New Zealand increased by 46% and for the first time ever a child in the 5 to 9 age group became a victim to suicide. [8]


One would think that Beautrais would give herself a pat on the back for trying. One would think that she could admit defeat or, at the very least, make some sort of press announcement that her ideas about suicide prevention just aren't working.


Instead, Beautrais continues down the path that medication is the answer. If it were then we would have seen a reduction in suicide on her watch. Sadly, the suicide figures here in NZ are ever increasing.


Changes, not postcards, horse tranquilizers, antipsychotics, bridge barriers and labelling children as having brain disorders, are very much needed.


The answer, to me at least, is very simple.


The NZ government need to review their thinking, they need to divert their thoughts away from mind-altering drugs that have been proven to increase suicidal thinking, attempts and completion. They need to stop, with immediate effect, labelling youth as having some sort of chemical brain dysfunction because that just distances them further away from real help.


Finally, the NZ government need to stop funding postcard and ketamine studies, it's a waste of tax-payers money. They also need to review all the claims made by Annette Beautrais.


I'm just a blogger with no academic background. If I can find flaws then the NZ Ministry of Health should surely be able to find the same.


What is needed?

The NZ government need to back away from mental health, they need to openly discuss suicide and not see it as a taboo subject. They need to involve real people that know about suicide, those that have felt its knife pierce their hearts, those that have experienced loved ones dying by suicide... and continue to struggle through life with that loss. These people are the real experts.


The CASPER Suicide Prevention Strategy [9] has been available for sometime now. It was put together by a mother who lost her only child to suicide in 2008. No funding was needed. No use of drugs are recommended.


Beautrais has been given more than enough opportunities to reduce the suicide rate. Her 'expertise' appears to have done nothing to eradicate this huge problem and given she is one of the key developers of the New Zealand Suicide Prevention Strategy, some would argue may well have been a significant influence on the increase in suicide.


The mental health approach is not the key. The sooner the NZ government wake up to this, the better it will be for all concerned. If they wish to hire experts to eradicate, or at least bring down suicide figures, then they should examine everything those experts have to say, their claims should be scrutinized with a fine tooth comb.


Anyone who has co-authored the above studies need to take stock and revisit the references and claims. Any scientific journal that has published them also need to do the same.



[1] Suicide Expert Quits Country in Despair - [LINK]
[2] Canterbury Suicide Project -Research Projects - [LINK]
[3] Canterbury Suicide Project - Teen Suicide and Youth Suicide - [LINK]
[4] Harvard University - Suicide Risk Factors Consistent Across Nations - [LINK]
[5] New Zealand Medical Journal - Effective strategies for suicide prevention in New Zealand - [LINK]
[6] Can Suicide Be Prevented? Tondo, Leonardo & Baldessarini, Ross J, MD Psychiatric Times vol  28, iss 2 (Feb 2011): 22,24-26 [LINK]
[7] British Journal of Psychiatry - Postcard intervention for repeat self-harm: randomised controlled trial - [LINK]
[8] New Zealand Herald - Horror Over Child Suicide Rate Surge [LINK]
[9] The CASPER Suicide Prevention Strategy - [LINK]