One in six teens inflict self-harm (TRIGGER WARNING: if you don’t want to see a photo of cuts on someone’s forearm, then don’t click this link), the Globe and Mail tells us today, and the sub-headline of that article is “Abusing yourself isn’t a suicidal or attention-seeking action, research suggests, but a coping mechanism.”

Well, duh. We’ve been trying to tell people that for years and years¹, but who bothers listening to self-injurers? Especially to teen self-injurers. We are not doing it to get attention.

The research, published in today’s edition of the Canadian Medical Association Journal, shows that 17.6 per cent of teenagers self-harm - a number that includes 21 per cent of girls and 8.7 per cent of boys.

This being the media, though, they have to warp the contents of the actual study, Nonsuicidal self-harm in youth: a population-based survey, so that “Ninety-six of 568 (16.9%) youth indicated that they had ever harmed themselves” from the original journal article, somehow becomes “17.6 per cent of teenagers self-harm” — present tense, plus an inexplicable 0.7 bonus. (Admittedly, I haven’t read the whole study yet because I was having computer problems earlier today and I am lazy, but I shall get around to it, and if there is an explanation that I missed for that extra 0.7, then sorry, my bad.) I suppose it’s mainly a case of people wanting shocking headlines, as the Globe and Mail article does continue as follows:

A total of 568 young people aged 14 to 21 were interviewed. Ninety-six of them said they had, at some point in their young lives, harmed themselves deliberately.

About one-third of the teenagers had done so only once, another third on two to three occasions and the other third had self-harmed repeatedly. On average, their mutilating actions began at age 15.

Much of the article is an interview with the study’s lead author, Dr. Mary Nixon, and it’s pretty good except for one comment that directly contradicts other things in the article:

“We’re trying to raise awareness that it’s not uncommon in young people and not related to mental health problems,” she said.

“It” being self-injury, of course. It’s such a weird quote that I’ve got to wonder if it’s a typo or a misunderstanding or something. I don’t think SI is always related to mental health problems, but I think it is the majority of the time.

The research shows a clear link between self-harm and mental health problems. Those who hurt themselves are more than twice as likely to suffer from depression, anxiety and impulse disorders.

It is not entirely clear why girls are more likely to self-harm than boys, but Dr. Nixon believes it is related to the fact that rates of depression soar at puberty and that girls not only mature earlier but react differently to stress.

See? Does not compute. SI is indeed related to mental health, although it’s very rarely suicidal or attention-seeking. (Never say never. All generalizations are bad. Tee hee.)

Dr. Nixon, a child and adolescent psychiatrist, said when teenagers harm themselves, it is often assumed they are doing so to get attention, but the behaviour is far more complex.

“A lot of these kids hide their cuts and burns. It’s not attention-seeking, it’s something else,” she said.

THANK YOU. I really appreciate somebody saying this and it being national news.

¹Although we don’t phrase it that way, because then it would sound like we were talking about masturbation.

Everybody has already read about this study and its claims that there is something called “subthreshold bipolar disorder,” and as far as most of us can tell, SBD equates to “simply being human, but big pharma thinks you need antipsychotics for it anyway.” I’m lazy, though, so I haven’t commented upon it until now.

CL Psych posts about the incredibly loose criteria for SBD and the media’s claims that there is “appropriate” medication for it in Subthreshold Bipolar: The Giant Sucking Sound and Subthreshold Bipolar: Media Blitz and Lilly.

Philip Dawdy has also written several posts about subthreshold bipolar disorder, including Name The New Bipolar Disorder, in which he urges people to come up with a better name for SBD. I haven’t come up with anything yet, or rather, I haven’t come up with anything that no one else hadn’t thought of and posted already!

I am vastly confused by the stats from the article in the Archives of General Psychiatry. No, they’re not too complex for me to understand; they’re too stupid for me to understand. Only a 2.4% prevalence of Americans who, twice in their lives, meet half of the criteria for hypomania? I would expect it to be more like 99% than the 4.5% it winds up as in this study once you add the 2.4% to the 1% prevalence for bipolar I and the 1.1% for bipolar II.

I am more of a fan of the bipolar spectrum than some people in the blogosphere are, but this subthreshold nonsense is taking things way, way too far. Honestly, sometimes I like the things that Akiskal has to say, and he’s one of the authors of this study. Some doctors overdiagnose bipolar disorder, and most people who diagnose it overmedicate their patients. But there are still plenty of health care professionals who don’t recognize bipolar disorder. Sometimes, it’s not their fault — they don’t see the patient when he or she is hypomanic, and even if they do ask him or her about past symptoms of hypomania, the patient, in the middle of a depression, is pretty much unable to remember ever feeling okay, let alone hypomanic, and doesn’t — can’t — answer accurately.

Then sometimes there are shrinks who think you’re not manic-depressive if you haven’t, like, married someone you’ve just met and then bought five cars. Doctors who think mania equals euphoria and if you’re having a dysphoric mania, you’re just an asshole. Who think that mixed states or rapid cycling must always be borderline personality disorder instead, and even, believe it or not, doctors who are always going to assume that if you’re psychotic, you’re schizophrenic.

Yes, this “subthreshold” stuff is ridiculous, but within limits, I like the idea of the bipolar spectrum because it makes people aware of things that actually are bipolar symptoms but aren’t necessarily the most classic ones. It’s when you start pathologizing mild things that occur infrequently that it gets to be harmful.

No, I don’t know where the line should be drawn. But I’d say somewhere way before “subthreshold bipolar disorder” as defined in that journal article, anyway.

I’ve taken Zoloft on and off (but mostly on) for over eight years. If you’ve read the posts Philip Dawdy made last month or last week about an article in The New England Journal of Medicine, “Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression,” or read this news article about it, you know that this study shows that antidepressants aren’t effective in treating bipolar depression.

Okay, so you probably could have figured that out anyway.

At this point, I am taking Zoloft for two reasons:

1. I’ve mostly been feeling good since I started taking meds again, so I don’t want to screw with my medications in case Zoloft is helping me avoid depression.
2. Some medications have made me extremely tired. Since Zoloft does the opposite, I assume it is helping me wake up in the morning. I have trouble falling asleep, but I wake up and I can function. I think it’s balancing out any drowsiness that my Epival might cause.

I don’t know if either of these are valid long-term reasons to be taking Zoloft, but they’re good enough reasons for me in the short term.

Zoloft is the only SSRI I’ve ever taken, but I took Effexor in January and February of 2006. Three weeks starting on it, and then three weeks coming off it. See, I was taking it all by itself without a mood stabilizer or an antipsychotic. I had gone off all of my medications in the fall, felt fine, then got really suicidal really quickly and wound up in the hospital. The psychiatrist on the unit discharged me with a prescription for Effexor although I told him I didn’t think it was a good idea for me to take an antidepressant without a mood stabilizer.

He told me it would be fine, and I figured I might as well listen to the doctor, because stopping all my meds all by myself hadn’t worked out too well for me. I was also not thinking very clearly and it didn’t occur to me that this could have more dire consequences than a mild hypomania followed eventually by another depression.

So what happened? Well, I once read the phrase “rapid cycling/mixed state hell” on an online forum, and that describes it perfectly. I don’t feel like going into any detail today, but suffice it to say that I wound up back in the hospital exactly three weeks later. It wasn’t pretty. It was, in fact, really ugly. I mean the situation, but come to think of it, the hospital was ugly, too.

I’m sure my being bipolar rather than unipolar had a lot to do with that in my particular case, but we all know that you don’t have to be manic-depressive for antidepressants to make you flip out. So it’s nice that the FDA has finally ordered updated black box warnings on antidepressants “to include warnings about increased risks of suicidal thinking and behavior, known as suicidality, in young adults ages 18 to 24 during initial treatment (generally the first one to two months),” whereas the warning only applied to those under 18 before that.

Health Canada had already issued a warning about this:

Health Canada is advising Canadians that Selective Serotonin Re-uptake Inhibitors (SSRIs) and other newer anti-depressants, now carry stronger warnings. These new warnings indicate that patients of all ages taking these drugs may experience behavioural and/or emotional changes that may put them at increased risk of self-harm or harm to others.

The new warning for each of these drugs, which are listed below, appears in the information package received by patients and in the prescribing information available to health professionals.

Patients, their families and caregivers should note that a small number of patients taking drugs of this type may feel worse instead of better, particularly within the first few weeks of treatment or when doses are adjusted. For example, they may experience unusual feelings of agitation, hostility or anxiety, or have impulsive or disturbing thoughts that could involve self-harm or harm to others…

That’s from a press release issued June 3, 2004.

It’s a bit different, though — it applies to all ages, not just people under 25; it includes harm to others as well as self-harm; and it doesn’t include all antidepressants, just newer ones.

I’m just mentioning that this Associated Press article exists: Benefits trump risks for children taking antidepressants: study. I don’t remember reading about it before.

The authors of a new comprehensive analysis of antidepressants for children and teenagers say the benefits of treatment trump the small risk of increasing some patients’ chances of having suicidal thoughts and behaviours.

The risk they found is lower than the one the U.S. Food and Drug Administration identified in 2004, the year the agency warned the public about the drugs’ risks for children.

After the warning, U.S. youth suicides increased and some mental health experts said reluctance to try antidepressants might be to blame.

The new analysis includes data from seven studies that were not part of the FDA analysis…

The abstract of the actual journal article is here, but I don’t think I can read the whole thing for free and don’t really feel like commenting on the study results without having read it.

Anyway, more from the AP article:

“The medications are safe and effective and should be considered as an important part of treatment,” said study co-author Dr. David Brent of the University of Pittsburgh School of Medicine. “The benefits seem favourable compared to the small risk of suicidal thoughts and behaviour.”

Effective, when only Prozac worked better than placebo in depressed children under twelve, and none of the other antidepressants in the studies did? When overall, 61 per cent of depressed kids and teens in the studies improved on antidepressants and 50 per cent on placebo? (The data are better for OCD and other anxiety disorders, which I think we already knew, but I’m less personally interested in anxiety disorders.) I know that research-wise, you can define this as “effective,” but as a patient, it’s not good enough for me. So I at least appreciate that the article mentions the need for careful monitoring of the effects that antidepressants have on children and teens taking them:

Dr. John March, chief of child and adolescent psychiatry at Duke University Medical Center, welcomed the study as “the most comprehensive analysis of the data yet put together.”

He said the suicidal behaviour risk, although lower than that found by the FDA, demands that doctors and families watch for warning signs…

If I thought antidepressants were completely evil, I wouldn’t be taking them. I’ve taken them since I was a teenager. I have found them beneficial at times. I’m finding Zoloft beneficial now. But I think that even if this study is accurate and antidepressants will cause suicidality in only one out of 101 kids who take them (and I’m not saying it is accurate; I haven’t even read the thing), that’s still a cause for concern. And so do the parents of kids who are suicidal or dead because of antidepressants.

Is it wrong for me to be amused that one of the co-authors of the study has the same name as the incompetent boss from The Office? Probably, but hey, if it’s wrong, I don’t want to be right. No offense meant to Dr. Brent, I swear.