Risk Factors for Depression and Suicidality
Although a suicide attempt may have medical consequences, it rarely
has medical (biological) causes. In general, suicide occurs when
a person makes a decision—a deliberate, cognitive, psychological
decision—to kill themselves because of unbearable psychological
pain (see Webb, 2010). Very rarely is suicidality caused by a malfunction
of the brain.
There are a lot of well-known factors that can trigger depression
and suicidal behavior: political, social and economic, emotional
and physical factors.
For example, in Nazi Germany, thousands of Jewish people escaped
from persecution and deportation by committing suicide; others who
had knowledge of secret resistance preferred suicide to ensure that
they would not disclose secrets if they were tortured.
There are also micropolitical reasons for suicide. For example,
to stay in Germany, Hitler, Göbbels and Göring and many
other Nazis killed themselves to escape punishment or to save themselves
from having to live in a non-fascist society.
Social and economical reasons:
Unemployment, combined with hopelessness
The inability to cope with the burdens of war; the unhappiness of
living alone or being divorced
Living with a severe illness
Failing in a relationship.
Unhappiness, depression, and suicidal ideation can each arbitrarily
be called a psychiatric disease
Each suicide can arbitrarily be called the result of a psychiatric
Fear of forced admission or desperation about an incurable psychiatric
diagnosis can trigger suicide, especially when this stigmatization
is combined with discrimination, self-stigmatization and social
Medical diseases and disorders:
Neurological diseases like cerebrovascular diseases, tumors, Parkinson's
Infections like AIDS or hepatitis
Endocrinological diseases like morbus Cushing
Metabolic disorders like dehydration
Other diseases like carcinoma or alcohol dependence
Genetic abnormalities in the serotonin system
Pharmacological Reasons for Depression and Suicidality
Depression, which may or may not lead to suicidality, can be caused
by medical drugs like:
Tuberculostatics (f. e., cyloserine)
Antihypertensive drugs (f.e., a-methyldopa or Beta blocker)
Chemotherapeutics (f.e.. decarbazine, prednisolon, procarbazine
and the interferones)
Oral contraceptive pills
Vitamins like the vitamin-A-derivative isotretinoin (which is used
in the treatment of severe acne)
Drugs to treat addiction, for example varenicline prescribed to
treat smoking addiction (trade name Chantix in the USA and Champix
Similarly, it can be caused by medical drugs like
Tranquilizers like benzodiazepines, f.e. diazepam
Mood stabilizers like antiepileptics
Depression, Suicidality and Tranquilizers
Tranquilizers can produce or enhance depression and suicidality.
There are several reports of depression and suicidality being caused
by benzodiazepines like diazepam or alprazolam in people who had
never dealt with depression (Hall & Joffe, 1972; Remschmidt,
1980; Van der Kroef, 1979; Lydiard, et al., 1987). And it is well
known that chronic dependence on benzodiazepines as well as withdrawal
from these drugs are combined with a high risk level of suicidality
(see Lehmann, 1996b, p. 361).
Depression, Suicidality and Mood Stabilizers
Since December 2008, the U.S. Food and Drug Administration (FDA)
requires manufacturers of antiepileptic drugs to issue a warning
that their use increases the risk of suicidal thoughts and behaviors
(suicidality). This includes all antiepileptic drugs, including
those used for psychiatric reasons. Recently, in 2010, a team led
by Elisabetta Patorno of the Harvard Medical School in Boston, Massachusetts,
published an exploratory analysis suggesting that the use of different
antiepileptics may be associated with an increased risk of suicidal
acts or violent deaths (Patorno, et al., p. 1401).
Depression, Suicidality and Antidepressants
Since the introduction of the classic antidepressants, psychiatrists
have noted a tendency towards the chronification of depression.
This phenomenon is not likely to disappear due to the “down
regulation” of serotonin and noradrenalin receptors. Down-regulation
results in a degeneration of the receptors as a reaction to artificially
raised transmitter levels at the synapses. In 1995, psychiatrist
Marc Rufer from Switzerland issued this warning regarding selective
serotonin re-uptake (SSRI)
In the long run, they diminish the effect of serotonin. If the
serotonin deficit hypothesis of depression were correct, SSRI would
have to cause rather severe depressions” (p. 144).
In 2004, the Medical Drug Commission of German Medical Professionals
came to the conclusion
that, especially in connection with the severe excitatory
side effects of SSRI, you have to expect a risk of suicidal activities
generally and non age-related, which is illustrated by accordant
case reports” (Arzneimittelkommission).
You all may know the website http://ssristories.com/
where you can find a collection of more than 3,800 news stories
that have appeared in the media in the English language (newspapers,
TV, scientific journals) or that were part of FDA testimony in either
1991, 2004 or 2006, in which antidepressants were mentioned.
Of course, there are also people saying that antidepressants like
SSRIs lower the risk of suicide, especially in teens (Kutcher &
Chehil, 2007, p. 77). This perspective has been advanced by Stan
Kutcher and Sonia Chehil, two psychiatrists from the Dalhousie University
in Halifax, Canada, in a booklet from the Lundbeck Institute. The
pharmaceutical firm Lundbeck produces the SSRI escitalopram (Cipralex)
and citalopram (Cipramil), the antiepileptic valproate (Convulex),
the neuroleptic fluphenazine (Lyogen—also marketed as Modecate,
Moditen, Prolixin), the tricyclic antidepressant nortriptyline (Nortrilen)
and many other drugs.
As so-called progressive psychiatrists like David Healy use criticisms
of antidepressants to justify electroshock administration as an
alternative, we should also bear in mind that depression and suicidality
are well-known effects of electroconvulsive treatment –procedure
involving the passage of electricity through the brain in order
to produce a convulsion—a barbaric method, which was not incidentally,
developed during the Zeitgeist of fascism. Manfred Sakel, the Austrian
psychiatrist who developed insulin shock “treatment”
in 1933, noted that the side effects of ECT, including amnesia,
confusion, disorientation, and temporary euphoria, may result in
a secondary reactive depression, sometimes leading to suicide (Sakel,
1956). Reports of suicide following the administration of electroshock
may be found in Leonard Roy Frank's anthology, The History of Shock
Treatment (1978, pp. 23, 27, 32, 43, 54, 58-59, 61, 73, 78, 101,
134, 154) or in Linda Andre's book Doctors of Deception: What They
Don't Want You to Know About Shock (2009). A detailed account of
how people experience suicidality, triggered by insulin shock, electroshock
and various psychiatric drugs, can be found in the book Mitgift
–Notizen vom Verschwinden (Dowry of Poison: Notes from disappearing),
authored by Kerstin Kempker (2000). The treatment she received as
an adolescent with emotional problems following her parents' divorce
severely traumatized her and triggered a series of suicide attempts.
Having survived both the treatment and the suicide attempts, Kempker
was also able to describe how the psychiatric workers seemed to
be unaware of the procedure's traumatizing and suicide-triggering
Depression, Suicidality and Neuroleptics
Neuroleptics block the transmitter dopamine resulting in Parkinson's
syndrome, a complex of symptoms, characterized by walking with a
stoop, muscle tremor, blurred speech and the so-called Parkinson
psyche. Parkinson's disease regularly results from dopamine blockage.
The potency of neuroleptics was defined by their power to create
Parkinson's disease. This is not an unwanted side effect; this is
the therapeutic main-effect as defined by psychiatrists.
Depression and suicidality are normal effects of neuroleptics, and
thus psychiatrists accept them without question. Frank J. Ayd of
the Psychiatric Department of the Franklin Square Hospital in Baltimore,
USA, wrote in 1975:
There is now general agreement that mild to severe depressions
that may lead to suicide may happen during treatment with any depot
neuroleptic, just as they may occur during treatment with any oral
neuroleptic. These depressive mood changes may transpire at any
time during depot neuroleptic therapy. Some clinicians have noted
depressions shortly after the initiation of treatment; others have
observed this months or years after treatment was started (p. 497).
Otto Benkert and Hanns Hippius (1980), two German psychiatrists,
answered the question of whether suicidality could perhaps be caused
by an excessive dosage:
Depression, suicidality, states of excitement and delirium under
the influence of drugs generally occur during doses prescribed by
the treating physician (p. 258).
R. de Alarcon and M.W.P. Carney, two English psychiatrists, studied
depressive mood changes after the administration of neuroleptics,
with other variables staying the same. In the British Medical Journal,
they reported a case of a 39-year old man who attempted suicide
after taking fluphenazine as part of his community treatment program.
When the psychiatrists realized that this man had developed suicidal
intentions some days after the two-week depot-injections, they wanted
to witness the mood-worsening effect of the neuroleptic firsthand.
In the psychiatric institution, the man was observed over four weeks,
without being treated with neuroleptics, and without displaying
anything remarkable mood fluctuations. They then injected him intramuscularly
with 25 mg of fluphenazine. These were their observations:
He was given the trial injection on a Wednesday at 3 p.m.; by
mid-afternoon on the following day he felt low, wanted to be left
on his own, and had no desire to talk to anyone, read, or watch
television. He took to his bed at about 4 p.m. In the opinion of
the charge nurse he was a suicidal risk. When interviewed on the
Friday the change in external appearance was striking—he looked
gloomy, he did not respond with a smile to a joke, and there was
no spontaneous conversation. His answers were limited to what was
strictly necessary. He denied any paranoid of hypochondriacal ideas
or any feelings of guilt. He simply said that he felt very low and
if he were alone in digs he would take his life. By Friday evening
there was some improvement, and when he was interviewed again on
Saturday he had returned to his usual normal self” (1969,
In his placebo-controlled study, psychiatrist Peter Müller
of the Psychiatric Department of the University of Göttingen,
Germany, found that a much higher percentage of people treated with
neuroleptics had depressive symptoms than people treated with placebos.
In relation to the reduction of withdrawal effects from psychiatric
drugs, he wrote in 1981:
From 47 cases, the depressive mood lifted in 41 cases, in only
two cases there was no change, and in four cases the effect was
dubious. It was very surprising to see that in the predominant number
of cases the reduction of the doses alone (normally to half of the
former dose) lead to an improvement of the depressive symptoms.
Often it was only a partial improvement, but even this brought clear
relief to the patient. On the other hand, in other patients, or
in the same ones whose situation improved only slightly when taking
lower doses, complete withdrawal made them feel much better. Some
patients reported that only now did they feel completely healthy
again, as they had long before their depressions. The depressive
symptoms, which were seen to be unchangeable by some psychiatrists,
and which could possibly have been taken to be a start of organic
disorder, vanished completely. The possible argument that these
could be psycho-reactive effects caused by the patients' relief
about the withdrawal of the psychiatric drug is refutable, because
nearly all patients received depot-injections and were not informed
about their doses or got placebo-injections….Their change
was quite impressive to themselves, their relatives and their medical
examiners in some cases. The patients reported that now they felt
completely healthy again. In the group of people still treated with
psychiatric drugs, this was mostly not the case. These results quite
definitely speak for pharmacogene influences and against psychiatric
morbidity developments (pp. 52-53 / 64).
Depressive syndromes after the remission of the psychoses and
under treatment with psychiatric drugs are not rare, but occur on
about two thirds of the patients, and sometimes even more frequently,
especially when depot-drugs are given. Without treatment with psychiatric
drugs, depressive syndromes after a complete remission are only
found in exceptional cases (p. 72).
Müller's reports are supported by many of his colleagues
(Lehmann, 1996a, pp. 57-87, 109-115). Some examples include Raymond
Battegay and Annemarie Gehring (1968) of the Psychiatric Department
of the University of Basel, Switzerland, who warned about the depressive
effect of psychiatric drugs:
During the last years, a shifting of the schizophrenic syndromes
to a depressive syndrome was repeatedly described. More and more
schizophrenias show a depressive-apathetic course. It became clear
that often exactly that develops under psychiatric drugs, what should
be avoided with their help and what is called a defect (pp. 107-108).
Rolf Hessö of the Psychiatric Department of the University
of Oslo, Norway, also spoke about the development in Finland, Sweden
and Norway in 1977; it seemed to be clear:
…that the increased incidence of suicide, both absolutely
and relatively, started in the year 1955. This was the year that
neuroleptics were introduced in Scandinavian psychiatric hospitals”
In 1982, Jiri Modestin wrote about what he observed in his place
of employment, the Psychiatric Department of the University of Berne,
Switzerland, as well as in the neighboring psychiatric institution
Our results show a dramatic increase of the suicide frequency
among the patients in Berne and Münsingen in the last years”
Firsthand Reports about Depression and Suicidality
In Coming off Psychiatric Drugs, the first book ever published about
the possibilities and experiences of coming off psychiatric drugs
(published originally in German in 1998 and later in English in
2004), Regina Bellion of Bremen, Germany, gave a report about her
experience with Haldol, a drug administered by her community psychiatrist:
I vegetate behind my neuroleptic wall and I am locked out of the
world and out of life. The real world is further from me than Pluto
is from the sun. My own secret world is also gone—my last
refuge, and I had destroyed it with Haldol.
This is not my life. This is not me. I may as well be dead. An idea
has begun to take shape. Before winter comes I will hang myself.
But before that I want to try and see if my life would be different
without Haldol. I reduce the number of drops. I take less and less
until I arrive at zero.
After one month I am clean. Then I begin to notice how unkempt I
am. I wash my hair, make the bed, clean the apartment. I prepare
a warm meal. I even enjoy doing this. I can think again (2004, p.
Even clozapine (trade name: Leponex), the prototype of so-called
atypical neuroleptics, seems to have suicidal effects, as the report
of Austrian Ursula Fröhlich shows:
Since I began taking Leponex I do not want sex anymore, did
not feel like moving and had no joy in life. A life without joy
is, however, worse than death. All that remained with me is watching
TV, where I have watched others living for seven years. I am still
alive biologically, but my senses are long since dead, everything
that I former enjoyed I am not able to do anymore. In a way, my
life does not exist anymore, I feel so empty and unimportant. In
the morning, the feeling is the worst. Every day I intend to start
a healthy life the following day, to throw away the drugs, to drink
many vitamins and fruit juices and to start with a daily fitness
routine. The psychiatric drugs cause a feeling as if it was possible
for me to start with a completely different, a new life the following
day. But when I wake up in the morning I feel like smashed, and
I never come out of bed before 9 o'clock, my depressions are so
extreme that I think of suicide every day (cited in Lehmann, 1996a,
Psychiatrists did not differ in their own experiences with these
drugs. In 1955, Hans Heimann and Nikolaus Witt of the Psychiatric
Department of the University of Berne, Switzerland, published their
experiences after once taking chlorpromazine (marketed as Largactil,
Thorazine), the prototype neuroleptic. They cited one example of
neuroleptic effects in normal people:
I felt physically and mentally ill. Suddenly my whole situation
appeared hopeless and difficult. Above all, the fact that one can
be so miserable and exposed, so empty and superfluous, neither filled
by wishes nor by something else, was torturing. ... (After finishing
the examinations): The tasks of life grew immense in front of me:
dinner, go to the other building, come back—and all of that
by foot. With that this state reached its maximum of uncomfortable
emotions: The experience of a passive existence with clear knowledge
of the other possibilities... (p. 113).
By Survivors of Psychiatry
In early 1983, the Irren-Offensive Berlin, a psychiatric survivor
organization (in that time a respectable non-dogmatic organization
not dominated by Machos), together with a group monitoring human
rights violations in psychiatry, publicly warned of suicides caused
by neuroleptics, after they had received information about people
who had hung themselves, gassed or poisoned themselves, or threw
themselves in front of subway trains. Through leafleting, they warned
the public of the widely distributed neuroleptic, haloperidol. Within
a short time, bereaved individuals came forward with reports of
suicides that were committed under the influence of neuroleptics.
On January 28, 1983, the foundation of the “Registration Center
for (Self-) Murders by Psychiatric Treatment” was published
within a press-conference, and a small minority of magazines and
newspapers reported about it. A public call to support the initiative
financially and structurally bore no results, and the initiative
eventually came to an end due to the immense expenditure of human
labor with the bereaved’s anguish when they realized the true
causes of their loved ones’ deaths. But the demand for a public
suicide register was born.
Another type of suicide register was developed in the form of the
“Arzneimittelüberwachung in der Psychiatrie” (AMÜP—a
drug monitoring system in the psychiatric field) in Germany, which
was founded in 1979 and was supported by the National Health Administration
of the German Government. Since the beginning of the 1990s, after
an experimental phase, psychiatric hospitals in this region have
gathered data on complications that may have resulted from treatment,
including the registration suicide attempts and suicides caused
by drugs, in order to make risks public and develop programs for
prevention and early detection (Haen, et al., 1999, p. 93). Findings
are discussed within the psychiatric community, where individual
psychiatrists know each other quite well, “without prejudices
and free of any know-it-all-habits” (ibid., p. 94). If a psychiatrist
identifies a drug as potentially suicide-triggering, they send a
report to the National Institute for the Safety of Drugs, the Drug
Commission of the German Medical Association and the Drug Produces.
Unfortunately, the authors of the article forgot to say how many
reports they sent after 89 registered suicide attempts and suicides
up to January 1998.
In a review published in 2002, Bavarian psychiatrists reflected
on their results from 1991 through 1999 and found many methodological
problems that arose from registering suicides and identifying one
exclusive cause that triggers suicidality. They mention, for example,
problems with the definition of suicidality and plead for the further
development of questionnaires and registration cards (Franke, et
I have made repeated friendly offers as a board member of the European
Network of (ex-) Users and Survivors of Psychiatry to discuss the
possibility of including users and survivors of psychiatry in the
Bavarian suicide register and to help make the registration criteria
sharper and more effective, but the professionals involved have
expressed no interest in collaborative work.
By a Governmental Administration
A suicide register in Sweden was reported by the Swedish journalist
Janne Larsson in November 2008. Referring to regulations in The
Act on Professional Activity in Health and Medical Services (called
Lex Maria), since February 2006 in Sweden, all suicides committed
by people who have received medical attention within the past four
weeks should be reported to the National Board of Health and Welfare
for investigation. He explains:
1255 committed suicide in 2006. According to preliminary data
from the National Board of Health and Welfare, these were comprised
of 377 women and 878 men. (...) Of the 377 women, 267 (71%) received
one or more psychiatric drugs in the categories of antidepressants,
neuroleptics, hypnotics/tranquilizers; for men the comparable figure
was 423 (48%). In total 690 (55%) of all the persons who committed
suicide 2006 received treatment with psychiatric drugs in one or
more of these classes” (pp. 4-5).
The data in 2007 were not better. “In total,” Larsson
according to the data received, 393 cases were reported to the
six regional offices for 2007. (...) In 338 of the 393 cases –
86% of the cases – the persons were treated with psychiatric
drugs within one year before their suicide. In 304 cases –
77% of the cases – the persons were treated with antidepressant
drugs and/or neuroleptics. In 261 cases – 66% of the cases
– the persons were treated with tranquilizers/hypnotics; drugs
of the class benzodiazepines or similar newer compounds. In addition
to the above, in 115 cases (29%) the persons were treated with psychiatric
drugs of other classes. These were drugs such as epileptic drugs
recently started to be used as ‘mood stabilizers’ (Lyrica,
Lamictal), ‘ADHD drugs’ (Concerta, Ritalin, Strattera)
and other types of psychiatric drugs like Buprenorfin (semi-synthetic
opiate, used as pain-killer) and Heminevrine (clomethiazol)”
Larsson summarizes the 2007 results of the report:
In 86% of the cases of suicide reported to the National Board
of Health and Welfare for 2007 (chapter 4) – that is in 338
of 393 cases – the persons were treated with psychiatric drugs.
In 0% (!) of these cases was the matter reported as a drug adverse
event to the registry for drug adverse events at the Medical Products
Agency (...). Instead of Eli Lilly claiming that the drug Zyprexa
(olanzapine; neuroleptic) was involved in 0 cases of suicide in
Sweden 2007, the fact was that the drug was involved in 52 cases
in this subgroup of 338 persons. Instead of Wyeth claiming the same
for Effexor (venlafaxine; serotonin / norepinephrine reuptake inhibitor),
the fact was that the drug was involved in 41 cases in this group”
Consequences and Demands
Updated product labeling has to include a warning about an increased
risk of suicidal thoughts or actions to help patients, their
supporters and psychosocial staff understand this risk. This
has to be a rule. Users of psychiatric drugs need to be informed
so that they can carefully consider the possible benefits and risks
associated with psychiatric drugs, and, if necessary, opt for alternatives
beyond psychiatry or less risky psychopharmacological treatments.
Reports of (ex-) users and survivors of psychiatry who have attempted
or contemplated suicide after traumatizing experiences with psychiatric
drugs, electro- and insulin shock must no longer be ignored. They
have to be included as keynote speakers, experts and teachers in
education programs, congresses and the public media.
As a form of user-led or user-controlled research, delegates of
independent organisations of users and survivors of psychiatry,
as well as competent and independent individuals, have to be included
in prevention programs and monitoring bodies with adequate remuneration.
It would be rather counterproductive to include Big Pharma (see,
for example, the reasonable proposals of the Institute of Medicine,
the health arm of the National Academy of Sciences in Washington,
DC, in: Steinbrook, 2009) or to include psychiatrists, family organisations
or so-called self-help organisations like GAMIAN who receive money
and other profits from Big Pharma.
We have to face the fact that the segregation of troubled or troublesome
people is not something that everyone agrees should be prevented.
This refers especially to people who have not violated any laws
and therefore cannot be criminally prosecuted and imprisoned, but
whose ideas and actions, values and lifestyles, disrupt or threaten
to disrupt established power relationships. In 1923, Fritz Lenz,
one of the most influential German eugenicists and advocates of
racist population control, praised suicide—with the support
of Eugen Bleuler, the leader of the mainstream psychiatry at that
time (see Lehmann, 1992)—as a measure against “vulgarization
of the race”:
From this, the selection through suicide lies in the direction
of the strengthening of the population's living will and its cheerful
temper (p. 23).
As an urgent measure, we have to use and improve advance directives
to protect ourselves from unwanted treatment (Ziegler, 2007), where
we can include important information about previous depressive states
caused by psychiatric drugs. And we should demand that criminal
charges be applied in cases of medical neglect and breach of standards
of care, especially in cases caused by recklessness. This means
“conduct whereby the actor does not desire harmful consequence
but... foresees the possibility and consciously takes the risk,”
or alternatively as “a state of mind in which a person does
not care about the consequences of his or her actions” (Garner,
2005, p. 1053). (For more information on this legal principle, see
http://en.wikipedia.org/wiki/Recklessness_(law).) In American and
many other courts, a wrongdoer who recklessly causes harm can be
held to the same liability as a person who does so intentionally.
If psychiatrists continue to administer psychiatric drugs with suicidal
effects to people who are known to have underlying risk factors,
they should know that there are prison cells waiting for them. This
should also be true for the owners and the leaders of drug companies
that produce drugs with suicidal effects. Laws should be applied
equally for all.
A suicide register with meaningful participation by independent
organizations of users and survivors of psychiatry could enhance
warnings of suicidal risks of psychiatric treatment methods. It
could work to publish and publicize its findings. It could be organized
nationally or regionally and should be required by law. It should
then be easily accessible (anonymous upon request) and operate independently
of medical and psychiatric institutions.
The rate of suicides in people with emotional problems or people
who are called “mentally ill” could be lowered meaningfully.
People could live their lives in freedom and peace. If the damage
is done already, at least there may be a chance to get financial
compensation, the only language people from the psychiatric-pharmacological
1An early version of this paper was unofficially
distributed at the conference “Coping with stress and depression
related problems in Europe,” organized by the World Health
Organization, the European Commission and the Federal Ministry of
Social Affairs, Public Health and the Environment (Belgium), Brussels,
October 25-27, 2001. Revised versions were published in: Journal
of Critical Psychology, Counseling and Psychotherapy (U.K.), Vol.
2 (2002), No. 1, pp. 54-58; Psychologie & Gesellschaftskritik
(Germany), Vol. 26 (2002), No. IV, pp. 99-111; Co`med – Fachmagazin
für Complementär-Medizin (Germany), Vol. 8 (2002), No.
3, pp. 32-34. For the time-limited lecture, this text has to be
abridged. The explanations in the italic brackets are written by
the author. The translations of the German citations into English
are made by Pia Kempker and Peter Lehmann.
Thanks to Craig Newnes and Eugenia Tsao for corrections on the translation.
Thanks to Leonard R. Frank, Jim Gottstein, Edmund Schönenberger
and David Webb for their comments on drafts of this paper.
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