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Wednesday, June 14, 2006

NATURAL SELECTIONS

DEALING WITH DEPRESSION

Where are these life-saving drugs in Japan?


Wataru Tsurumi's book, "The Complete Manual of Suicide," was a best seller in Japan and it's easy to see why. He was writing for a market that is particularly interested in self-destruction.

Japan has one of the highest rates of suicide in the world. Last year, more than 30,000 people took their own lives in Japan. That's about the same total number as in the United States, which has a population of nearly 300 million, compared to Japan's 130 million.

People under 40 are increasing their share of the total number of suicides. For the age groups 15-24 and 40-54, suicide is the second most common cause of death. And Internet suicide clubs are a growing concern. It seems almost every week that police report finding bodies in a fume-filled car somewhere in the mountains. Often the dead people had only recently met in a suicide chat room, and made a pact to kill themselves together.

What can be done? On some railway lines, the authorities have placed mirrors opposite the platforms, to deter people contemplating jumping. But this is hardly enough, and seems more like an attempt by train companies to avoid the mess -- and worse, the delays -- that a jumper causes.

Perhaps drugs are the answer. Amazingly, Eli Lilly, the company that manufactures Prozac, made no attempt to sell their product in Japan, apparently because they thought there was no market. How can anyone, let alone the marketing and product placement team for an international pharmaceuticals company, think that there is no market for antidepressants in Japan?

Perhaps because in Japan "depression" was a dirty word. The Japanese word, utsubyo, was used almost exclusively by professionals, and then only when discussing serious mental illness. Mental health care in Japan is considered way behind the rest of the modern world.

Things are changing, however. Depression is starting to be something that normal people can admit to suffering, without being thought of as mentally ill. Some of this change in perception has come about through publicity given to Crown Princess Masako's depression. It is now well known that the princess is on antidepressants, even if it is difficult for normal Japanese to get hold of the drug for themselves. The U.S. State Department's advice to its citizens traveling to Japan is that Prozac is illegal, and that purchasing on the black market when visiting Japan could result in arrest.

This needs to change. Much has been made of Prozac's over-prescription, and links have been alleged with suicide in certain circumstances. But this week a study links the gradual decline in suicide rates in the United States since 1988 with the spread of use of the antidepressant, which Eli Lilly introduced onto the U.S. market in that year.

Michael Milane and colleagues at the University of California, Los Angeles, analyzed suicide rates in the U.S. population from 1960-2002. They found that the rates fluctuated between 12.2 and 13.7 per 100,000 until 1988, and then gradually fell, with the lowest value of 10.4 per 100,000 in 2000.

The researchers also analyzed data on prescriptions of fluoxetine (the chemical name for Prozac). They increased from about 2.5 million in 1988 to over 33 million in 2002. Eli Lilly have made billions of dollars from their product, and since they lost a lawsuit in 2001, other pharmaceutical companies have been allowed to manufacture and market generic versions of the drug.

Milane and his team ran mathematical tests on their data and found that the steady decline in suicides was statistically associated with the increased number of fluoxetine prescriptions. In other words, the more prescriptions, the fewer suicides. The authors admit there might be another reason why suicides have declined, but they hypothesize that Prozac might have saved 33,600 lives since its introduction.

So how can there be controversy about whether fluoxetine (and other similar antidepressants, in the class known as Selective Serotonin Reuptake Inhibitors) actually cause suicides?

"Although the current issue concerning antidepressants and suicidality requires further examination," the researchers write in the free online journal Public Library of Science Medicine, "we believe that many more lives have been saved than lost since the advent of these drugs."

Independent commentators say that Milane's team may be right. Bernhard Baune and Philippa Hay of James Cook University, Australia, say that the study "does not support an association between increased suicide and increased fluoxetine prescription rates."

The controversy is unlikely to disappear soon, however, especially since the European Medicines Agency has just given the go-head for doctors to prescribe Prozac for young children. The U.S. Food and Drug Agency already allows children to take the antidepressant.

It would be nice to see a book called "The Complete Manual of Mental Health" make it to the best-seller lists. Failing that, Japanese doctors should be aware that, with more young people living alone, Internet-arranged suicide pacts are likely to rise.

A book of Natural Selections columns translated into Japanese, "Nou to sekkusu no seibutsugaku (Evolution, Sex and the Brain)," is published by Shinchosha.


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