The Tale of the Two Millers

Today I’d like to tell two very sad tales, stories about suicide. One paints a very sad picture, the other, only half of one.The first story is about a depressed teenager.

In 1997, Matt Miller, a 13 year old started having behavioural problems; his grades dropped, he was banging his head against his locker at school, he began urinating on the bathroom floor. His parents, alerted to the problem by school officials, took him to an adolescent psychiatrist who diagnosed an unspecified depression. Since the boy did not show improvement after three weeks, the psychiatrist prescribed the anti-depressant Zoloft, a so called selective serotonin reuptake inhibitor (SSRI). A week later the young man committed suicide by hanging himself.

The parents suspected the medication played an important role in their son’s death and sued the maker of the antidepressant – pharma giant Pfizer. They enrolled the help of an expert witness, Dr. David Healy. Healy had studied the effects of SSRIs on individuals not suffering from depression and reported that a few had reacted with obsessive suicidal thoughts. Pfizer’s counsel argued that Healy’s testimony not be admitted because it did not meet the so called Daubert standards requiring judges to act as gatekeepers in the case of expert testimony and requiring evidence to have won “widespread acceptance” in professional circles. (This is the same standard defendants in the Kitzmiller vs. Dover case attempted to use in order to prevent Barbara Forrest from testifying. They failed and her testimony later proved damning to the Intelligent Design case.)

The second Miller story is not about someone who committed suicide, but someone studying it. Dr. Matthew Miller is the Associate Director of Harvard Injury Control Research Center and does research into methods for preventing suicide.

In a study appearing in the April issue of The Journal of Trauma, Miller is presenting his research into the correlation between the presence of firearms in households and suicide rates.

In the first nationally representative study to examine the relationship between survey measures of household firearm ownership and state level rates of suicide in the U.S., researchers at the Harvard School of Public Health (HSPH) found that suicide rates among children, women and men of all ages are higher in states where more households have guns. The study appears in the April 2007 issue of The Journal of Trauma.

“We found that where there are more guns, there are more suicides,” said Matthew Miller, Assistant Professor of Health Policy and Management at HSPH and lead author of the study.

Suicide ranks as one of the 15 leading causes of death in the U.S.; among persons less than 45 years old, it is one of the top three causes of death. In 2004, more than half of the 32,439 Americans who committed suicide used a firearm.

It should also be noted that there are more suicides in America per year than murders. It is clear that this study will be used by gun control lobbies to argue for more restrictions and attacked by firearm lobbies for being flawed.

While I am highly sceptical of handgun ownership, my alarm bells started ringing while reading the article describing the study. I got more suspicious when I read the summary,

The researchers recommend that firearm owners take steps to make their homes safer. “Removing all firearms from one’s home is one of the most effective and straightforward steps that household decision-makers can take to reduce the risk of suicide,” says Miller. “Removing firearms may be especially effective in reducing the risk of suicide among adolescents and other potentially impulsive members of their home. Short of removing all firearms, the next best thing is to make sure that all guns in homes are very securely locked up and stored separately from secured ammunition. In a nation where more than half of all suicides are gun suicides and where more than one in three homes have firearms, one cannot talk about suicide without talking about guns,” he adds.

Laudable sentiments all. But they only tell half the story.

You see, worldwide, America stands head and shoulders above the rest of the world with respect to access to firearms. There are many studies showing a strong correlation between the number of suicides, homicides and accidents using firearms. Unfortunately these studies usually don’t tell everything.

Let’s compare the data between Germany and the US. Germany requires firearms to be registered and gun owners to be licensed, both practices are handled in a patchwork fashion in the US. With only 8.9 percent of the households having firearms, Germany had a rate of 1.44 unintentional deaths by firearm per 100,000 residents (0.21 murders and 1.23 suicides) . During a similar reporting period, the US boasted a whopping 41 percent coverage of firearm availability with 13.47 firearm related deaths per 100,000 (6.24 murders, 7.23 suicides). This looks damning.

I would agree that data does point to a correlation between firearm availability and a direct increase in homicides. I think that is the paradox of the NRA argument of keeping weapons to defend oneself.

But if one concentrates on suicides, the picture changes. Let’s look at the overall suicide rate for the two countries. The US has a lower overall suicide rate than Germany (21.7 to 27.4 per 100,000).

Thus it would seem that any strong correlation between firearm ownership and suicide rates isn’t valid. What is valid is that if firearms are available, they will be used as the preferred method; but there are many, many ways to kill yourself.

So, even though I truly believe Dr. Miller’s heart is in the right place, I don’t trust his research. And any attorney attempting to use it in court will probably fail against an analysis similar to mine. Which brings me back to the first story.

Having research that only shows one side of an issue is one of the things that led to the creation of the Daubert standards. In the case of the suicide of Matt Miller the judge asked for help. According to the excellent Nation article about this,

To help evaluate Healy’s research, US District Court Judge Kathryn Vratil appointed two independent experts, Yale epidemiologist John Concato and University of Illinois psychiatrist John Davis, to answer her questions. “I had envisioned a freewheeling scientist-to-scientist dialogue,” says Vickery, the Millers’ attorney. Vratil, an appointee of the first President Bush, had other ideas: To avoid any appearance of bias, she barred the experts from talking with Healy or any other witness as they prepared their findings.

In their report, the two men called Healy an “accomplished investigator.” But they also said Healy’s methodology “has not been accepted in the relevant scientific community” and that the psychopharmacologist holds a “minority view” about SSRIs and suicidality. Agencies like the Food and Drug Administration (FDA), they noted, had found no such relationship.
[…]
In February 2002, Judge Vratil issued her key rulings in Miller v. Pfizer. “Dr. Healy is an accomplished researcher,” she wrote, “and his credentials are not in dispute.” But his belief in the SSRI-suicide link is a “distinctly minority view,” she added, and the flaws in his methodology “are glaring, overwhelming, and unexplained.” With that, Vratil rejected Healy as an expert witness–and dismissed the lawsuit against Pfizer. The Millers appealed all the way to the Supreme Court, which in October 2004 rejected their petition for a hearing.

It would seem that the minority opinion lost the day, a single researcher reading too much into the data. It would seem that Dr. Healy is analogous to Dr. Miller. Both had valid claims but were overreaching.

Dr. Miller correctly points out that the number of suicides using firearms is directly correlated to the number of firearms available. That does not lead however to the result that lowering the number of firearms will directly lower the number of suicides. If that were true, Germany should have a much lower rate of suicide than America indeed one would expect a dramatic drop. We don’t see that.

Dr. Healy looked at the data and worried about people being severely damaged by the very treatment meant to save them. Other researchers argued he was wrong. Perhaps the saddest factor in this story is that Dr. Healy was likely right. Returning to the Nation article

In April 2006 the drugmaker GlaxoSmithKline disclosed that adults with major depression were almost seven times more likely to attempt suicide after taking the SSRI Paxil than after taking a placebo, although these events were rare. In November an FDA analysis of 372 clinical trials, involving almost 100,000 patients, revealed a twofold risk of suicidal behavior for adults under 25 who took SSRIs. To those who share David Healy’s views, the latest research is an affirmation–too late for the Millers but perhaps early enough to avert future tragedies. “I believe it vindicates Healy in a major way,” says Antonuccio, the Nevada professor. “Here mainstream scientists are saying, Yes, these antidepressants cause suicidality–which is what Healy has been saying all along.”

So perhaps there is a more important moral here.

Sometimes, it doesn’t matter whether the science is right or wrong. Sometimes it might be better to err on the side of safety – licensing and regulating guns on the one hand and strictly controlling the use of SSRIs on the other.

But for many this kind of pragmatic solution comes too late and at a much too high a price; the high price of legal fees, lobbyists – and lives.