Jonathan Javitt is an adjunct professor at the Johns Hopkins School of Medicine and founder and chief executive of NeuroRx, a start-up biopharma company. He served in health-care advisory roles in the Reagan, George H.W. Bush, Clinton and George W. Bush administrations.
Just a month has passed since the high-profile deaths of Kate Spade and Anthony Bourdain, yet suicide has already dropped off the public radar. That’s because it’s far too easy to personalize individual tragedies; far more difficult is confronting the public-health crisis at hand.
Suicide claims the lives of more than 120 Americans each day. Each year, more Americans die from suicide than were killed in action during the entire Vietnam conflict. It’s time we confront this epidemic with the same determination that tamed HIV/AIDS. To do this, we must address the biology of suicide.
Today, we regard suicide as a failure of psychology and perhaps personal circumstances, rather than a failure of neurochemistry. In fact, suicidal depression may be as treatable as diabetes. It’s just that we may have been focusing on the wrong chemical target in the brain.
For 60 years, the medical community has treated depression with drugs that target serotonin, the chemical in the brain that makes us feel good. Although these drugs help many people cope with symptoms of depression, they are not effective in treating suicidal ideation or behavior.
The medical literature and the Food and Drug Administration clearly recognize that these drugs can increase the risk of suicide in vulnerable patients — especially young adults and teens. In fact, researchers have been forced to exclude potentially suicidal patients from clinical trials for antidepressants. With little success in developing new antidepressants, most major pharmaceutical companies have essentially abandoned their efforts in psychiatry.
Fortunately, science shows that old treatments can lead to a new future. Despite six decades of antidepressant research, the only treatment currently approved by the FDA for severe and suicidal depression remains electroconvulsive therapy (ECT). This treatment might seem antiquated, and it is known to cause memory loss, confusion and more severe complications. However, it has recently been shown to cut the incidence of suicide in half , compared with serotonin-targeting antidepressants alone.
Similarly, studies show that ketamine can achieve rapid and potent reduction in both depressive and suicidal thoughts. Unfortunately, ketamine is also highly addictive, it can kill brain cells and cause hallucinations, and it must be delivered either intravenously or via the nose.
These two treatments are obviously different, but they both point to an entirely new chemical axis in the brain that could be targeted to treat depression: the glutamine/glutamate axis. Commonly abbreviated Glx, these chemicals are suppressed in people with severe depression and post-traumatic stress disorder (PTSD) and do not increase when patients take serotonin-targeting antidepressants.
The company I lead is working to develop drugs to raise Glx without the damaging side effects of ketamine or ECT. The science is promising: The FDA recently issued a biomarker letter of support, its first in psychiatry under the 21st Century Cures Act, recognizing that an increased level of Glx correlates with decreased levels of depression and that drugs targeting Glx are linked to a reduction in depression and suicidal ideation.
If we are to save 120 lives a day, the work is just beginning. We need nontoxic, nonaddictive and orally available drugs that can accomplish what ketamine does without the side effects. We need to mobilize federally funded research efforts and the nation’s financial community to apply these findings to developing new cures.
For me, this fight is personal. I lost a close friend to suicide in 2008. As I told his daughter just before his funeral, it makes no sense to blame him for his death; he died from a chemical short in his brain, over which he had no more control than if had he died of a heart attack. Now it’s up to us to pinpoint the cause and find the cure.
As a medical intern in 1982, I treated three of the first 618 Americans who died of AIDS. Back then, we didn’t even have a name for the disease. In 1995, the peak year of the epidemic, about 50,000 Americans died of the disease. Along the way, the United States said “enough.” Federal funding for AIDS research grew from a few hundred thousand dollars in 1982 to $32 billion last year. The virus was found. Drugs were developed. In 2015, 6,465 Americans died from the disease. Still too many, but a public-health triumph nonetheless.
In 1987, advocates spread a massive quilt on the Mall that stretched from the Capitol to the Smithsonian National Museum of Natural History to recognize those who had died of AIDS. A “suicide quilt,” on the other hand, would stretch even farther, from the Capitol to the Washington Monument and the White House. Yet only a little more than $100 million is allocated each year to the National Institutes of Health for research on suicide and prevention.
We need the same public commitment to end the suicide epidemic as was marshaled to conquer AIDS. We need to fully explore new chemical pathways in the brain. We need our financial community and major pharmaceutical companies to target suicide as a condition that can be treated and overcome. Along the way, we need to ensure that people with suicidal depression and PTSD have timely access to care.
We have the science to fight this deadly epidemic. We need the societal will to make it a national priority.