Abstract
This paper critically analyzes the findings of a research presented in the article “Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study” where the link between the patients using isotretinoin and the resulting cause of death. The research is based on patient discharge register after isotretinoin use between 1980 and 1999 and the resulting causes of death between 1980 and 2001.In the research, a sample of 5756 patients aged between 15 and 49 years old using isotretinoin. The risk calculation was calculated up to three years before administration of the drug stretching to fifteen years after the drug was last administered. A follow up of 17,197 persons was done based on their pre-treatment activities, for 2905 persons during treatment period and 87120 after administration of the treatment. Out of the 5756 patients earlier mentioned, 128 were hospitalized after attempting to commit suicide a year within the pre-treatment year. The standardized incidence ratios of 1.57 overall and 1.36 for first suicide attempts. The paper reveals rise in incidence rate for the initial post-treatment six months. The standardized incidence rate rose to 1.78 for all reported incidences and 1.98 for first suicide attempt reported incidences. In general the paper indicated that 38% of patients had made first suicide attempt before administration of the treatment in comparison to a whooping 78% after treatment cases.
Introduction
Isotretinoin is the leading and appropriate treatment of severe acne. The drug has however been often criticized as causing depression and in severe circumstances suicide (Chia et al. 2005). Prior to prescription, doctors have often had to inform the patients of the likely negative effects and programs have been developed to monitor and support patients who have been prescribed to use the drug. Additionally, the prescription of the drug online, sharing it and use without adequate supervision is discouraged (Malone, 2006). Various studies have cited the drugs controversial usage as a likely sauce of the death of the user through suicide. Concerns have been raised regarding the drugs association to suicide, prompting lots of research in this area. Although biological causative association remains evident, little evidence has been found in epidemiological studies (Callen, 2010). Some studies have insisted that no association exists between persons using isotretinoin and attempted suicide and that no outcome changes are recorded prior to and after using the drug.
Research aims/ objective
Noting these variations in research, this paper aims to review an article that explicitly assesses the risk of attempted suicide associated with use of isotretinoin for severe acne treatment. Through this review the paper aims to come up with a justifiable stand as to the relation between the drugs usage and the resulting suicide risks.
Research methodology
This paper basically undertakes a qualitative evaluation of this research. It is based on evaluation of the steps that the research has used to come with the results and hence conclusion. Areas of weakness will also be evaluated and an appropriate an appropriate conclusion drawn as to the validity or invalidity of the research. Each section of the research paper will be critically evaluated and appropriate opinions/conclusions drawn with respect to the same.
Critical appraisal of literature
The article appears in a leading UK medical journal that is widely acclaimed across the world further reinforcing the validity and acceptability of the information it presents. The researcher presents interesting literature about the drugs usage and the resulting changes in suicide incidence rates. In the introduction, the author gives historical relation of isotretinoin in treatment of acne and reported cases of adverse reactions (Magin & Sullivan, 2010). Among the side effects that are mentioned in the introductory part of the paper include depression, and suicidal attempts. The author also mentions a close relation between the use of isotretinoin and psychiatric reactions and as having contributed to the labeling changes displaying stronger warnings to intended users. However, he reiterates that acne is a severe treatment and often despite these possible grave effects, a harm-benefit analysis favors usage of the drug. The introduction also introduces the papers hypothesis stating that persons suffering acne as subjected to high suicide risks regardless of whether or not they use isotretinoin. Additional, at the introduction, the author describes the aim of the paper which is assessment of suicide risk attempt in the pre-treatment, during treatment and post-treatment periods (Magin & Sullivan, 2010). Its title reveals a lot on what to expect within the paper. It brings out the three fundamental aspects of the paper, which are, acne as a medical condition, use of isotretinoin in treatment of acne and suicide attempt relating to the two. It’s easy to know what to expect from the title and hence the title can be termed as sufficient and self-explanatory.
Methodology section of any research paper is usually very fundamental. This section provides the audience of the research with a clear picture of what the researcher did to come with the conclusion he/she came up with. Often it is stressed that a good methodology should provide enough details to allow replication of the research by someone who was not present at the time the research was conducted. In the paper, the author begins by defining the study population of the study, the time and the place where the research was conducted. They bring a new issue into the research which he ought to have probably brought up earlier in the paper stating that at the time of data compilation form the patients, use of isotretinoin was prohibited in was not registered in Sweden and all cases of usage had to be reported to a regulatory authority (Magin & Sullivan, 2010). This adds lots of strength to the research as it in essence means that records of user of the product are readily available given the stringent procedure with which it is applied. Acquiring data was rather central as no fieldwork was necessary. The data was readily available from the hospital records and the program through which the drug is administered. Additionally, knowing the treatment duration was rather easy given that the applications for administration held information regarding prescription dosage and the overall quantity applied for. The date that approval is granted was used as the date when the treatment was initiated. The date of prescription granting was used as the date of treatment initiation. In instances where dosage information was not present that is in 3.45 of the sample, sex specific mean daily dosages were applied and likewise in cases where the total quantity of prescription was missing (Magin & Sullivan, 2010).
Additionally the research took into consideration the fact that some dermatological clinics had been allowed to prescribe the drug beginning 1986 to 1987 and hence some additional data was sought from the clinics. Obtained list was then sent back to the clinics for identification of data relevant to the study.. Generally, the information presented adequately takes the audience through the processes that guided the data collection in the research. The process of data identification and classification are discussed. The suicide attempts were classified as having occurred either before administration of the treatment, during drug administration and after the drugs administration. Additionally, the author describes the exclusion-inclusion criteria whereby the patients who had attempted suicide before administration of the drug and were not include in the exposure to treatment time analysis.
In analysis of the data, comparison was made of the cases of attempted suicide recorded during the various window periods described that is before, during and after administration of the drug. The expected event numbers within the study populations were calculated to further assist in evaluation of the results obtained.
The results section of the paper displayed the outcomes of analysis described above. The man age of male and female patients was calculated and likewise the mean treatment duration for both group of patients and the corresponding standard deviations calculated. The results of the study showed that there is increased risk of suicide within the first year after treatment commencement though the author stresses that more risk is presented by acne itself rather than the drug administered. Results indicated that a total of 128 patients got admission into hospital for suicide attempt cases and that the risk was much higher during the initial six months after treatment. This is best illustrated by the graphical presentation presented by the article’s authors.
In the discussion section, the authors tactfully takes the readers through an inductive session discussing the possible implication of the author’s findings. The authors interpreted the findings that most patients attempting suicide after administration of the treatment are simply distraught of not having seen improvement in their social life to accompany their well being and not necessarily as a result of the drug.
The authors generally acknowledge that there is increased likelihood of suicide attempt, they however, stress that no direct evidence links the use of the drug to increased suicide. In conclusion the article summarizes that monitoring focus should no be during or before treatment but after treatment. A period they put at one year after administration of the drug. However, they mention that as no clear difference in suicide rates between acne patients and patient treatment exists, monitoring should cover all acne patients regardless of whether they are on treatment of not (Magin & Sullivan, 2010). Generally the authors draw recommendations as to what needs to be done based on the research. The references used by the authors in their research are sourced from reliable authors who enjoy vast base of knowledge in primacy and hence are valid and provide accurate information that useful information the research development and application process.
Research weaknesses
The article is however not without weaknesses. Often experience is a critical evaluation of an individual’s ability to present a trustworthy and well researched paper. The authors to this article have not published any other medical papers in the renowned medical journals. This puts to question the credibility f their works and hence the article. Secondly, the authors fail to account to incidences of attempted suicide which may have gone unreported. They fail to take into consideration the fact that most cases could go unreported. The authors also fail to offer clear evaluation criteria they used in selecting and differentiating valid data from invalid data.
The discussion section gives little relation to the data evaluation displayed. While the authors maintain that no clearly links exist between use of the drug and suicide attempt, there results tempt to show otherwise. Additionally, the fail to link their study to other studies that have dealt with area of study. Lastly it is important to mention that the authors use data that was collected along time ago. Probably many changes and variations could have occurred during these periods which are not accounted for. Additionally, the manufacturers could have modified the drug since then the authors do no talk about this. The author also fails to adequately critic the literature he refers to and link it to the current study.
The article presents fresh information from raw data and hence can be reasonably considered as primary source of information. The weaknesses are however catered for by the references the authors. Most are primary research materials and are written by authors who have published a number of articles within the medical journals globally. The references used are also relevant to the study as they present crucial information that the authors uses to deepen the audiences understanding of the condition and the usage of the drug in its treatment.
Conclusion
In conclusion, it is important to note that the authors of this paper take the order through an ideal research process. From the introduction to the conclusion section, the authors describe each step ideally. The methodology section ideally enables anyone to conduct a similar research without need for modification. Based on the findings discussed by the author, one would not be wrong to argue that yes in deed the drug increases the likelihood of suicide whether directly or indirectly. The increased rates recoded during the first six months after stoppage of the treatment are likely indicators of post-effects of the drugs and hence it causes the increased likelihood of a patient attempting suicide.
References
Callen, J. P. (2010). Depressing News Relating to Oral Isotretinoin? Journal Watch Dermatology, 15(6), p 69-74.
Chia C. Y. et al. (2005). Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Arch Dermatology, 141 (5), p 557–600.
Magin, P. & Sullivan, J. (2010). Suicide attempts in people taking isotretinoin for acne. British Medical Journal, 11(1), p 341-347.
Malone, P. M. (2006). Drug information: a guide for pharmacists (3rd ed). Stockholm: Appleton and Lange.