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Depression and kids: Why antidepressants shouldn't be ruled out

The “black box” warning on antidepressants that the medications could increase the risk of suicidal thinking and behavior in youth may have resulted in an increase in suicide among this group over the last ten years, according to a new study.

The "black box" warning on antidepressants that stated the medications could increase the risk of suicidal thinking and behavior in youth may have resulted in an increase in suicide attempts over the last ten years, concludes a study published last week in the British Medical Journal.

This research, which included data on 2.5 million adolescents and young adults, confirmed that, from 2000-2010, there was indeed a substantial reduction in anti-depressant treatment. There was at the same time a small increase in suicide attempts via drug overdose, an increase the authors note is probably a gross underestimate given that other forms of attempt were not measured in their study. Fortunately, no increase in completed suicides among the study sample was found.

How did this happen to a group of antidepressant drugs that had considerable scientific backing? Well, a funny thing occurred in the field of child health in February of 2003. The U.S. Food and Drug Administration issued a safety warning that these medications appeared to increase rates of suicide ideation and attempts among the young based on a review of 24 studies involving 4,400 youth where antidepressants were compared to placebos. The FDA's decision was based, in part, on the finding that the risk of these behaviors was higher in these studies among the patients who received antidepressants (4 percent) relative to those who received placebos (2 percent). The FDA required that this warning appear in all advertisements as well as on package inserts that came with the medications.

Question: What is the rate of suicide ideation among American teens in the general population?

» READ MORE: Answer: 14.5%.

Question: What is the rate of suicide attempts among American teens in the general population?

Answer: 6.9%.

Note that both figures are quite a bit higher than the 4 percent reported by the youth in the reference group of 4,400 that resulted in the FDA decision to add the black box warning.

Final question: Of the 4,400 patients reviewed by the FDA, how many actually committed suicide? Answer: None.

I referred to the FDA's decision to add the black box warning as "funny," – but really, it wasn't.  It was widely viewed as an over-reaction, and one that may have backfired as this new study indicates.

Because, you see, about a minute after the FDA's decision, the rate of physicians prescribing these drugs, and the number of families willing to allow their child to take them, dropped dramatically.

I see the consequences of this all the time in my own practice. When I suggest to parents that they might consider adding a psychiatric medication to their child’s treatment because he is suffering so much or is so ill that he is having difficulty even engaging in therapy, parents are often quite wary and reluctant, with many of them asking: “don’t these pills cause kids to commit suicide?”

The new study reminds me of another one, published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2006.  In this research, all youths who committed suicide in New York City from 1999-2002were autopsied in order to determine whether antidepressants were present in their bloodstream.

Question: How many youths committed suicide during the study period?

Answer: 41.

Question: And how many were being treated via antidepressants at the time they took their lives?

Answer: One.

The take-home message here is that depression is woefully undertreated in this country, to tragic effect.

So what can a worried parent do?

"It is important for parents to be aware of the signs of a child who is depressed or who may attempt suicide, regardless of whether that child is taking antidepressant medication," states Laurel Weaver, MD, PhD, a child psychiatrist at CHOP.

Weaver also advises that parents pay attention to are changes in eating and sleeping, decline in schoolwork, loss of interest in activities, aggressive behavior, drug or alcohol use, social withdrawal, and marked personality change, including bizarre ideas and hallucinations.

She further recommends that declarations such as "I will no longer bother you," a suicide note, clear statements about wanting to commit suicide, and acts such as stockpiling pills should be taken very seriously and immediate help from a mental health professional should be obtained.

Finally, Weaver states, "parents should not be afraid to ask their child if they are depressed or thinking about suicide.  These questions will not intensify depression or precipitate a suicide attempt, and may facilitate communication and offer a sense of relief to the child."

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