To recognize World Suicide Prevention Day, I wanted to post again about the topic of medications, suicide and young people.
First, the sad statistics: Worldwide, suicide is the second-leading cause of death among young people ages 15 to 19. In the United States, according to the CDC, suicide was the third-leading cause of death in 2009 for people ages 10-14, 15-19 and 20-24. It was the second-leading cause of death for people ages 25 to 34.
The vast majority of people who commit suicide have a mental illness. But for nearly a decade doctors and researchers have been debating whether certain classes of medications used to treat mental illness increase or decrease the risk of suicide – as well as suicidal thoughts and behaviors – in young people.
In 2004, the FDA placed a black-box warning on all antidepressants, warning that they increase the risk of suicidal thinking and behavior (called “suicidality”) in children and teens.
An FDA analysis had found that one type of antidepressants in particular, the SSRIs, which include Prozac, Zoloft, Paxil, Lexapro and others, doubled the risk of suicidality in young people from 2% to 4%. But it found no completed suicides in the studies it looked at, which included some 2,200 children.
In 2005, the European medications regulatory authority urged European countries to put strong warnings about using either SSRI antidepressants, or SNRI antidepressants, such as Effexor and Cymbalta, for children or teens. The warning was based on the drugs’ potential to induce suicidality and hostile or aggressive behavior.
Also in 2005, the UK’s National Health Service issued guidelines urging doctors to avoid prescribing antidepressants to kids under 18 unless other therapies for depression didn’t work.
In 2007, the FDA expanded its black box warning on antidepressants to include all young people under age 25. The risk is greatest in the first month or two of treatment, the FDA warned.
After the U.S. and European warnings went into effect, prescribing of antidepressants to children and teens decreased. At the same time, some studies showed suicide rates in young people increasing, though they couldn’t show a direct link between less prescribing and more suicides.
Other studies, including one published in the prestigious Archives of General Psychiatry this year, showed that that antidepressants don’t increase suicidality in youth.
And a major federally-funded study of adolescent depression treatment found that both Prozac and a combination of Prozac and cognitive-behavioral therapy, or CBT, actually reduced suicidal thinking in teens with moderate to severe depression who started out the study with these thoughts. (The combination treatment reduced suicidality more than Prozac alone).
Then, in 2009 the FDA began requiring drug manufacturers to include a warning about increased risk of suicidal thinking and behavior for 11 anticonvulsant drugs, which are often used as mood stabilizers for bipolar disorder.
This is just a small sampling of the vast amount of information and debate on this topic. There are no easy answers.
As is always the case in medicine, it’s a question of balancing benefits and risks. Many doctors and researchers have argued that for certain mental illnesses – notably severe depression, bipolar disorder, and schizophrenia – the risk of suicide is greater without treatment than with medication.
But other mental illnesses that have lower rates of suicide can still cause serious, and protracted suffering.
I believe it would be a shame if all the hype discourages parents and doctors from giving antidepressants and mood stabilizers to young people whose suffering is severe and persistent.
That said, I would echo treatment guidelines urging that doctors carefully monitor young people taking these drugs, especially in the first weeks of treatment.
Parents should watch for changes in their children’s moods and behavior, too. And they shouldn’t be afraid to ask kids straight-out if they are suicidal, as many are ashamed or frightened to volunteer the information.
Please feel free to weigh in on this debate – especially if you have a personal experience you’d like to share.
Have you or someone you know experienced suicidal thoughts you attribute to meds? Did all the suicide warnings scare you or make you think twice about treatment? Or is the controversy overblown in light of the suicide risk posed by untreated mental illness?
Image courtesy of The Black Dog Institute