Psychiatric Times.
No. 7
Reexamining the Link Between Antidepressants and Suicidality in Children and Adolescents
By Nancy C. Winters, MD |
June 22, 2006
Despite these caveats, the available data
appear to warrant the conclusion that
there is a modest increase in suicidal
ideation and suicidal behavior associated
with antidepressant use in children
and adolescents. Since there were no
occurrences of suicide in any of the
trials, a far larger sample size would be
needed to demonstrate increased risk
of actual suicide.
The more complicated issue is how
to apply this information in clinical practice.
While it does make sense to be
cautious in using antidepressants as
first-line treatment for mild to moderate
major depression, especially in the
absence of a trial of psychotherapy,
caution needs to be weighed against the
risk of limiting treatment options for
depressive disorders that can be associated
with major psychosocial and
biologic impairments.
Observing that much of the increased
prescribing of SSRIs has occurred in
patients with mild depression and
anxiety, Gunnell and Ashby15 posit that
the risk-benefit ratio may depend on the
individual's underlying suicide risk. For
severe depression, which carries significant
suicide risk, the balance may be
more favorable than for anxiety and mild
depression, in which suicide is less
common.
The American Academy of Child and
Adolescent Psychiatry (AACAP) and
the American Psychiatric Association
(APA) have issued guidelines for antidepressant
prescribing for pediatric
patients.16 These experts recommend
that physicians closely monitor patients
who have just started taking antidepressants
in order to detect behaviors
that could be precursors to suicidal
ideation or behavior. These potential
precursors include:
Agitation
Akathisia
Irritability
Hostility or aggressiveness
Impulsivity
Anxiety or panic attacks
Insomnia
Switching to hypomania or mania
Patients who experience 1 or more
of these may be at risk for worsening
depression or for suicide.
Physicians should also ask directly
about past and present history of suicide
attempts, suicidal thinking, and plans
for suicide. Ruling out bipolar disorder,
including family history of bipolar disorder,
is also important before antidepressant
treatment is initiated. Patients
should be monitored once a week for
the first 4 weeks of treatment and
biweekly for the next 8 weeks. Drugs
with a short half-life may cause more
adverse effects than those with a long
half-life because of the risk of withdrawal
syndrome and worsened depression
following missed doses.
Table 2 lists clinical recommendations
for antidepressant use in children
and adolescents, based on a variety of
sources, including guidelines and practice
parameters developed by the
AACAP and the APA.16,17
Finally, it is important to remember
that when used with appropriate caution
and monitoring, antidepressants offer
hope to millions of young people suffering
from mental illness, who need to
have access to all available treatments.
Dr Winters is associate professor in the department
of psychiatry and pediatrics and
program director of the child and adolescent
psychiatry residency program at Oregon
Health & Science University, Portland. She
was an investigator in the multi-site study of
paroxetine(Drug information on paroxetine) in adolescent major depression. She
reports no conflicts of interest regarding the
subject matter of this article.
Drugs Mentioned in this Article:
Bupropion (Wellbutrin)
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor)
References
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