Suicidality and Depression Treatments in Youths

August 22, 2014
Karen Dineen Wagner, MD, PhD

Psychiatric Times, Vol 31 No 8, Volume 31, Issue 8

A brief review of interesting new findings on suicidality and depression treatment in youths.

This article discusses interesting new findings on suicidality and depression treatment in youths.

[[{"type":"media","view_mode":"media_crop","fid":"27043","attributes":{"alt":"suicide and depression in children and adolescents","class":"media-image media-image-right","id":"media_crop_5185887727084","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2590","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 125px; height: 221px; float: right;","title":" ","typeof":"foaf:Image"}}]]Nock and colleagues1 assessed the lifetime prevalence of suicidality in adolescents. The sample consisted of 6483 US adolescents aged 13 to 18 years who participated in the National Comorbidity Survey Replication Adolescent Supplement. This survey used structured diagnostic interviews to assess DSM-IV psychiatric disorders and suicidal behaviors.

Their findings indicate that the lifetime prevalence rates of suicidal ideation, plans, and attempts were 12.1%, 4.0%, and 4.1%, respectively. The rates of suicidal ideation, plans, and attempts were low through age 11 (less than 1%). After age 12, suicidal ideation increased rapidly through age 17, and suicide plans and attempts increased rapidly through age 15 and more slowly to age 17. One-third (33.4%) of adolescents with suicidal ideation developed a suicide plan and 33.9% made a suicide attempt.

The majority of adolescents who had suicidal ideation transitioned from ideation to plan or from ideation to suicide attempt within the first year of the onset of suicidal ideation. Similarly, most adolescents who transitioned from plan to attempt did so within a year of developing the plan. About 60% of adolescents with a suicide plan went on to attempt suicide.

Of those youths with suicidality, MDD and/or dysthymia was the most common psychiatric diagnosis. Prevalence rates were 56.8% ideation, 69.7% plan, and 75.7% attempt in this group. MDD and/or dysthymia also predicted the development of a suicide plan and was a predictor of transition from suicidal ideation to suicide attempt. These findings highlight the importance of treating adolescents with depression.

Suicide attempts and antidepressants

Some parents are concerned about the use of antidepressants for treatment of their depressed children because of the warning about an increased risk of suicidal thinking and behavior in children and adolescents treated with these medications. Parents sometimes ask whether a particular antidepressant would be less likely to increase suicidality than another antidepressant.

Cooper and colleagues2 compared the risk for suicide attempts among youths treated with antidepressants. This retrospective study included 36,842 youths aged 6 to 18 years who were enrolled in the Tennessee Medicaid Program from 1995 to 2006. These youths were new users of fluoxetine, sertraline, paroxetine, citalopram, escitalopram, or venlafaxine. Medically treated suicide attempts were confirmed on the basis of medical record review. Because fluoxetine has FDA approval for the treatment of major depression in children and adolescents, the risk of medically treated suicide attempts was compared between fluoxetine and the other SSRIs and SNRIs.

Medically treated suicide attempts were reported in 419 youths; the rate was 24 to 29 over 1000 person-years for users of the SSRIs and SNRIs. There were no significant differences for risk of suicide attempts among those taking SSRI and SNRI antidepressants and those taking fluoxetine.

Factors such as sex, age, and absence of a suicide attempt before initiating antidepressant therapy did not affect the results. Importantly, a higher risk of medically treated suicide attempts (adjusted relative risk = 1.70) was found for youths who were treated with multiple antidepressants concomitantly compared with users of fluoxetine alone.

This study demonstrated that no specific antidepressant is more likely than another antidepressant to be associated with a risk of suicidality in the treatment of children and adolescents.

PCPs and adolescent depression

Given the shortage of child and adolescent psychiatrists, primary care providers (PCPs) often evaluate and treat children and adolescents with major depression. Radovic and colleagues3 conducted a study to determine how PCPs make treatment decisions for adolescent depression. PCPs within a large pediatric practice network in the greater Pittsburgh area participated in a cross-sectional survey. These 58 PCPs were shown 2 vignettes of adolescent girls who met criteria for MDD but who were not suicidal. The vignettes differed in the level of symptom severity: one girl had moderate depression and the other had severe depression.

The PCPs were asked to rate their likelihood of using one of the following treatment options: watchful waiting (ie, follow-up visits with the PCP), prescribe antidepressant, refer for therapy/counseling, refer to a child psychiatrist for antidepressant treatment, or refer for crisis management or hospitalization. The PCPs were also asked to rate the importance of an array of factors that influenced their decision about treatment. Scales that assessed depression knowledge and perception of the burden of the patient’s psychosocial problems were completed by the PCPs.

The PCPs were likely to recommend therapy for moderate (100%) and severe (98%) depression. PCPs were more likely to refer to a child psychiatrist for severe depression than for moderate depression. The proportion of PCPs who recommended antidepressant treatment was low, both for moderately depressed adolescents (25%) and severely depressed adolescents (32%). PCPs with greater depression knowledge and with access to an on-site mental health provider were more likely to prescribe an antidepressant. Factors that influenced PCP treatment decisions were adolescent substance abuse, family support, and functioning in school and extracurricular activities. The PCPs who perceived a higher burden related to addressing the adolescent’s psychosocial concerns were less likely to prescribe antidepressants.

The researchers concluded that there are 3 factors that may increase the likelihood that depressed teenagers with moderate to severe depression receive appropriate antidepressant treatment: PCPs’ increasing knowledge of depression, reduced feelings of burden involved in addressing psychosocial problems, and the presence of an on-site mental health therapist. These findings are particularly important with current changes in the health care system. The integration of mental health services within primary care settings allows PCPs access to child psychiatrists and other mental health professionals. These services could be provided on-site or via telepsychiatry.

Long-term effects of antidepressants

A frequent question raised by clinicians is whether there are long-term neurobiological effects of antidepressants in depressed children and adolescents. Although there is an absence of data addressing this issue, Iñiguez and colleagues4 examined the long-term effect of exposure to fluoxetine on behavioral reactivity to emotion-eliciting stimuli in rodents. Following treatment with fluoxetine, adolescent rodents were exposed to aversive stimuli (social defeat stress, forced swimming, and elevated plus maze).

Compared with rodents who had not been exposed to fluoxetine, the fluoxetine-exposed rodents were less likely to exhibit depression-like behavior when exposed to aversive stimuli in adulthood. However, anxiety-like responses were greater in the rodents exposed to fluoxetine in adolescence. The implications of this rodent study for humans remain to be determined.


1. Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70:300-310.

2. Cooper WO, Callahan ST, Shintani A, et al. Antidepressants and suicide attempts in children. Pediatrics. 2014;133:204-210.

3. Radovic A, Farris C, Reynolds K, et al. Primary care providers’ initial treatment decisions and antidepressant prescribing for adolescent depression. J Dev Behav Pediatr. 2014;35:28-37.

4. Iñiguez SD, Alcantara LF, Warren BL, et al. Fluoxetine exposure during adolescence alters responses to aversive stimuli in adulthood. J Neurosci. 2014;34:1007-1021.