and suicide risk
There's been a lot in the lay press
about the possibility of an increased risk of suicide in children
on antidepressants. What does this stem from?
It all started with a paper published in Britain last year that
concluded that children under 18 shouldn't take four popular antidepressants—Paxil,
Zoloft, Effexor and Celexa—because there was increased risk
of suicidal behavior, especially during the first nine days of
use or after a dosage change. Prozac is the only antidepressant
they suggested using in pediatric patients, and it is the only
one approved by the FDA for treating depression in children.
In February of this year the FDA convened an expert panel to
review this, and in August released a statement that said, "While
there remains a signal of risk... for some drugs in some trials,
it is important to note that the data are not black-and-white
in providing a clear and definitive answer."
How did the FDA suggest treating
patients on these medications?
They suggested close monitoring, especially in the days and weeks
immediately after starting the medication. But that should always
be true of someone being initiated on an antidepressant, because
suicidal thinking and behaviors are common in depression. So it's
difficult to say that it is a result of the medication.
I think part of what's contributing to this problem is the potentially
premature use of antidepressants. The first course of treatment,
especially if patients have mild-to-moderate depression without
other complications, should be psychotherapy. If that isn't sufficient,
then medication should be added.
When is medication appropriate?
If the patient has had four to six weeks of therapy and is still
having significant difficulty, then it's time to think about medication.
Of course, there are some instances when it should be considered
sooner. For example, if the child has psychotic depression or
bipolar disorder, or severe depression with suicidal ideation,
then he will likely need medication earlier.
Should PCPs diagnose and treat depression?
Unfortunately there aren't enough psychiatrists to treat depression,
so I think it's important for pediatricians to feel comfortable
diagnosing it and even prescribing an antidepressant.
Data show that while parents are really good at reporting their
child's behavior, they don't necessarily know the child's mood,
or if he is having suicidal thoughts. So a clinician the child
is comfortable with should be involved.
For straightforward depression, it's perfectly reasonable for
a child's pediatrician to get things started, and if needed, move
the child on for more specialized assessment or treatment. PCPs
can recommend therapy and keep updated through the family and
the therapist on their patient's progress. They know the child
and the family, and will have a sense of how they are doing. However,
if the child has suicidal thoughts or behaviors, psychosis, substance
abuse, or bipolar disorder, then he should probably be referred
to a psychopharmacologist.
What should clinicians say to families
concerned about the media stories?
The most important thing is to urge parents not to suddenly stop
the medication, because doing so can cause significant physical
symptoms or worsening of depression. If there are going to be
difficulties with the medication, they generally will emerge early
on, so a pediatrician can tell the family of a child who is new
to the medication to pay close attention to behaviors and possible
If the child has been taking a medication for a longer period
of time and is doing well, the pediatrician can reassure parents
that these medications are helping their child and have saved
many lives. And tell them that if they have any concerns, they
should call, especially early on. Finally, let them know that
you're not expecting any problems and wouldn't be recommending
the medication if you didn't think it was needed and potentially
Anything else you'd like the referring
community to know about this topic?
We need them to be involved with this, because depression is an
unfortunately common problem and treating it is not all about
medication. There has to be a multi-faceted plan involving therapy,
school intervention, family work and coordination between various
If medication looks like the best option, ask if there's a family
history of depression and whether a close family member has responded
to a specific antidepressant. If so, that would be a good place
to start since that may increase the likelihood of a positive
response. And if one antidepressant isn't effective, that doesn't
mean another one won't be.
Another thing to note is that the U.S. and Sweden have had a
significant decrease in the rate of completed suicides for youth,
and these are the two countries where there's active treatment
of depression in kids, including the use of medication.
There was a recent article in JAMA that found the combination
of Prozac and cognitive-behavioral therapy in adolescents with
major depression was the most favorable. So the use of medications
has contributed to saving lives and lessening of suffering, but
it has to be prudent use with close follow up.
Editor's note: On September 14, an
FDA advisory panel recommended adding a "black box"
warning to all antidepressants, noting a "consistent link"
between their use and suicidal tendencies in children under
18. A decision on whether to accept the recommendation is expected
within several months. For
more information, visit the American Academy of Child and Adolescent
Psychiatry at www.aacap.org/Announcements/antidepressants.htm