Sunday, September 19, 2004
Suicide and Antidepressants
There has been a lot of media coverage recently about youth suicide and antidepressants. The "post hoc, ergo propter hoc" story is essentially: a depressed young person goes on antidepressant therapy, subsequently commits suicide and thus the suicidal thoughts and behaviors were caused by the antidepressants (as opposed to, you know, the depression).
For those who have studied depression, it is a given that risk of suicide can increase following initiation of a successful treatment - that is, the severely depressed patient suddenly has more energy and can take more initiative, and is thus at increased risk of acting on sucidal thoughts. It follows that this will be the case with some younger patients who are responding to antidepressant therapy.
There is another factor at issue, which is that mental health care in this nation, particularly for depression, is now often handled by the family doctor. There are antidepressants which can cause agitation, or which can increase energy level, without necessarily providing an associated improvement in depressive symptoms. A health care provider might view the agitation or increased energy as evidence that "it is starting to work", but might not have the clinical awareness to know that such an increase in energy level could create risk of action on existing suicidal thoughts.
I think it is also true, from my discussions with people who have used even the current generation of "SSRI" antidepressant medications, that some people do experience changes in their thought patterns while taking SSRI's. I think it is pretty much taken for granted that such changes can be a side-effect of the older tricyclic and MAOI medications. Accordingly, it is appropriate for all patients trying a new antidepressant medication (and their doctors, and family members) to watch for any troubling changes.
I am not particularly impressed with the notion that SSRI's dont' work for teenagers, based upon narrow studies of particular SSRI medications, as it seems to be broadly the case that some people will not respond to particular antidepressant medications. Many depressed people have to try several medications, and in some cases pretty much all of them, before they find one that works for them. It is possible along the way to become discouraged, and assume that the only thing an antidepressant has to offer is a constellation of unpleasant side-effects. But if you find one that works for you, there will be no question left in your mind that an appropriate antidepressant has a genuine therapeutic value. Patients should not be deprived of that value merely because of their age - arguably (and in my opinion, almost certainly), it is the youngest patients who can see the greatest lifetime benefit from early, effective treatment.
It may well be that some SSRI's are less effective in younger patients - that should be studied, and the pharmaceutical companies have done their younger patients a disservice by pressing for (often off-label) prescriptions without having first tested their efficacy for kids and teens. If it turns out that some of those medications actually do not work in children or teenagers, or have higher levels of negative behavioral symptoms in young patients, the pharmaceutical companies which pushed for inappropriate use deserve any liability that follows.