Antidepressant Risks in Children: a balanced view
The debate about use of antidepressants in children continues. It is one of the most vigorous in psychiatry.
The two sides, roughly:
A) antidepressants can increase suicidal thinking in some susceptible individuals with depression, probably particularly in bipolar depression. Therefore, physicians should warn patients and families about this risk before antidepressants are started.
B) since the FDA (and the Brits as well) posted their warnings along these lines, antidepressant use has declined sharply in children and adolescents. Now research has been published suggesting that the suicide rate in children and adolescents might actually be going up, possibly as a result. If true, this is a most unfortunate unintended consequence in the FDA should change their warning.
As in most such matters, this issue is much more complicated than these two opposing views suggest. A balanced view on this issue was just published along with one of the studies suggesting the increase in suicide risk. A link to that essay, and a translation into non-medical English, is available on my education website for those interested in this topic.
Dr. Phelps
3 Comments:
An important point made in your link,( which I don't believe was made in your essay about the FDA warnings on PsychEducation.com) is that "available research suggests that the benefit of antidepressants is only slightly greater than that of a placebo" in this age group. In fact, if we look at the data closely and don't accept effectiveness that is not "statistically significant" beyond placebo response I believe only fluoxetine made the grade as effective. It really was this finding, in conjunction with the suicidal thoughts data that led the FDA to issue the warning. Some evidence of risk (albiet unclear what it represented) weighed against a class of medictions that could not legitimately demonstrate significant efficacy (in this age group) left the FDA essentially no choice but to issue a warning. Data may be indicating that the antidepressants are in fact effective in children as measured by increasing rates of suicidality in their absense though it will take time to know this.
A last point would be that many of the medicines that we (psychiatrists) use and present as effective have very poor proven efficacy beyond placebo or very poor studies supporting their efficacy.
The data underpinning a claimed link between increased suicide rates in children and adolescents, and a decrease in antidepressant prescription rates is fundamentally flawed, on just about every level. In addition consider the following meta analysis which demonstrates the dangers of claiming causality re population suicide rates and antidepressants. That is why one has randomised trials- which show little if any therapeutic benefit, and increased suicidality in children..
Review Article
Do antidepressants reduce suicide rates?
D.J. Safera, ,  and J.M. Zitob
aDepartments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
bDepartments of Pharmaceutical Health Services Psychiatry, University of Maryland, Schools of Pharmacy and Psychiatry, Baltimore, MD, USA
Received 13 February 2006; revised 30 August 2006; accepted 28 September 2006. Available online 21 February 2007.
Summary
Investigators from a number of countries have linked temporal declines in the rate of completed suicide in children and adults to the increasing utilization of selective serotonin reuptake inhibitor (SSRI) antidepressants. They suggest that the relationship is causal. We undertook a thorough literature search of the rates of completed suicide using data from 1980 onwards, from the World Health Organization, the US National Center for Health Statistics, and related studies, in order to ascertain if a broad array of epidemiological evidence would or would not support a consistent association between suicide completion and SSRI utilization. The major findings were: (1) within and between countries, suicide rates vary prominently by age group; (2) national differences are marked with respect to a temporal association between rates of completed suicide and SSRI utilization; (3) in nearly half of the countries of the world, the decline in the suicide rate preceded the onset of the use of SSRIs; (4) suicide rates have fluctuated dramatically over the last century; and (5) the association between declining rates of completed suicides and increased SSRI use in the USA between 1990 and 1999 was no longer present between 2000 and 2004. We conclude that available ecological evidence does not support an inverse temporal relationship between rates of completed suicide and SSRI utilization.
Keywords: Suicide; SSRIs; Antidepressants; Ecological evidence
Corresponding author. Tel.: +1 410 366 1912; fax: +1 410 366 3876.
Public Health
Volume 121, Issue 4, April 2007, Pages 274-277
Thanks for that additional article. Hard to know where this pendulum is going to settle down. One finds cogent arguments on both sides (antidepressants carry risks, and is there any benefit?; antidepressants offer benefits despite risks, or is there a risk?).
How to cope? For now, for us clinicians, one can always retreat to the pragmatic: what difference does it make? It makes a difference when you think about prescribing an antidepressant for anyone, particularly if she/he is young. Keep your eyes open, and do what you can to make sure bipolar disorder is not likely as the basis for that depression or anxiety you're treating.
JP
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