Serotonin Reuptake Inhibitors, Suicidality in Children and Adolescents.

There has been a major controversy in the media because of the relationship between suicidality in children and adolescents and SSRI antidepressants.  The FDA (Food and Drug Administration) in America state that antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder and other psychiatric disorders.  Anyone considering the use of an SSRI or any other antidepressant in a child or adolescent must balance this risk with the clinical need.  Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour.  Families and care givers should be advised of the need for close observation and communication with the prescriber.  Pooled analyses of short term placebo / controlled trials of nine antidepressants (SSRIs and others) in children and adolescents with major depressive disorder, Obsessive Compulsive Disorder, or other psychiatric disorders have revealed a greater risk of adverse events representing suicidal thinking or behaviour (suicidality) during the first few months of treatment in those receiving antidepressants.  The average risk of such events on drugs was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. This is a good and reasonable summary of the current situation.  It emphasises close monitoring in the early weeks and suggests close attention to risks / benefit of the medication.  Clearly the benefits will outweigh the risks in those with more severe depressive states.


It is interesting that efficacy could not be established for the SSRIs except for Fluoxetine in paediatric usage.  It is important as well to note that major depression increases the risk of childhood suicide about 12 fold.  More than half of the kids with this disease try to kill themselves, and about 7% do complete suicide according to USA Today 2004. One has to measure this against the fact that 2 in 100 children on antidepressants become more suicidal because of the pills and there were no reported suicides again according to USA Today 2004. The reasons for the increased suicidality might be due to the fact that the medications can increase impulsiveness and that as the children who have been depressed become more energetic this increases the likelihood of suicidality.  It is interesting that there isn’t evidence for the tricyclic antidepressants in children but the current controversy might drive clinicians because of the concerns about the SSRIs to go back to prescribing the tricyclic antidepressants which are generally regarded to have higher side effect rates. This would be a retrograde step.  The worry is now is that some severely depressed children wont get the antidepressant treatment they require because of the current controversy.  Indeed a report in USA Today states that some doctors ‘fear kids could be denied needed care’.  This is where the good clinician comes in who is able to weigh up the risks and the benefits, who is able to identify a depression as being severe and in need of antidepressant treatment.  Clearly mild depressions should be treated with psychotherapy.  The British Medical Journal 2004 came to a reasonable conclusion that doctors should not hesitate to use antidepressants for clearly defined depressive disorders but they should carefully monitor patients in the first weeks of treatment.  There is a signal for suicidality when you look at studies of antidepressants that is the SSRIs nevertheless a report in the Journal of the American Academy of Child and Adolescent Psychiatry 2004 stated that ‘none of the reported differences with regard to suicidality between any of the drugs and placebo are statistically significant’.  This report claims that there has been an underestimation of the reduction of suicidality in patients treated with antidepressants.  My own personal conclusion is that there is a signal for suicidality but this can be managed within the context of the doctor patient relationship and careful monitoring in the early weeks after prescription. It is difficult to communicate this common sense approach in the context of media controversy.