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Getting to the Bottom of Suicide Risk and Antidepressants
This past October, the Food and Drug Administration issued warnings that one of the newer treatments for attention deficit hyperactivity disorder (ADHD), Strattera, may cause suicidal thoughts in teens. This non-stimulant drug is similar to antidepressants, like Effexor, which also contain warnings about suicide. The actual risk that adolescents who take these drugs will commit suicide is relatively small, most experts say. In studies on Strattera, for example, 5 out 1,357 patients who took the drug had suicidal thoughts compared to 0 out of 857 who took a placebo.
What happens outside a tightly-controlled study is harder to know. Indeed, any chance that a teen may take his or her life is reason for concern. Suicides accounted for nearly 32,000 American deaths in 2002, with most of them occurring in teens between 18 and 19 years of age. Dr. David Shaffer, the director of child and adolescent psychology at Columbia University and a leading expert on suicidal behavior, discusses these risks and puts the recent controversy over antidepressants into perspective.
How common is it for adolescents to have suicidal thoughts?
They are very, very common. Suicidal thoughts occur in around 20 percent of all high school-aged kids. One in five high school kids have thought about suicide within the last year.
Have the thoughts or attempts of suicide gone down in recent years?
The rate of attempts doesn't appear to have gone down. The rate of ideation [suicidal thoughts] that's being tracked has gone down from about 25 percent two years ago to about 19 percent today
These lower rates have happened while more and more teens are taking antidepressants. Is it possible that the antidepressants are decreasing the risk of suicide?
I think it's highly likely. There have only been two previous periods in the last 105 years when suicide rates have gone down and both were during World War I and World War II. They were probably related to alcohol, because alcohol tends to drive the suicide rate. If you look at the 1990-2004 alcohol use rates, there has been no decline in alcohol use at all. So there are other possible explanations and I think we've all looked at them, and nothing strikes one as very convincing.
What about the possibility that antidepressants may increase the risk of suicide?
The really big argument that antidepressants are not causing a lot of suicides comes from autopsy studies. There are two places, one in New York and one in Salt Lake City, where they've been doing toxicology on youth suicides, and they're just not finding any trace of SSRIs [antidepressants, like Prozac] there. So my best guess is that non-treatment is more likely to lead to suicide than the reverse. However, that's not to say that antidepressants don't influence your behavior in a way that might make you talk much more about suicide, and it may also make you more aggressive and hostile.
Why has there been such a concern about antidepressants?
Most suicidal thoughts are kept inside, with even more attempts never revealed to anyone. When you're on an SSRI, you become less inhibited, and kids who have been totally silent and really uncommunicative within a few doses may be over-talkative and disclosing a lot. You are more likely to disclose your thoughts after taking an antidepressant. That doesn't necessarily mean to say the antidepressant is working; it's just one of the nonspecific effects.
Is there no risk of suicide from taking these drugs?
There are some kids who become quite hostile and aggressive when they take antidepressants. If you become aggressive and hostile, it's possible that you will get into trouble.
Do the benefits outweigh the risk?
I think the risk of not treating depression is much, much greater than the possible effects of treatment. But I think because you can get side effects, you can't just hand out a starter pack and say, "Try these and come back in a month."
How do you prevent this kind of reaction in teens who take antidepressants?
You tell the parents about the risk, and you start the patients on a very low dose. If you're not going to see the patient for a week or for two weeks, then you make sure that there are telephone contacts. And so you telephone the parent to ask what changes they've noticed, if any. And you give them a list of some of the things to look out for, like losing your temper, having difficulty sleeping or talking about suicide.
