October 9, 2006 (New York) - Research using large databases,
published reports, and cohort-matching techniques has founds that,
overall, antidepressants - particularly selective serotonin reuptake
inhibitors (SSRIs) - may reduce the risk for suicide in children and
adolescents. However, youngsters who have been recently hospitalized
for a suicide attempt may be at increased risk for suicide with
antidepressant use and should be watched closely, researchers said.
Mark Olfson, MD, MPH, clinical professor of psychiatry at Columbia
University in New York City, described his work at the American
Psychiatric Association's 58th Institute on Psychiatric Services. He
drew data from multiple sources and various time periods. These
included Medicaid and other federal government databases, prescribing
information from drug companies, Alleghany County (Pennsylvania)
medical data, private entities that collect health data, published
journal articles, and death certificates. He was even able to obtain
Social Security numbers from the federal government so he could connect
Medicaid data with death certificate data.
Dr. Olfson observed that there has been a "slow, steady decline" in
youth suicide since the 1980s, and "a big increase" in rates of
antidepressant use in children after the introduction of SSRIs. "More
than half of all the young people who present with depression in the
United States receive antidepressants," he said. Taken as a whole,
these observations suggest that antidepressant medications are having a
protective effect.
To study how recent hospitalization for a suicide attempt might affect
suicide rates in youth and adults who took SSRIs, Dr. Olfson identified
completed suicides who had been recently hospitalized. He then
identified 4 or 5 age-, location-, days in hospital-, and
diagnosis-matched controls for each of them. (Recent hospitalization
for a suicide attempt is a known risk factor for subsequent suicide.)
The numbers were small - he found 8 suicides among people aged 18
years and younger and 39 suicides among those aged 19 to 64 years who
met criteria. All patients were Medicaid recipients.
Among the adults, antidepressant use had no observable effect on
completed suicide rates, Dr. Olfson said. But 50% of children and
adolescents who completed suicide had been taking SSRIs compared with
37.5% of the matched controls (P =.002). What remains unknowable is
whether the youngsters who received SSRIs had more severe depression
than the controls.
While suicide is a leading cause of death among people aged 15 to 19
years in the United States, in a population-based analysis, "youth
suicide, thankfully, is very uncommon," Dr. Olfson said. Fewer than
1500 suicides occur annually. Consequently, "There will never be a
randomized trial that is large enough" to study this issue in youth or
adults, even if the trial were worldwide, because suicide is rare.
"Obviously, that's a very good thing," he added.
David A. Fox, MD, associate clinical professor at the University of
California Medical Center in Fresno, called Dr. Olfson's lecture "a
wonderful survey of the data that's out there."
Dr. Fox had asked Dr. Olfson about the effect of the US Food and Drug
Administration's "black box" warning regarding the risk of suicide and
paroxetine (Paxil) in adolescents. The warning was issued in October
2004. "Obviously, parents in particular are well aware of any published
data and will ask about it, always," Dr. Fox told Medscape.
The FDA warning affected practices at his institution. "Pediatricians
who previously had been very comfortable writing prescriptions for
antidepressants for kids became much less comfortable," Dr. Fox said.
"Pediatricians called me and said, 'I don't want to prescribe this for
these kids anymore, you do it.' "
Dr. Fox estimated that his referrals from pediatricians who initially
prescribed an SSRI increased about 20% to 25%, "even if the kid was
fine." He added that this is "mostly, probably, a good thing," because
many pediatricians do not have the time to follow such patients
closely.
Dr. Olfson reports no relevant financial relationships.
SSRIs Appear to Decrease Youth Suicide Overall 
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