An article in the June 14, 2014 issue of BMJ reported that safety warnings about an increased risk of suicidality associated with antidepressant use by children and adolescents led to decreased prescribing of these drugs and increased rates of attempted suicides among young people. That should not be a surprise to readers of The Medical Letter, which has always maintained that antidepressants are more likely to prevent suicide than to cause it.
This story has an interesting background. It began in the summer of 2003 when GlaxoSmithKline submitted the results of 3 clinical trials to the FDA in an effort to gain approval for use of the SSRI antidepressant Paxil to treat children with obsessive-compulsive disorder. The boilerplate list of side effects that must be documented in such trials included “emotional lability,” which was defined as crying, mood fluctuations, thoughts of suicide, and attempted suicide. Among a total of 1,134 children aged 7-18 years, emotional lability was observed in 3.2% of those who took the drug and 1.5% of those who received a placebo. There were no suicides.
The FDA took no notice of those rather unremarkable numbers, but as a matter of routine, forwarded the trial results to the UK’s Committee on Safety of Medicines. The Chairman of the Committee issued a press release and sent a letter to British physicians saying that new data had shown “an increase in the risk of harmful outcomes including episodes of self-harm and potentially suicidal behavior [with paroxetine]” and that the risk was between 1.5 and 3.2 times greater with the drug compared to placebo. Those erroneous multipliers were repeated endlessly in the press reports that followed.
Could SSRIs cause suicide? Possibly. They have side effects like agitation and insomnia and can cause aggressive behavior, especially when they are first started. But worldwide use of these drugs in children and adolescents has been associated with declines in suicide rates, not increases. Not using the drugs was the wrong answer to the problem of their side effects. The right answer is that depressed patients of any age, whether they are treated with drugs or not, should be monitored for suicidal ideation and behavior.