Antidepressant drugs and the risk of suicide in children and adolescents.

Government agencies have issued warnings about the use of antidepressant medications in children, adolescents, and young adults since 2003. The statements warn that such medications may cause de novo 'suicidality' in some people. This review explores the data on the treatment of depression that led to these warnings and subsequent data that are relevant to the warnings. It also addresses the effectiveness of antidepressant treatment in general and the relationship of suicide rates to antidepressant treatment. It concludes that the decisions for the 'black box' warnings were based on biased data and invalid assumptions. Furthermore, the decisions were unsupported by the observational data regarding suicide in young people that existed in 2003. The following recommendations would seem to follow from these observations. First, drug authorities should re-evaluate the basis for their imposed warnings on antidepressant medicines, and analyze the actual public health consequences the warnings have had. In the absence of substantial evidence supporting the warnings, they should be removed. Second, physicians and other providers with prescription privileges should continue to be educated regarding the importance of aggressively treating depression in young people, using antidepressants when indicated. Third, physicians and other professionals who treat depressed young people must always be aware of the risk of suicide (albeit quite low) and observe them closely for any signs of increased risk of suicide. This is necessary regardless of the type of treatment being provided.

The increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

Numerous ecological studies have shown an inverse association between antidepressant use and suicide rates and a smaller number of individual-based studies have shown an association between current antidepressant use and reduced suicide risk. Such evidence is often cited in support of the notion that antidepressants prevent suicide. However, more recently, the premises underlying this proposition, namely that suicide is caused by depression and that antidepressants relieve depression, have been challenged and the potential harm caused by antidepressants has been highlighted. In this article, Goran Isacsson and Charles Rich debate with Jon Jureidini and Melissa Raven the motion that the increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

Does acute treatment with sedatives/hypnotics for anxiety in depressed patients affect suicide risk? A literature review.

BACKGROUND: Anxiety (among several other symptoms) has been identified in one prospective study as associated with suicide risk in depressed patients early in treatment. It has been suggested that treatment of anxiety in depression with sedative/hypnotic agents, especially benzodiazepines, in the first several weeks may decrease suicide risk. Sedative/hypnotic agents also have depressant and disinhibitory properties which might increase suicide risk, however. This review addresses the potential benefits and risks with regard to suicide of using sedative/hypnotics as an early adjunct to antidepressant treatment in anxious depressed patients. METHODS: Pertinent medical literature was reviewed using Medline/PubMed search as well as bibliographies from related publications. Reports in English from 1958 to 2006 were included. RESULTS: The review did not reveal any evidence that using sedative/hypnotics as an early adjunct to antidepressant treatment of anxious depressed patients decreases their suicide risk. There is considerable evidence that sedative/hypnotics produce depressant and/or disinhibitory effects in a small proportion (perhaps 5%) of people who take them. However, there is no clear evidence that their brief use early in depression increases suicide risk. Toxicological data of suicides indicate that a majority of people who commit suicide are under the influence of sedative/hypnotic chemicals (including alcohol) at the time. CONCLUSIONS: The authors conclude that the question of whether sedative/hypnotics may prevent or provoke suicide in anxious depressed patients cannot be answered definitively with the available information. They believe the potential risks of prescribing sedative/hypnotics for depressed patients who may be suicidal are serious. They suggest that alternatives to sedative/hypnotics should be used if early adjunctive treatment for anxiety in depressed patients is thought to be indicated.

Antidepressant drug use and suicide prevention.

Depression has been identified as occurring in the majority of people who commit suicide. Effective antidepressant medications have been available for over half a century. It seems logical to conclude that treatment of depression with antidepressants would have a suicide preventive effect. This has been difficult to demonstrate due to the infrequency of suicide and methodological problems in prospectively testing the hypothesis. Pooled data from controlled clinical trials of antidepressants have not demonstrated a suicide preventive effect, but patient selection and the brief time of most trials limits the power of the data. Some reports from either long-term or very large databases have provided evidence that antidepressants prevent suicide. All but one study using aggregated data from naturalistic settings have shown inverse relationships between use of antidepressants and suicide rates in various populations. Definite conclusions cannot be drawn from naturalistic studies since unknown confounders cannot be excluded. The number of geographically widespread studies reporting positive results with varying methods leads us to conclude, however, that antidepressants do exert a suicide preventive effect.

Delusional Depression and Electroconvulsive Therapy: One Year Later.

This study reports the outcome of a 1-year follow-up study of 37 patients with a delusional depression treated with electroconvulsive therapy (ECT). Thirty-two (86%) of the patients initially responded to ECT. However, 16 (50%) of the 32 responders relapsed within 1 year. The authors suggest that further research is indicated to decrease this relapse rate.