With the recent FDA warning about the use of antidepressants with children and adolescents, doctors and patients are more cautious about treating youth with antidepressants. Parents and doctors are challenged to make a balanced assessment of risk and benefits. Dr. Nancy Rappaport, Dr. Jefferson B. Prince, and Dr. Jeff Q. Bostic of the psychiatry department of Harvard Medical School in their article in the December 2005 issue of The Journal of Pediatrics “Lost in the Black Box: Juvenile Depression, Suicide and the FDA’s Black Box” encourage clinicians to pay careful attention to identify and address modifiable risk factors for suicide that include treating depression/ anxiety, storing guns safely, and treating substance abuse. Important risk factors for suicide include depression, stressful life events, substance use/abuse, irritability, agitation, and impulsivity.
The authors detail the FDA concern about the possible association between selective serotonin re-uptake inhibitors (SSRIs-a class of antidepressants) and worsening of suicidal thoughts and/or new onset of increased suicidal behavior. In the FDA review of suicidal data, there are limitations; many of the patients seen in the office of pediatricians and psychiatrists were excluded from the 24 studies (patients who were very sick with depression and were significantly suicidal, and patients with other disorders present, such as ADHD). The FDA examined past records of the patients (rather than interviews), and it was difficult to identify /assess and classify the suicidal intent of the patients. Interestingly, examining large databases between 1990 and 2000 for the changes in antidepressant prescription and adolescent suicides showed that geographical areas where SSRI prescriptions increased, there were reductions in adolescent suicide. In another study, Valuck identified 24,119 adolescents diagnosed with depression and/ or receiving antidepressants. Adolescents treated for longer periods with antidepressants (more than 180 days) were less likely to make suicide attempts than those treated for less than 55 days.
With Dr. Rappaport’s experience as a doctor working with high- risk adolescents at school-based health centers and assistant professor of psychiatry at HMS, she was asked about guidelines for parents dealing with depressed teenagers: ” It is key that they know that they are not alone, and that probably one of the most stressful problems for parents is to deal with a teenager who has an ‘invisible disease’ – major depression – that can make it hard for their adolescent to function or want to be alive. Given the recent events, pediatricians and child psychiatrists, families, and patients need to weigh the risk and benefit of treatment to promote growth and avert the debilitating impact of juvenile depression. Medication may be one important aspect (consideration) of treatment,” said Rappaport.