Rethinking Antidepressants and Youth Suicide

Rosa Rodriguez,* now a college student, recalls her suicide attempt at 13 years old: "I decided I couldn't take it anymore, so I took some pills and went to bed early. I threw it all up within 20 minutes, and thinking back, I'm glad it didn't work out."

She goes on: "I share my bed with my sister, and it would have been really selfish of me if I did that knowing that she was lying next to me. I obviously wasn't thinking rationally."

While Rosa looks back with remorse, she does not look back with confusion. She has continued to struggle with depression throughout her life, a disease that affects 5 percent of adolescents and children. According to the Centers for Disease Control (CDC), 90 percent of those who attempt suicide have a significant psychiatric disease. Rosa is not an anomaly.

Two new studies confirm that the suicide rate among young people has increased, particularly among girls between the ages of 10 and 14. The numbers have researchers, health advocates, parents, educators, and teens debating the potential causes -- the most controversial of which is the corresponding drop in antidepressant use among youth after U.S. Food and Drug Administration (FDA) warnings in early 2003.

The first study, conducted by the CDC's National Center for Injury Prevention and Control confirms that between 2003 and 2004, the suicide rate among children and young adults rose 8 percent; the suicide rate for girls ages 10-14 jumped 76 percent. CDC researchers are quick to point out that, though they are interested in the corresponding drop in antidepressant use, the study doesn't prove a causal relationship.

Robert Gibbons of the University of Illinois at Chicago, the head researcher on the other study, believes he has that proof. His study, published in the American Journal of Psychiatry, found that the youth suicide rates in the United States rose 14 percent between 2003 and 2004 and 49 percent in the Netherlands. Youth antidepressant prescriptions fell 22 percent among children aged 0 to 19 in both the United States and the Netherlands after the 2003 warnings were issued.

The study, however, has come under scrutiny recently because two of its eight authors, including Gibbons, have ties to big pharma. Gibbons once served as an expert witness for Wyeth, maker of Effexor; J. John Mann, a neuroscience professor at Columbia University, has received research funding from GlaxoSmithKline, creator of Paxil, and has been an adviser to Eli Lilly, which sells Prozac.

Still, these conflicts of interest do not necessarily mean the study's conclusions are wrong. Any way you slice it, these numbers are alarming and worth a closer look. Especially when you consider that prior to 2003, the suicide rate among youth aged 10 to 24 had fallen by 28.5 percent over a 13-year period. Dr. Ileana Arias, director of the National Center for Injury Prevention and Control told reporters: "We don't yet know if this is a short-lived increase or if it's the beginning of a trend."

Rethinking antidepressants
Though the FDA has never approved Zoloft, Paxil or most similar drugs (with the notable exception of Prozac) for use by younger patients with depression, many doctors prescribe them. According to the Journal of the American Academy of Child and Adolescent Psychiatry approximately 1.4 million pediatric patients are currently taking antidepressants.

In the FDA review, no completed suicides occurred among nearly 2,200 children treated with selective serotonin reuptake inhibitor (SSRI) medications. However, about 4 percent of those on the drugs experienced suicidal thinking or behavior, including suicide attempts -- twice the rate of those taking the placebo.

In 2003, following this review and lengthy hearings, the FDA issued a warning that the use of antidepressants -- particularly the very popular SSRI type, including Prozac and Paxil -- could increase the chances of suicidal thoughts or actions in children and teenagers. The warnings were added in a "black box" on the medications in October 2004.

The FDA posted a revised warning on its website on Feb. 3, 2005, changing the wording to say only that the drugs "increased the risk of suicidal thinking and behavior in short-term studies of adolescents and children" with depression and other psychiatric disorders.

This significant change came after several months of aggressive lobbying by the pharmaceutical industry, a fact that remains in many health and consumer advocate's minds.

Vera Hassner Sharav, for example, president of the Alliance for Human Research Protection, testified in many of the original FDA hearings and is not convinced that the new studies point to antidepressants' ultimate safety. As she told NPR: "You cannot determine a causal affect because you're not looking at other circumstances."

She suggests that other factors, like the use of antipsychotic drugs, could also be affecting the spike in the suicide rate. Sharav is concerned that news of these studies will give consumers the spurious idea that antidepressants are, indeed, no longer potentially dangerous for children and teens.

But other experts, while saddened by the rise in the suicide rate, are heartened by evidence that antidepressants really do have the potential to save children and teen lives.

Dr. Benjamin Shain, co-author of a clinical report on teen suicide by the American Academy of Pediatrics, explains, "There is no treatment that is 'safe,' as even talk psychotherapy, another important treatment for depression, has risk. The risk of serious side effects from antidepressant medications, however, is low and must be balanced against the risk of inadequate treatment of depression: lower grades, difficulty with relationships with family members and friends, loss of ability to have fun and enjoyment, and just general misery, as well as a much higher risk for suicide."

Dr. Brad Sachs, a psychologist specializing in clinical work with children, adolescents and their families, explains, "When it comes to treating childhood and adolescent depression, clinicians should leave no stone unturned, and that includes the possible use of antidepressant medication. There is no question that antidepressant medication has relieved the unnecessary suffering of numerous children and adolescents, and has saved lives in the process."

From Sachs' perspective, however, writing a prescription for an adolescent to take antidepressants is never a simple matter. For starters, many of the newer medications have not been studied longitudinally, so we don't yet know about the long-term impact. Second, children and adolescents have been known to misuse medication. And, as Sachs explains: "In addition to whatever physical side effects these medications stimulate, there are also nonphysical side effects, such as conveying the unfortunate message that all of one's problems can be solved by 'taking a pill.'"

Demographic shifts
These findings raise many new questions: the most urgent of which is, Why the rise in suicide among young women, and particularly among such young women (aged 10-14)?

Patti Binder, who has worked with girls from this age group for over seven years in various nonprofit capacities and blogs at What's Good for Girls, has a hypothesis: "Middle school girls are not ready for adult pressures, including those that come with the sexualization of girls that we are seeing today." She refers to the American Psychological Association's 2007 Task Force on the Sexualization of Girls, which found that increased pressures to appear and act in a sexually explicit way at a younger age were linked to mental health disturbances in teen girls. Mental health disturbances, of course, are linked to suicide.

Dr. Roni Cohen-Sandler, psychologist and author of Stressed out Girls: Helping Them Thrive in the Age of Pressure, also believes that there is an important link between the pressure girls face and the rising suicide rate: "I am seeing an increase in such desperation among young teens. There are more mixed messages in this culture, fewer opportunities to conform to societal ideas of success, and sometimes a lack of support in families, which are experiencing increased stress and dissolution."

The rise in suicides among tween, or pre-teen, girls may also have something to do with weight issues, some experts speculate. Abby Ellin, health writer for the New York Times, reports that the single group of teenagers most likely to consider suicide are girls who think they are overweight. In a recent study of 11,000 American adolescents by UT sociology professor Robert Crosnoe, for example, he found that obese girls often engage in negative behavior to cope with isolation and social stigmatization, like skipping school, using alcohol or drugs and considering suicide.

Eating disorders, such as bulimia and anorexia, also on the rise among tween girls, may be contributing as well. Shain stresses the need for more research in this area, but points out that the malnutrition associated particularly with anorexia typically leads to depression.

Looking towards healing
The spike and demographic shifts are motivating those in the long-established field of suicide prevention to rethink some of their strategies, but they are also adamant that the public not overgeneralize based on these new numbers.

Chris Gandin Le, an expert on suicide prevention and technology, explains: "Suicide is complicated by cultural factors and outside influences, but it is such an individual decision."

Thanks to the Garrett Lee Smith Memorial Act, passed in 2004, more money is being spent on suicide prevention -- particularly among teens -- than ever before. Gandin Le is hearted by the efforts he sees to incorporate social networking sites, like Facebook and MySpace, into the widening and varying approaches to keeping kids aware that they have options.

He also points out that progress is being made with regards to "postvention" -- intervention efforts into communities, both physical and virtual, to prevent suicide clusters (the devastating phenomenon where multiple suicide attempts or deaths follow an initial loss.)

In 2004, about 161,000 youth and young adults between 10 and 24 received medical care for self-inflicted injuries in hospital emergency rooms across the nation, proving further that being aware of the warning signs for child/teen depression is critical.

Sachs sums up the task ahead: "When we shrink and distill our conversation regarding adolescent depression and suicidality down to whether or not to prescribe medication, or which medications to prescribe, we miss a crucial opportunity to examine and evaluate our collective priorities, and to perhaps begin redesigning them so that not only adolescents, but adults as well, discover new ways, or rediscover old ways, to bond, care, grow and heal."

*Indicates a pseudonym.


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