Antidepressants and Suicide Risk

Several years ago I was speaking in a family practitioners office in Marshall, TX. I started out with a question, "If you were treating President Clinton, what would you prescribe him?"

He immediately answered, "Prozac."

I said, "Good, and that’s because …"

He said, "It causes people to commit suicide."

Of course, I was thinking more along the lines of reducing libido, but he had raised an interesting point.

Does Prozac or other SSRI’s increase the risk of suicide?

The best answer is, usually not. Studies have shown that overall, antidepressants decrease suicide risk. In one large study, patients with depression were twice as likely to commit suicide if they weren’t on antidepressants. So you could say that antidepressants reduce the risk but don’t eliminate it. But, can antidepressants sometimes increase risk? Unfortunately, yes.

How can antidepressants increase suicide risk?

  1. Some patients are very sensitive to side effects and become very anxious or agitated on antidepressants, and anxiety is one of the main symptoms associated with acute suicide risk.
  2. A second possibility is that a person with depression associated with hopelessness and immobility may be activated enough by the antidepressant to carry out a suicide plan.
  3. More common would be a situation where someone is bipolar or at least has bipolar genetics and the antidepressants cause a dysphoric hypomania. This is one of the most suicidal states where someone has symptoms of depression and hypomania at the same time. (see bipolar newsletter for details of these states). Why would it be more of a problem in kids and teens? Because, the earlier the age of significant depression, the more likely they have bipolar genetics.

(1)"In June, the Child and Adolescent Advisory Commitee of the International Society for Bipolar Disorders issued a position statement on antidepressant medications for children and adolescents: ‘they (primary care doctors) should monitor their children for the emergence of specific symptoms that may warrant referral to a psychiatrist: anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity and severe restlessness.’

"The statement also identifies signs of mania in children, including a decreased need for sleep, exaggerated or inappropriate silliness, exaggerated optimism, behaving as if invincible, atypically high energy levels, exaggerated talkativeness, racing thoughts, extreme restlessness or impulsivity, and inappropriate sexual behavior.

"The committee stressed the need for extra attention when medication is first prescribed or when it is changed. In some children these events have been linked to an increased risk for suicidal behaviors, so they caution against abrupt discontinuation of medication, which can exacerbate the illness and its symptoms."

Would it just be better to avoid antidepressants in kids?

No. There are definite benefits, especially with anxiety disorders, but also some depressions. The important thing is that patients, parents and clinicians be aware that these paradoxical reactions occur. They must monitor for negative reactions, which usually occur in the first few days or weeks. Kids that have done well on these meds for several months are at very low risk of an adverse reaction.

(1)"A recent analysis of suicide rates in the Journal of American Academy of Child and Adolescent Pyschiatry (2004:43) showed no significant difference between SSRI’s and placebo."

But they recommend additional studies to separate the effects of the illness, the medication and the interaction of the two. Of course, in formal studies patients are more closely monitored than in most office practices.

A recent study of communities looking at number of kids/teens taking antidepressants and rate of suicide in them found that the highest suicide rates occur in the communities using the least antidepressants. So in general, the benefit outweighs the risk. But in any given individual a complete history, including family history, good patient/family education, and close monitoring are essential for good medical care.

Footnotes: (1) CNS News, October 2004

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