Two new studies reported increasing suicide rates in teenagers. The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.
1. In previous research,
increased suicidality was associated with SSRI use in teens. Now this study
suggests that lower SSRI use is associated with increased suicidality. How do
you explain this?
Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens. However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant. The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage. What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living. A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented. This is not being done in enough instances. With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.
Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.
First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.
Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.
Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).
2. Is there a role for
SSRIs in teens?
Dr. Smaller: I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.
Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.
3. What would you counsel
parents about these drugs?
Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help. The mental health professional and the parent must have a working alliance to insure that the treatment is successful.
Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
4. What do you make of
the suicide rate increase in girls? What could be behind
Dr. Smaller: This is alarming. The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty. The teen years can be fraught with family issues that exacerbate moods and create symptoms. Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls. Social roles, peer pressure and issues, academic demands and family strife all contribute. The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.
Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.