Antidepressants and Suicide

The New York Times Magazine has a good overview of the possible link between antidepressants and pediatric suicide: http://www.nytimes.com/2004/11/21/magazine/21TEENS.html?pagewanted=1.

In the first several weeks of treatment, antidepressants can cause activation and this can increase suicide risk. In general, antidepressants over the longterm decrease the risk of suicide:

"The pharmaceutical companies are clearly making a product that most psychiatrists consider critical to treating depressed adolescents. Not prescribing these drugs may very well pose a greater threat than prescribing them. Studies have shown that areas in which antidepressant use among young people is widespread have experienced a dip in teenage suicide rates; according to Dr. John Mann, a suicide expert at Columbia University, fewer than 20 percent of the 4,000 adolescents who commit suicide in America each year are taking or have ever taken antidepressants."

Each patient responds to an differently to an antidepressant, and he must be monitored closely for side effects. My adult patients often need to take benzodiazepines such as klonopin or ativan to treat the anxiety, jitteriness, and activation that can be experienced during the first 1-2 weeks of antidepressant treatment.

Child and Adolescent Psychiatry is a difficulty field (which is one of the reasons that they make about $50,000 more per year than us general psychiatrists). There is currently a shortage of Child and Adolescent Psychiatrists. The new FDA black box warning on antidepressants and suicide is going to make pediatricians and family practitioners less willing to treat behavioral problems in children:

"while many child psychiatrists are unlikely to change their attitude toward S.S.R.I.'s, most pediatricians and general practitioners, who until now have written the bulk of these prescriptions, no doubt will. This could mean a lot of untreated children. There are only 7,400 child and adolescent psychiatrists in America; even in areas with high per-capita concentrations, the average wait to see one is six weeks. There is also the matter of cost. Many child psychiatrists charge steep hourly rates that are only partly offset by health insurance providers."

Part of my job as the Consult Psychiatry director at the U of MS is performing consults on pediatric patients (we have a shortage of child psychiatrists and our few child psychiatrists are not available to perform inpatient consults). Due to the legal risk, I now limit myself to triage of pediatric patients who I am asked to see for depression- I basically determine if the child needs transfer to a psychiatric ward or if he needs outpatient treatment with a child psychiatrist (of course, just recommending outpatient child psychiatric follow up doesn't ensure that it happens- it's a broken system out there, and not every child receives the help that he needs). With the current legal climate, I would never myself initiate treatment with an SSRI on a pediatric patient.