Antidepressant medications:
Are they safe for depressed children?
John F. Greden, M.D.
Rachel Upjohn Professor of Psychiatry and
Clinical Neurosciences
Executive Director, Depression Center
The University of Michigan
A report (New York Times, August 7, 2003) described a growing debate about whether paroxetine (Paxil), a Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant, is safe when used to treat depressed adolescents. Several British reports have suggested that using such medications might produce a modest increase of suicidal acts in children and adolescents.
Such a debate is certain to generate concern among adolescents, family, and clinicians. Fortunately, there are perspectives that help those facing choices.
First, suicidal thinking and occasional attempts are integral parts of depression in all ages. Such thoughts commonly increase as severity of depression increases and routinely diminish and even disappear with effective treatment of depressive episodes.
Antidepressants like paroxetine (Paxil) are most commonly prescribed for adolescents who are the most severely ill. These are precisely the individuals that struggle most with suicidal thoughts and behaviors. Some of those given such antidepressants have had suicide attempts prior to starting such medications. Such overlap produces confusion for scientists trying to determine cause and effect and makes it difficult even for experts to know when suicidal attempts—which are rare—might be part of the illness or secondary to the treatment.
Is it possible that the very medications designed to treat depression and improve suicidal thoughts could stir up such behaviors? Yes. It has been known for 30 - 40 years that one of the most vulnerable times for suicide risk occurred during the days immediately following the beginning of antidepressant medication treatment. This was observed with older tricyclic antidepressants such as Elavil, and Tofranil as far back as the 1960's. Common explanations were that such medications “activated" the depressed patient who became energized enough to act on prior suicidal thoughts that had been dormant. Based upon newer brain research, it may be more likely that PROMPT changes in serotonin and other neurotransmitters in key brain areas contributes to perturbations of suicidal thinking and attempts. Such "flare-ups" and adverse events are most common whenever people begin or suddenly stop medications. This pattern is found with almost all medications in almost all clinical specialties and is not new. However, in the LONG RUN, proper treatment is essential for resolution of the underlying illness, whether that be hypertension or depression.
Virtually all effective medications have risks. Antidepressants are no exception. The challenge to the FDA and other agencies when assessing these is to do a "risk-benefit" analysis. The FDA approved Paxil and other SSRI medications after a thorough review, commonly reviews prior approvals whenever indicated, and may choose to look at this risk-benefit ratio anew.
While agencies review such data to assess the risk-benefit ratio for the medications, patients, families and clinicians should recall that both depressive and bipolar (manic-depressive) illnesses produce profound risks. These illnesses lead the world in disability and burden according to World Health Organization data. Antidepressants, when effectively used, lessen these burdens, disabilities, and suicidal behaviors for many.
