This article first appeared in the St. Louis Beacon: September 12, 2008 - Suicide rates among 10- to 19-year-olds are on the rise in the United States, according to research published in the Sept. 3 Journal of the American Medical Association. While the overall numbers declined from 1996 to 2002, an increase of 18 percent was seen from 2003 to 2004. Suicide trends continued to be higher in 2005, although the numbers fell by 5.3 percent between 2004 and 2005. An excess of 326 and 292 deaths were seen in 2004 and 2005, respectively, relative to what was expected based on the trend predictions, the report indicated.
Parents, educators and clinicians have reason to be concerned. The causes of suicidal thoughts and suicide are multi-faceted, making it difficult to identify causative factors and target interventions. The alarming trend may, in part, be due to fewer teenagers being prescribed antidepressants, according to Dr. Duru Sakhrani, medical director of Child and Adolescent Inpatient Services at St. John's Mercy Children's Hospital. "We started to see the initial changes in the increased suicide rates about a year after the black box warnings were place on antidepressants," she said.
Antidepressants Get Blacklisted
A "black box" warning, as defined by the Food and Drug Administration, "is the most serious warning placed in the labeling of a prescription medication." Reminder advertisements to prescribing health-care professionals are not allowed for products with this warning.
The FDA first issued a public health advisory in October 2003, warning health-care professionals of an increased risk of suicide-related behavior among children and teens taking a specific type of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Prozac, Zoloft and Paxil are among the commonly prescribed drugs in this class of medication.
One year later, on Oct. 15, 2004, the FDA issued a labeling change requirement. Manufacturers of antidepressants were now directed to include a black box warning on their products, alerting health-care providers about an increased risk of suicidal thoughts and suicide in children and teens. Up until that point, only 10 child-approved drugs had a black box warning pertaining to their use in children, according to the FDA.
While the warning does not ban antidepressant use in children and teens, it may have significantly decreased the practice of prescribing the drugs to youths. "It has been well documented that prescription rates have declined, specifically in teenagers," said Sakhrani. "We in the clinic have been seeing suicide and suicidal ideation go up, but now many doctors are feeling hesitant about antidepressant use. We saw an upward trend [in suicide] after this."
Prescribing antidepressants to teens has decreased, and indeed so has the comfort level of those who still do prescribe them. "Before we use to give them right away; now because of the black box warning, we are much more hesitant," said Sakhrani. And this has also transcended to the parents: "Families are really more hesitant to get aggressive, as well."
Still, Sakhrani asserts that no one knows for sure what the truth is about these medications and any link to increased suicide, saying it is "hard to prove that one is independent of the other. We know that suicidal thoughts are part of severe depression. How do you prove that the medications are the direct cause of the thoughts?"
Sakhrani does point to a phenomenon of "activation," whereupon an antidepressant medication can actually cause a worsening of mood rather than an improvement. It is also well known in clinical circles that it can take weeks for an antidepressant to kick in, and one may not always work, necessitating a switch to another.
Yet, in a multi-faceted approach to a multi-faceted issue, drugs are only part of the equation. "Psychotherapy is a very good option," said Sakhrani. "Cognitive behavioral therapy is a very effective therapy, but not all therapies are equal; there is varied training, and therapists are at different levels."
This highlights the importance of working with the health-care team, to ensure safety in the process and the appropriate setting of therapy goals, with benchmarks of progress.
And most important is to be aware of what is going on with your child(ren). "Be parents: watch and listen," said Sakhrani. "If your child is becoming sad or withdrawn or having other problems, something is wrong. When you are seeing something as a parent that is not right, trust your gut and get help."
This column by HealthDay's Dr. Cindy Haines, managing editor of the Physician's Briefing news service, runs each week in the St. Louis Beacon. Dr. Cindy Haines is managing editor of Healthday-Physician's Briefing and president of Haines Medical Communications Inc., a full-service medical communications and consulting firm. As a board-certified family physician, Haines is well-versed in all areas of health care, with particular interest in fitness, nutrition, and psychological health.