The potential link between the use of certain medications and an increased risk of suicidal thoughts and actions has been a source of significant concern and debate in recent years. Research has been conducted into many medications and their likelihood to trigger suicidal thoughts and behaviors, although most of the attention has centered on the use of antidepressants by children and teenagers.
To date, the U.S. Food and Drug Administration (FDA) has only approved one antidepressant – fluoxetine (Prozac) – as a treatment for depression in children age 8 and older. However, after a drug has been approved by the FDA, any physician may prescribe it to any patient for any purpose, a common practice known as “off-label” prescription. In this manner, physicians have prescribed antidepressants other than fluoxetine to children.
A recent FDA analysis concluded that short-term therapy with the latest antidepressants also appears to increase suicidal thoughts and behaviors in young adults up to the age of 25. A U.S. panel has advised the FDA to amend the black box warning on antidepressant medications to reflect this new information. However, there is no evidence demonstrating that the use of antidepressants actually increases the risk for completing suicide.
Clinical studies of one such antidepressant called paroxetine (Paxil) indicated that children who took the drug were at increased risk for suicidal thoughts and actions compared to children who took a placebo (sugar pill).
As a result, the FDA investigated these findings. In October 2004, the agency issued a strong caution advising the public that antidepressants may increase the risk of suicidal thinking in some children and teens. Today, all antidepressants carry a “black box” warning about this potential danger.
Although the FDA does not prohibit the use of antidepressants in children, it has urged close monitoring of youths who use these drugs. Parents, teachers and others are asked to watch for any unusual changes in behavior after a child begins taking antidepressants. If these shifts occur, parents are urged to promptly notify the child’s physician.
The potential link between antidepressant use and suicidal thoughts is not fully understood, although several theories have been proposed. For example, one popular theory suggests that antidepressants cause improvements in the physical symptoms of depression (such as relieving fatigue), before providing relief from the emotional symptoms of the illness, such as sadness. This may give individuals who had previously contemplated suicide the energy to act on their impulse.
It is important to note that in the vast majority of cases, people who take antidepressants, including children, are far more likely to be helped by the medications than hurt by them, including children. The FDA urges parents to consider several factors before deciding whether or not antidepressants are appropriate for their child. These include weighing the potential risks of not treating the child with medication against the smaller risk of using the medication.
In addition, the FDA and other experts urge parents of children who already take antidepressants to tell their child to not stop taking these drugs without first consulting a physician.
The FDA maintains ongoing monitoring of drugs and their effects. The agency also recently required the manufacturer of the attention-deficit hyperactivity disorder (ADHD) drug atomoxetine (Strattera) to include a label warning that this drug may increase the risk of suicidal thoughts and behaviors in children.
Some experts have similar concerns about the use of other medications, such as benzodiazepines and anticonvulsants. The therapeutic use of many other non-psychiatric medications can also be associated with depression and an increase risk for suicide.
About medications & suicide risk
Many medications used to treat mental illnesses and other conditions may have side effects on a patient’s emotional health. In recent years, concerns have grown over a potential link between the use of certain medications – chiefly the use of antidepressants among children and teenagers – and an increased risk of suicidal thoughts and behaviors. The U.S. Food and Drug Administration (FDA) has issued its strongest caution (known as a “black box” warning) alerting the public to this increased risk in children and teens who use antidepressants.
To date, the FDA has only approved one antidepressant – fluoxetine (Prozac) – as a treatment for depression in children age 8 and older. However, after a drug has been approved by the FDA, any physician may prescribe it to any patient for any purpose, a common practice known as “off-label” prescription. In this manner, physicians have prescribed antidepressants other than fluoxetine to children.
The controversy over the use of antidepressants in children began with clinical studies of the antidepressant called paroxetine (Paxil). These studies seemed to indicate that children who took the drug were at increased risk for suicidal thoughts and actions compared to children who took a placebo (sugar pill).
The FDA investigated these claims by examining all the available data on the use of antidepressants by children and teens. The results of 24 independent small studies of thousands of children and teens using antidepressants found that there was an increase of suicidal thoughts among youths taking the medications. Although none of the youths in the study actually killed themselves, the FDA issued its ruling in October 2004 as a precaution.
A recent FDA analysis concluded that short-term therapy with the latest antidepressants also appears to increase suicidal thoughts and behaviors in young adults up to the age of 25. A U.S. panel has advised the FDA to amend the black box warning to reflect this new information. The panel also endorsed the FDA’s proposal to inform patients that the risk of suicidal thoughts and behaviors associated with antidepressant use begins to decline after a patient reaches age 30, and that the drugs appear to protect older patients, especially those over age 65, against suicidal behavior.
The FDA advisory and new studies which suggest that some antidepressants reduce suicidal thoughts and behaviors in adolescents and adults have generated great controversy. Some experts voice significant doubts about the true existence of a link between antidepressants and increased risk of suicide, and researchers continue to examine this issue. Furthermore, though the FDA requires the black box warning on all antidepressants, there is no research demonstrating that the tricyclic antidepressants are associated with increased suicidal thoughts in children, adolescents, or adults.
The potential link between antidepressant use and suicidal thoughts is not fully understood. In some cases, it may be because antidepressants often cause improvements in the physical symptoms of depression, such as fatigue, before providing relief of emotional symptoms, such as a sad mood or anxiety. This may give individuals who had previously contemplated suicide the energy to act on their impulse. In other cases, patients who take antidepressants may have undiagnosed bipolar disorder, and the medication may trigger an episode of manic behavior that leads to self-injury. Finally, antidepressants may cause side effects such as anxiety, agitation, hostility and restlessness that deepen depression, leading to suicidal thoughts. For all these reasons, it is important for people taking antidepressants to be monitored for unusual behavior.
It is important to note that in the vast majority of cases, people who take antidepressants are far more likely to be helped by the medications than hurt by them. A recent study by the National Institute of Mental Health found that suicidal thinking decreased in 71 percent of 439 adolescents who were treated with a combination of fluoxetine and psychotherapy. Meanwhile, just 6.94 percent of participants threatened suicide or actually made a suicide attempt.
In addition, parents of children who take antidepressants should tell their child to not stop taking these drugs suddenly. A physician should always be consulted before a patient stops taking antidepressants because withdrawal symptoms may develop and patients may be at risk of their mental illness (such as depression, obsessive-compulsive disorder [OCD] or anxiety disorder) returning once therapy is ended.
Experts have cautioned that other drugs may also increase the risk of suicidal thoughts and behaviors. These include:
- Atomoxetine (Strattera). This drug, used to treat attention-deficit hyperactivity disorder (ADHD), may increase the risk of suicidal thinking in children and adolescents. The FDA recently required the drug’s manufacturer to include a label warning that this drug may increase the risk of suicidal thoughts and behaviors in children.
- Benzodiazepines. A Canadian study found what is characterized as a statistically significant link between attempted suicide and the use of benzodiazepines, which slow down the central nervous system (CNS) and are used for anxiety and insomnia. The risk appears to be greatest for patients who do not use antidepressants, young patients and males.
In addition, the FDA recently asked pharmaceutical companies to look into claims that certain anticonvulsant drugs may increase the risk of suicidal thoughts and actions in patients who take these medications. The companies have been asked to re-examine data compiled during clinical trials and to look for a link between anticonvulsants and suicide risk.
Previously, the FDA made a similar request for a re-examination of data on the part of the manufacturers of antidepressant drugs. The results of that survey resulted in the agency’s decision to issue its “black box” warning regarding antidepressants.
Tips for parents on medications & suicide risk
The U.S. Food and Drug Administration (FDA) urges parents to consider several factors before deciding whether or not antidepressants are appropriate for their child. In many cases, antidepressants remain a vital component in treating youths with depression. For example, antidepressants may be beneficial for children whose depression is severe enough that they have thoughts of killing themselves or who engage in behaviors that appear to indicate suicidal tendencies. In fact, failing to treat youths with antidepressants often may pose a far greater risk of suicide than the relatively small risk that has been reported by some patients who used the medication.
Parents should also weigh certain risk factors before deciding whether or not a child should use antidepressants. Youths with bipolar disorder, a family history of bipolar disorder or a family history of attempted suicides may be at highest risk for suicide attempts associated with antidepressant use, according to the FDA.
Special precautions should be taken if parents and a physician agree that a child should begin taking antidepressants. Children and teens who use antidepressants must be closely monitored. Parents, teachers and others close to the child are urged to closely observe the patient and to watch for sudden shifts in mood or behaviors. This monitoring is especially important when a child starts using a new antidepressant or the child’s dosage level is altered. Once a child begins an antidepressant regimen, parents are urged to take their child to the physician weekly for the first month, every two weeks for the second month and again at the end of 12 weeks. Visits to a physician may be more frequent if problems arise.
Parents should immediately contact a physician if their child or teen displays any of the following symptoms while taking antidepressants:
- New or additional thoughts of suicide, or suicide attempts
- New or increasing depression or anxiety
- Agitation or restlessness
- Aggressive, angry or violent behavior
- Mania or hypomania
- New or increasing irritability
- Panic attacks
- Other unusual changes in behavior (e.g., giving away possessions)
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients’ families may wish to ask their doctor the following questions related to suicide risk:
- How can I determine whether or not antidepressants are appropriate for my child?
- Does my child have any other options, such as psychotherapy?
- If my child takes antidepressants, what signs and symptoms should I look for that might indicate a problem?
- What signs and symptoms should I tell my child’s teachers, coaches, etc., to look for?
- How often should my child be checked by a physician?
- My child has been taking antidepressants, but I’m now concerned about the potential dangers. Should my child stop using these drugs?
- My teenager has attempted suicide before. Are antidepressants recommended?
- Should my child see a therapist in addition to taking medications? Will the therapist be able to identify suicidal behavior?
- Are any other medications a concern for suicidal behavior in teens?
- Is one antidepressant better than another for children?