Behaviour, Depression, Infant and Children | March 22, 2016 | Author: The Super Pharmacist
Parents who have teenagers with major depressive disorder face a challenging decision. Antidepressant medications may provide a solution to their child's depression. On the other hand, antidepressants have been shown to increase the risk of suicidal thoughts in teenage patients with depression. It can be a confusing and difficult decision, but it is a decision that can be made easier by understanding the latest information on the subject.
In 2004, the FDA began to require manufacturers include warnings on antidepressant medications, first on selective serotonin reuptake inhibitors (SSRIs), and soon after on tricyclic antidepressants, and monoamine oxidase inhibitors. The warning cautioned physicians and patients that antidepressants may increase the risk of suicidal ideation and behavior in children's, adolescents, and adults younger than the age of 25. This increased risk of suicidality was of particular concern when starting therapy or when changing the dose of antidepressant.
The decision whether to treat children and adolescents with antidepressants is a question of evaluating risk. Multiple studies have shown untreated or undertreated pediatric depression is associated with an increased risk of suicide. This means that if parents decide not to treat their depressed teenager with antidepressants, they run a certain risk of their child contemplating, attempting, or completing suicide.
On the other hand, the major treatment itself, namely antidepressants, is also associated with increased risk of suicide. In other words, neither option eliminates the risk of suicide in depressed teenagers. One reasonable solution is to determine the lesser of two evils, that is, which decision is associated with less risk of suicidality.
One key to understanding any clinical study is to determine whether the results show an association or causation. Most studies are association studies, mainly because they are easier and less expensive to perform. The authors of these studies can state that two things tend to occur together, or that one is associated with the other. Importantly, association is not causation. To show causation, a prospective, randomised, controlled study is usually required, which is considerably more expensive. Moreover, since suicide is relatively (and thankfully) rare in clinical trials, it makes it very difficult to establish causation even during the course of a prospective, randomised controlled clinical trial. The bottom line of this discussion is that physicians and parents are left to make treatment decisions based on studies showing associations rather than causations.
If one simply considers randomised controlled trials alone, the link between antidepressant use in teenagers and suicide is tenuous. The combined analysis of 24 short term, placebo-controlled trials covering nine antidepressant medications in more than 4400 children and adolescents provided the following:
In a separate meta-analysis of 17 clinical trials including over 3000 children and adolescents, SSRIs or newer SNRIs (serotonin-norepinephrine reuptake inhibitors) increase the risk of suicidal ideation or behaviour by 58%. More importantly, however, this translated into a 1.5% increase in suicidal events compared to an increase in depression remission of 6.8%. Stated another way, remission from depression was 4.5 times more likely to occur than suicidal events in these patients.
Since there is a risk of suicide both with and without drug therapy for depression, a reasonable third option is to pursue psychotherapy, specifically cognitive behavioral therapy (CBT). The Treatment for Adolescents with Depression Study (TADS) tract suicidal behavior in teenagers treated with fluoxetine (an SSRI) or cognitive behavioral therapy or both. The study authors found that suicidal ideation occurred in 15% of patients treated with an SSRI alone compared to 6% for cognitive behavioral therapy alone and 8% for both antidepressant and psychotherapeutic treatments. As before, there were no completed suicides in this study. These results suggest that the risk of suicidal ideation and behavior is lower in patients treated with cognitive behavioral therapy or dual treatment compared to an SSRI alone.
The evidence suggests that there is a slightly increased risk of suicidal thoughts and behaviors in children and adolescents treated with antidepressant medications.
There is no causal evidence to suggest antidepressants increase the risk of completed suicides, however. Pediatric patients and their caregivers should receive thorough counseling from a trained clinician prior to starting antidepressant therapy.
The United Kingdom's Medicines and Healthcare Products Regulatory Agency (MHRA) considers fluoxetine to be the only antidepressant with a favourable risk-benefit profile.
The American College of Neuropsychopharmacology (ACNP) Task Force on SSRIs and Suicidal Behavior in Youth reached a similar conclusion about fluoxetine.
The American Academy of Child and Adolescent Psychiatry (AACAP) considers fluoxetine a first-line medication, but also recommends considering other treatments including cognitive behavioral therapy.
If parents opt for antidepressant treatment, children and adolescents should be started on a low dose and monitored closely during treatment initiation. Likewise, any increase or decrease in the dose of medication should be done under close supervision by mental health professional. Moreover, parents should be especially vigilant for suicidal thoughts or actions at the start of antidepressant treatment and during any dose adjustments.
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