question and answer
Kids, antidepressants and suicide
August 2011
Please review SSRIs in the pediatric population. Helene Bouvier, MD, Montreal, QC

The use of SSRIs in the pediatric population remains somewhat controversial for two reasons. First, the evidence for the efficacy of SSRIs in kids is less clear than in the adult population, and second the link between the use of SSRIs and suicide is still controversial. The most evidence in support of SSRIs is for fluoxetine with weaker evidence for escitalopram, sertraline and citalopram. Paroxetine and venlafaxine didn’t seem to show a significant difference from placebo. Statistically significant effects increase with age and severity of illness so SSRIs appear to have a lower placebo response in depressed adolescents and an even lower one in adults.

The relationship between increased suicidality and depression in children has yet to be confirmed or understood and remains very controversial. Suicidality can be measured in many different ways from simple transient ideation to plans to non-lethal self-harm to completed suicide, making it difficult to determine what risk is being assessed. Some studies do show an increase in suicidality following the initiation of anti-depressant, most apparent in the first few weeks of treatment. Other studies show a decrease.

The increased risk may be associated with certain at-risk subsets of the depressed patient population, e.g., those with severe depression with psychomotor retardation who show an initial increase in energy without the lifting of mood. Those suffering bipolar disorder may start showing psychomotor agitation before a change in mood. Others might get side effects which would exacerbate insomnia or lead to activation symptoms that could initially exacerbate suicidality. Some studies have suggested that there may be a very small population for whom antidepressants actually make the depression worse.

In the majority of cases, however, antidepressant use seems to be protective. The best evidence for this is historic: with the increased use of antidepressants following the introduction of SSRIs, the completed suicide rate went down. Evidence now shows that, when the black box warning was introduced (warning of suicidal ideation) and the adolescent use of antidepressants went down as a result, completed suicide rates increased in the U.S. and the Netherlands.

Severe depression in the pediatric population continues to be a serious illness which can lead to suicide. On the whole treating the illness with medication continues to be indicated. Recommendations are that a good history be done to look for risk factors, including bipolarity and previous response in the patient or family members, psychoeducation of the patient and the family, as well as close monitoring — particularly at the outset of treatment — for the emergence of danger signals such as agitation, hypomanic symptoms or exacerbation of depression.

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