Youth Suicides Increased As Antidepressant Use Fell

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Youth Suicides Increased As Antidepressant Use Fell

Study: Warnings Coincided With Rise

By Shankar Vedantam

Washington Post Staff Writer

Thursday, September 6, 2007; A01

http://www.washingtonpost.com/wp-dyn/content/article/2007/09/05/AR2007090502303.\

html?hpid=topnews

Warnings from federal regulators four years ago that antidepressants were

increasing the risk of suicidal behavior among young people led to a

precipitous drop in the use of the drugs. Now a new study has found that

the drop coincides with an unprecedented increase in the number of

suicides among children.

From 2003 to 2004, the suicide rate among Americans younger than 19 rose

14 percent, the most dramatic one-year change since the government started

collecting suicide statistics in 1979, the study found. The rise followed

a sharp decrease in the prescribing of antidepressants such as Prozac,

Zoloft and Paxil after parents and physicians were confronted by a barrage

of warnings from the Food and Drug Administration and international

agencies.

The data suggest that for every 20 percent decline in antidepressant use

among patients of all ages in the United States, an additional 3,040

suicides per year would occur, said Gibbons, a professor of

biostatistics and psychiatry at the University of Illinois at Chicago, who

did the study. About 32,000 Americans commit suicide each year.

Insel, director of the National Institute of Mental Health, said,

" We may have inadvertently created a problem by putting a 'black box'

warning on medications that were useful. " He added, " If the drugs were

doing more harm than good, then the reduction in prescription rates should

mean the risk of suicide should go way down, and it hasn't gone down at

all -- it has gone up. "

The new finding, published in the September issue of the American Journal

of Psychiatry, is the latest development in a controversy marked by

complex science and passionate advocates. In 2003 and 2004, the FDA issued

a series of warnings that clinical trials had detected an increase in

suicidal thinking among children and adolescents taking a class of

antidepressants known as selective serotonin reuptake inhibitors (SSRIs),

compared with children and adolescents given sugar pills. In late 2004,

the agency called for a " black box " warning on the drugs to call attention

to the potential risk, and expanded it last December to include young

adults.

The warnings led to a broad decline in SSRI prescriptions for all patients

younger than 60, Gibbons said. Prescription rates continued to rise among

those older than 60, and this was the only group in which suicides dropped

between 2003 and 2004, his study found.

The study included the Netherlands, which had a 22 percent decrease in

antidepressant use among children between 2003 and 2005. The suicide rate

among youngsters there increased by 49 percent in that period.

The trend lines do not prove that suicides rose because of the drop in

prescriptions, but Gibbons, Insel and other experts said the international

evidence leaves few other plausible explanations. Previous studies have

shown that U.S. suicide rates are lower in counties where antidepressant

use is higher, and a recent study of 200,000 depressed veterans found that

those taking an antidepressant had one-third the risk of suicide of those

who were not.

Healy, a British psychiatrist who has been critical of the drugs,

disagrees. He said that the increase in suicides was more likely caused by

the growing use of antipsychotic drugs among children rather than a

decline in antidepressant use. " I would be absolutely certain that the

increase is not because kids are not being treated, " he said. " They may

not be getting SSRIs, but they are getting psychotropics. "

The new study was largely funded by the federal government. Pfizer, which

makes Zoloft, provided some money for data collection, Gibbons said, but

was not involved in the study and did not review the results before they

were published.

The FDA required the warnings on the drugs' labels to prompt doctors to

closely monitor patients they put on antidepressants, because of some

evidence that the risk of suicide is highest shortly after treatment

begins. Gibbons said that the decision was misguided and that the

situation called for better education of physicians, not warnings.

Laughren, director of the agency's division of psychiatry products,

said, " FDA is obviously concerned about possible negative impacts of

labeling changes but also feels a strong obligation to alert prescribers

and patients to possible risks associated with the use of

antidepressants. " He added, " We will continue to monitor antidepressant

use and suicide rates, and will take appropriate regulatory actions as new

data become available. "

NIMH's Insel said it is possible that antidepressants are lowering the

risk of suicide overall, even as they increase the risk among a subset of

patients. New research to be published soon examines genetic factors that

may put some patients at particular risk, he added.

If regulators base their decisions on risks alone, he said, " you focus on

that very tiny number of kids who may be at greater risk when they are

treated and you ignore the very large benefit that might accrue to the

other 99.9 percent. "

Insel acknowledged that it may be a while before physicians have tests

that can reliably predict which patients are likely to become suicidal as

a result of the drugs. In the interim, he said, " if I had a child with

depression, I would go after the best treatment but also provide the

closest monitoring. "

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