The findings challenge recent claims that Prozac, Paxil, Zoloft, and the other drugs in the class known as selective serotonin reuptake inhibitors (SSRIs) increase suicide risk.
As a result of such fears, physicians in the United Kingdom can no longer prescribe the antidepressants to new patients under the age of 18. And in the U.S., the FDA recently ruled that SSRIs and other antidepressants must carry the strongest warning about suicide risk on their package information.
The government actions and the negative press have led to a dramatic drop in SSRI use among children and adolescents. UCLA psychiatry professor Julio Licinio, MD, who conducted the review, argues that the under-treatment of depression poses a much greater threat than the drugs do.
"It is true that in a small number of cases these drugs could make a person more prone to suicide," Licinio tells WebMD. "But by far the biggest cause of suicide is untreated depression. My concern is that when people don't get the treatment they need, the suicide rate is going to start going up again."
Licinio is not alone. In a news conference held Tuesday, representatives of the nation's top mental health and suicide prevention organizations expressed similar concerns. They cited recent data showing a 16 percent decline in antidepressant use among children and adolescents in the last quarter of 2004, compared to the same time period a year earlier.
"The general clinical consensus is that when used appropriately, the benefits of SSRI antidepressants far outweigh the potential risks," says child and adolescent psychiatrist and coalition chairman David Fassler, MD, who represented the American Psychiatric Association.
"We really can help most children and adolescents who suffer from psychiatric disorders like depression," he tells WebMD. "The real tragedy is that there are still so many young people who don't get the treatment that they need and deserve."
11th Leading Cause Of Death
Licinio and colleagues reviewed studies published between 1960 and 2004. They found that suicide rates rose steadily between 1960 and 1988 — the year that Prozac became the first SSRI to be approved for use in the U.S. After 1988, suicide rates began a continuing decline.
In 1988, suicide was the 8th leading cause of death in the U.S., accounting for 12.4 deaths per 100,000 people. By 2002 it was the 11th leading cause of death, with 10.6 suicides for every 100,000 people.
When they reviewed studies in which blood samples from suicide victims were screened, the researchers found that fewer than 20 percent showed evidence of recent antidepressant use. The analysis is reported in the February issue of the journal Nature Reviews Drug Discovery.
"Our findings strongly suggest that these individuals who committed suicide were not reacting to their SSRI medication," Licinio notes. "They actually killed themselves due to untreated depression. This was particularly true in men and in people under 30."
New Users Most Vulnerable
Licinio tells WebMD that antidepressant-related suicide risk can be minimized by monitoring patients closely during the initial phase of drug treatment. That is when they are most vulnerable, he says, because the drugs tend to relieve symptoms of lethargy before they start to improve a patient's sense of well-being.
"The last symptom that tends to improve when a person begins antidepressant treatment is the feeling of despair," he says. "So in this initial period of treatment they may be more at risk because they have more energy to act on their feelings and are still depressed."
He adds that children and teens may be especially vulnerable because they tend to act more impulsively than adults.
Sources: Licinio and Wong, Nature Reviews Drug Discovery, February 2005; vol 4: pp 165-171. Julio Licinio, MD, professor of psychiatry and medicine, UCLA; researcher, UCLA Neuropsychiatric Institute, Los Angeles. David Fassler, MD, child and adolescent psychiatrist, Burlington, Vt.; clinical associate professor of psychiatry, University of Vermont College of Medicine; trustee-at-large, American Psychiatric Association. News release, Medco Health Solutions Inc.
By Salynn Boyles
Reviewed by Michael W. Smith, MD
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