“Antidepressant suicide warnings ‘may have backfired’,” BBC News reports.
During 2003 and 2004, there were high-profile media reports in the US that children and adolescents who were prescribed antidepressants had an increased risk of suicidality (thoughts and attempts).
This led the Food and Drug Administration (FDA), which is responsible for regulating drugs in the US, to issue warnings about all antidepressants (these warnings were modified in 2007).
This latest research studied antidepressant-prescribing patterns for 10 million people during the time period, as well as reported suicide attempts (both successful and unsuccessful).
The study found that two years after the warnings, antidepressant prescriptions for adolescents had decreased by almost a third, and by a quarter in young adults.
There was also a corresponding increase in drug overdoses of a fifth in adolescents and a third in young adults over the same period.
Thankfully, there was no change in the overall rate of completed suicides, as the majority of these overdoses did not prove fatal.
UK recommendations on children and adolescents
In the UK, the use of antidepressants is not usually recommended in children and adolescents under the age of 18.
Concerns have been raised that their use could affect the development of the brain in children and adolescents.
An exception is usually only made if:
- the person being treated has failed to respond to talking therapies such as cognitive behavioural therapy (CBT) and
- the person being treated will continue to receive talking therapies in combination with antidepressants
- the treatment is supervised by a psychiatrist
If an antidepressant is recommended, then fluoxetine (Prozac) is usually the first choice.
Where did the story come from?
The study was carried out by researchers from Harvard Medical School, Boston; Group Health Research Institute, Seattle; the University of Washington; Center for Health Policy and Health Services Research, Detroit; Center for Applied Health Research, Texas; and several Kaiser Permanente Research Institutes across the US. It was funded by the National Institute of Mental Health and the Health Delivery Systems Center for Diabetes Translational Research.
The media’s coverage of the story has been fair, with the BBC providing comments from experts highlighting the powerful impact the media can have on prescription practices.
A case could be made that some sections of the media have been guilty of scaremongering in regards to the potential risks of treatment or intervention, without considering the benefits. The most infamous example of this in recent years were the scare stories about the MMR vaccine being linked to autism – a claim that turned out to be baseless.
What kind of research was this?
This was an ecological study looking at trends in antidepressant use, suicide attempts and completed suicides in young people before and after the FDA issued warnings about potential risks of these drugs.
It aimed to see if there were any changes according to age group before and after the FDA issued the warnings about all antidepressants increasing suicidality (thoughts and attempts) in adolescents over the 2003 to 2004 period.
They also wanted to see if there were any further changes when this warning was extended to include young adults in 2007.
The researchers report that the FDA warning was based on a meta-analysis of studies, which showed that the relative risk for suicidal thoughts or behaviour for young people on antidepressants compared to a placebo was almost double.
The researchers wanted to investigate if the warnings and media coverage were associated with changes in antidepressant use and suicidal behaviour.
An ecological study is a study of a population or community, rather than a study of individuals. Common types of ecological study include geographical comparisons, time-trend analysis or studies of migration.
A before and after study is a comparison of particular characteristics in a population, before and after an intervention or event. An example of this would be a public health campaign, such as a healthy eating campaign.
What did the research involve?
Data was obtained from 11 healthcare organisations that care for around 10 million people in 12 US states. This included inpatient and outpatient details, antidepressant prescriptions, drug overdoses and suicide deaths for all:
- adolescents aged 10 to 17
- young adults aged 18 to 29
- adults aged 30 to 64
They compared the levels from 2000 to 2003 (before the warnings) and up to 2010 (after the warnings).
What were the basic results?
The study included 1.1 million adolescents, 1.4 million young adults and 5.0 million adults.
In 2006, compared to 2003 to 2004 when the warnings were first issued:
- antidepressant use was reduced in adolescents by -31.0% (95% [CI] -33.0% to -29.0%)
- antidepressant use was reduced in young adults by -24.3% (95% CI -25.4% to -23.2%)
- antidepressant use was reduced in adults by -14.5% (95% CI -16.0% to 12.9%)
- drug overdose of psychotropic medication (medication that can affect the working of the brain) increased in adolescents by 21.7% (95% CI 4.9% to 38.5%)
- drug overdose of psychotropic medication increased in young adults by 33.7% (95% CI 26.9% to 40.4%)
- there was no significant increase in drug overdose in adults
- there was no increase in completed suicides in any group
There was no additional change in antidepressant use or suicidality after the warning was modified in 2007. After 2008, the level of antidepressants being prescribed began to increase again.
How did the researchers interpret the results?
The researchers concluded that “safety warnings about antidepressants and widespread media coverage decreased antidepressant use”, and that there were “simultaneous increases in suicide attempts among young people”. Therefore, they say “it is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting”.
This study saw a decrease in the prescribing of antidepressants in adolescents and young people, and an overall increase in psychotropic medication overdoses. Thankfully, however, there was no change in completed suicide rates, following the FDA’s warnings that they can increase suicidality.
Strengths of this study include the very large number of people included in the analysis. The researchers used the same parameters for assessing antidepressant prescriptions, overdoses requiring medical attention and death due to suicide throughout the study period. Although this will not capture all of the attempted overdoses, the data collection was consistent, so trends in the rates should be comparable.
However, the authors report several limitations, including the fact:
- they could only take into account overdoses that required medical attention
- the sample was almost exclusively of people with medical insurance, so the results may not be applicable to uninsured people in the US (who tend to be poorer and/or come from an ethnic minority)
Further limitations of this study are that it looked at the population as a whole and did not look at any difference according to:
- sex, race, ethnicity or socioeconomic status
- diagnosis or severity of illness
- other confounding factors, such as the recession
The study only looked at the incidence of antidepressant use, psychiatric drug overdose and number of completed suicides across the whole population. The study design means that it was not possible to link any of these factors together. For example, it did not measure how many people taking antidepressants took an overdose and how many completed suicide. Therefore, although this study is interesting from a population basis, the results cannot be directly applied to individuals.
In addition, the study has only looked at overdose and suicide as outcomes. It did not examine the length of illness, impact or quality of life – all of which may be improved through the appropriate use of antidepressants.
The treatments for depression and reducing suicidal ideation needs to be tailored to the individual and may include antidepressants, talking therapies, increased social support and practical help. Antidepressants remain an important part of treatment for depression and other mental health problems, and should not be stopped abruptly.
As the modified FDA recommendation in 2007 puts it, a balance needs to be struck between the potential increased risk of suicidal ideation when commencing antidepressants and the risks of suicide if antidepressants are not used.
Close supervision and awareness of the risks should be taken into account when antidepressants are first prescribed.
Current UK recommendations state that if antidepressants are recommended for a person under the age of 18, they should be used in combination with a talking therapy, such as cognitive behavioural therapy (CBT), and not as the sole treatment.
If you are suffering from suicidal thoughts, it is advisable to see your GP or to call a helpline such as the Samaritans, on 08457 90 90 90.
Read more about getting help if you are thinking about suicide, as well as spotting the warning signs of suicidal thinking and behaviour in others.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.