Suicide in children and adolescents: Underlying depression, or antidepressant medication?

Suicide is-or should be-a major concern for pediatrics. It ranks third as a cause of death for children between 10 and 14 years of age. So when reports surfaced linking suicidality in children and adolescents to antidepressant medications, especially selective serotonin reuptake inhibitors (SSRIs), the US Food and Drug Administration (FDA) responded in October, 2004, by mandating a so-called black box warning on the label for these drugs.

The warning appears to have effectively discouraged prescription of SSRIs for pediatric patients. In the year since the warning first appeared, pediatric prescriptions for SSRIs decreased by about 10%, according to data presented at a recent meeting of the American Academy of Child and Adolescent Psychiatry.

But a new study published in the November issue of the American Journal of Psychiatry questions whether the warning was really a reasonable reaction. When researchers looked at county-by-county suicide rates among 5- to 14-year olds between 1996 and 1998 and matched that data with prescription rates for SSRIs in the same counties, they came up with a rather startling result: The counties with the highest rates for prescribing SSRIs to children and teenagers had the lowest suicide rates for that age group.

It is well to remember that the data on which the FDA based its decision dealt not with completed suicide, but with "suicidality"-a state of mind that can change from moment to moment-points out the study's lead author Robert Gibbons, professor of biostatistics and psychiatry at the University of Illinois in Chicago. The take-home message may be that youngsters with untreated depression are at high risk for suicide. Sufficient data to show how that risk compares with the suicide risk that may be a side effect of SSRI treatment are not available.