Healthy Skepticism Library item: 8320

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Publication type: news

Smith M.
Teen Suicide Spike Linked to SSRI Black Box
MedPage Today 2007 Feb 6
http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb2/5005#ayk

Notes:

See comment by Sara Bostock

Full text:

By Michael Smith, Senior Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
February 06, 2007

ATLANTA, Feb. 6 — Teen and childhood suicides rose sharply in 2004, for the first time in more than 10 years, and some are linking this to a reduced use of antidepressants that year because of black box label warnings mandated by the FDA. Action Points

Explain to interested patients that a statistical picture of the U.S. shows that teen suicides spiked sharply upwards in 2004 — a time that coincided with increased concern about the use anti-depressants by youngsters.

Caution that the statistical survey does not draw any conclusions about the cause of the increase, and note that other factors — such as lack of access to care — may also play a role.
According to figures compiled by the CDC there were 1,985 suicides among those ages 10 through 19 in 2004, compared with 1,737 in 2003.

That’s a rate of 2.6 per 100,000, up from 2.2 per 100,000 the year before, according to the Annual Summary of Vital Statistics, published in the February issue of Pediatrics.

Overall, the death rate from suicide increased by 18.2% — a change that was deemed “unacceptable” by David Shern, Ph.D., president of Mental Health America.

Dr. Shern said it’s premature to draw conclusions about the cause of the increase, but noted that it coincided with the FDA’s warning that selective serotonin reuptake inhibitors (SSRIs) had been linked to suicidal thoughts in young people.

The warnings created a barrier to treatment “by scaring young people and parents away from care” that may be linked to the rise in suicide, Dr. Shern said in a statement.

Charles Nemeroff, M.D., Ph.D., of Emory University School of Medicine here told reporters he has no doubt that the warning contributed to the suicide increase.

“The concerns about antidepressant use in children and adolescents have paradoxically resulted in a reduction in their use, and this has contributed to increased suicide rates,” Dr. Nemeroff said.

Noting that the adolescent suicide rate had been falling, David Fassler, M.D., of the University of Vermont in Burlington, Vt., called the new data “very disturbing.”

“The sudden increase in the adolescent suicide rate,” Dr. Fassler told reporters, “corresponds to the significant and precipitous decrease in the use of SSRI antidepressants in this age group.”

He said there are no data showing that SSRIs increase the risk of suicide and “the current data suggest that the decreased use of these medications is, in fact, associated with an increase in actual deaths attributable to suicide.”

But the warnings may not be the only reason for the spike, according to Bernadette Melnyk, Ph.D., R.N., of Arizona State University in Phoenix. She told reporters the U.S. is short about 30,000 child psychiatrists “so the gaps in mental health services for those children and youth who need them are huge.”

She said that one in four teens has a mental health problem and only about a quarter of them are treated.

Aside from the teen suicide numbers, the survey presented a statistical grab-bag, including:

A record high life expectancy. The expectation of life at birth reached 77.8 years for all gender and race groups combined.
Declining death rates for nine of the 15 leading causes, including heart disease (down by 6.6%), cancer (down by 2.3%), strokes (down by 6.5%), and influenza and pneumonia (down by 10.0%).

The statistical survey noted that most of the causes of death among youngsters remained unchanged, with the exceptions of suicide and of influenza and pneumonia, which fell by 40%.

Overall, 25,325 children and adolescents died in 2004, 44% of them from unintentional injuries, according to Brady Hamilton, Ph.D., of the CDC.

The death rate for youngsters was 32.7 per 100,000 populations, slightly lower (0.9%) compared with the 33.0 in 2003.

Over all age groups, the death rate was 816.5 per 100 000 population, a 3.0% decrease from the final 2003 rate of 841.9. All told, 2,397,615 Americans died in 2004.

As for births, the survey found, the excess of birth over deaths in 2004, was slightly more than 1.7 million, while the preliminary data for 2005 show 4,140,419 births, an increase of about 1%.

The survey also found:

The general fertility rate in 2005 was 66.7 births per 1,000 women ages 15 to 44, which is the highest level since 1993.
The birth rate for teen mothers — those 15 to 19 years — fell by 2% between 2004 and 2005 to 40.4 births per 1,000 women, the lowest seen in the 65 years for which there are good data.
The birth rate for women 30 years old rose in 2005 to levels not seen in almost 40 years.
Pronounced differences in infant mortality rates by race and Hispanic origin continue, with non-Hispanic black newborns more than twice as likely as non-Hispanic white and Hispanic infants to die within one year of birth.
Childbearing by unmarried women also surged to historic record levels for the United States in 2005 — to 1,525,345, compared with 1,470,189 in 2004.
The caesarean-delivery rate rose by 4% in 2005 to 30.2% of all births, another record.

The authors reported they have no relevant financial relationships.

Primary source: Pediatrics
Source reference:
Hamilton BE et al. “Annual Summary of Vital Statistics: 2005” Pediatrics 2007;119:345-60.

Contribute your own thoughts…

Sara Bostock, Patient Advocate, MA, MBA – Feb 07, 2007
I am interested that you do not cite where you have the information that antidepressant usage was actually down in 2004. In fact reports that I have seen are mixed. Medco does report a slight decrease in 2004; IMS Health, however, actually reports an 8% increase in the first 6 months of 2004 over 2003. It was in fact because of the IMS report which was presented at the FDA hearing in September 2004 that the advisory committee’s fears regarding “untreated depression” were somewhat allayed and thus they voted for the black box. (I was there.) Thus for 2004 at least it is not even clear that antidepressant usage was down at all so to assert a link between usage and suicide rate is tenuous. At best, these are sweeping correlations you are making regarding antidepressant usage and suicide rate when there could be countless other factors at work leading to a rise in suicide including a rise in atypical antipsychotic use and polypharmacy both of which could contribute to increased risk. Withdrawal from antidepressants also increases suicide risk if not done properly and few professionals offer wise guidance to this process. Black box warnings might indeed have increased the risk of withdrawal and discontinuation induced suicides.

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Scott D. Mendelson, M.D., Ph.D. – Feb 07, 2007
I agree with Dr. Nemeroff that the black box warning has frightened away the parents of children that would benfit from antidepressants. Bernadette Melnyk, Ph.D., is also correct in stating that the lack of well-trained child psychiatrists is contributing to the high suicide rate in children. What would be important to consider is if the shortage of child psychiatrists existed before the precipitous black box warning and the sharp increase in the suicide rate among children. I suspect that the shortage has existed for many more years, and that the black box warning can thus be seen as being primarily responsible for this terrible upturn. The black box warning probably became an issue because people that don’t know what they are doing throw antidepressants at anyone with tears in their eyes. Unfortunately, many of these patients have Bipolar Disorder, and not unipolar depression. This activates dysphoric hypomania and suicide.