Have Suicide Rates in Adolescents Gone Up?

Chris Ballas, M.D. Health Guide
  • A perplexing finding about suicide rates:

    As many know, the CDC has reported that the suicide rates have jumped since 2004, especially in young people, and especially in girls aged 10-14. While this is noteworthy in itself, it is also near the time when the first black box warnings concerning the link between antidepressants and suicide came out.

    The controversy about antidepressants and suicide has a long history, but it can be summarized with a few key points:

    First, even in the early psychoanalytic days, experts observed that people often attempted suicide as they began to improve from depression. Consider that suicide attempts are often highest immediately following discharge from a hospital. The explanation was that their motivation, or cognition, improved before their sadness; so while at first they were too depressed to do anything-- including suicide, as they began to improve they got well enough to plan and execute a suicide.

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    Next, in the 1970s, came the observation that antidepressants (specifically, tricyclic antidepressants) might flip a bipolar person into mania. This "antidepressant-induced suicide" link hasn't been found with SSRIs (this doesn't mean it can't happen-- it just hasn't been observed in studies) but it supports the semantic argument that improvement in depression might result first in an improvement in energy, without an accompanying improvement in sadness.

    Finally, and more recently, a review of old clinical trials of SSRIs indicated that rates of suicide attempts that did not result in death were higher in patients taking medication than in the placebo group. These rates are frequently quoted as "double the rate," but this can be misleading since it is specifically an increase of about 2% (placebo group) compared to 4% on SSRIs, or 20 attempts vs. 40 attempts out of 2000 patients in each group. It is worth noting that patients in clinical trials are screened for suicidality, so these patients are, conceivably, less suicidal than the average depressed person.

    The flip side of the argument is twofold. First, all of the above refer to suicide attempts, not actual deaths, which may be very different phenomenologically. Second, since the black box warnings have been put in effect - and as they were initially targeted towards young patients - patients might avoid antidepressants, with the resultant effect of increased suicides. Is that the cause? It's hard to say, but certainly one would have to at least show that they were, indeed, used less, to even make that claim. So far, all we know is that there were black box warnings - not whether or not they actually kept anyone away.

    While antidepressants have not been shown to cause suicide, it is worth mentioning that they have never been shown to prevent them; the rate of suicide on or off medications is about the same. The only medications that have been shown to reduce suicidality are lithium and clozapine. And there's no clear reason why they should do this.

Published On: October 02, 2007