CORRESPONDENCE

Adolescent suicide and SSRI antidepressants

DEAR SIR,
I agree with Dudley et al. that the controversy in recent years regarding the safety and efcacy of SSRIs and related medications in children and adolescents has created considerable uncertainty for child and adolescent psychiatrists. With an estimated point prevalence of 46%, adolescent depression is a major public health concern and contributes to considerable morbidity in terms of pervasive and prolonged functional impairment, increasing the risk of suicidal behaviour and increasing the risk of psychopathology into the adult years. Warnings about an increase in suicides in adolescents treated with SSRIs has been very troublesome, but no compelling data are available to substantiate these claims. There have been several studies of randomized control data, which support these claims. However, there have also been studies that counter them. In child psychiatry, as in adult psychiatry, the use of combined treatments, namely medication with talk therapy, has been shown to be of benet

rather than any treatment alone. We in Australia, as in most other countries, run the risk of prescribing medication without a thought for the humanity of these young people and the environment in which they grow. If we continue this practice, we run the risk of patients using the medications we prescribe to harm themselves. This is not the concern of those who are against antidepressant use they believe that a majority of adolescents with major depression will get better with psychosocial treatments. I agree with the authors that antidepressants reduce the risk of suicide attempts and that most suicides in adolescents have occurred without the benet of treatment with antidepressants. From a clinicians point of view (I am a trained psychotherapist and child psychiatrist), the SSRIs have been a boon to psychiatry, considering the frequent side effects of the tricyclics, not to mention the risk of tricyclics if taken in overdose. I have experienced one adolescent suicide in 25 years of private practice the patient, who met criteria for major depression, killed herself by violent means. That patient did not have the benet of taking antidepressants, because she believed that she did not need them, and she did not have family support. I rmly believe that psychosocial treatments are the rst line of treatment, but I also believe that antidepressants are the rst line when a good diagnostic and psychosocial formulation lead to a positive diagnosis. However,

antidepressants should not be used as the only line of treatment. More effort needs to be put into this area of research, before we conclude with certainty that the SSRIs lead to increased suicidal risk and completed suicide in adolescents. However, the means to achieving this would mean delaying the onset of meaningful treatment in nonresearch settings of adolescents with moderate to severe major depression when placebo in randomized control trials will not be ethical or clinically appropriate.

REFERENCES
1. Dudley M, Goldney R, Hadzi-Pavlovic. Are adolescents dying by suicide taking SSRI antidepressants? A review of observational studies. Australasian Psychiatry 2010; 18: 242245. 2. Jureidini JN, Doecke CJ, Manseld PR et al. Efcacy and safety of antidepressants for children and adolescents. British Medical Journal 2004; 328: 879883. 3. Kessler RC, Avenerol S, Ries Merkanges K. Mood disorders in children and adolescents: an epidemiological perspective. Biological Psychiatry 2001; 49: 10021014. 4. Weismann MM, Wolk S, Goldstein RB. Depressed adolescents grown up. Journal American Medical Association 2000; 281: 17071713. 5. Bridge JA, Iyengar S, Salary TS et al. Clinical responses and risk for reported suicidal ideation and suicide attempts in paediatric antidepressant treatment: a meta-analysis of randomized controlled trials. Journal American Medical Association 2007; 297: 16831696. 6. Kennard BD, Silva SG, Mayes TL. Assessment of safety and long term outcome of initial treatment with placebo in TADS. American Journal Psychiatry 2009; 166: 337344.

Joan Haliburn Sydney, NSW

Australasian Psychiatry Vol 18, No 6 December 2010

doi: 10.3109/10398562.2010.502574 2010 The Royal Australian and New Zealand College of Psychiatrists

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