Sunday, September 20, 2015

Teens, Anti-depressants, and a bit of context

Recently, there has been increasing media attention toward use of antidepressant medications to treat depression in adolescents. On August 3, 2015 an article was published in the New York Times arguing that antidepressants are safe and should be used more widely in the treatment of depression in young people (here's the link). On September 16, 2015, an article was published, also in the New York Times, alerting the public that a recent study identified Paxil (an antidepressant) as potentially dangerous for young people based on a re-analysis of an old study (here's the link to that article). 
Both of these articles were well-written and convey interesting information and interpretations of the science involved in evaluating treatments for mental illness. However, neither article provides the context within which these findings should be interpreted.  As a result, we are being distracted from the real problem: Depression is a life-threatening illness.

Why would antidepressants be unsafe for youth? 

Currently, there is an FDA black box warning on antidepressant medications. This first sentence reads, "Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders." Let's unpack this. This warning was developed following publication of a study that examined changes in suicidal thoughts and behavior for more than 100,000 youth undergoing antidepressant treatment trials for depression across more than 300 studies. They found that 2% of youth taking the placebo medication, but 4% in people taking the antidepressant, reported suicidal thoughts or behaviors. 

There are two important points to be made about the result of this study. First, the term suicidal thinking and behavior is misleading. Thoughts about suicide are common in depression, and more common among young people than the world likes to acknowledge. There were no differences in suicide completions between the two groups, only increases in thoughts related to suicide. Thoughts can be addressed in therapy. The truth is that a person with depression should see a mental health professional once per week during treatment, regardless of whether they are on antidepressants or not. For this reason, the best practices for treating an adolescent with depression include weekly visits with a psychologist, and bi-weekly to monthly visits with a psychiatrist. Unfortunately, among all of the young people with depression today, half of them are receiving no treatment, and those who are receive antidepressant medications from their primary physician, instead of a psychiatrist, which comes with its own set of risks. These risks are best managed by seeking mental health professionals, psychologists and psychiatrists, who specialize in treating children and adolescents.  

The second point to be made is that 4% is still low. This black box warning is quite misleading, as many statistics can be. The results of this study could be presented, accurately, by saying that youth taking antidepressants are twice as likely to have suicidal thoughts than depressed youth taking a placebo medication. Saying it this way is alarming. However, one could also say that 96% of youth taking antidepressant medications did not report suicidal thoughts, which is actually encouraging. In truth, 2% and 4% are statistically different from one another, but both are very small percentages. Yet, as a result of this black box warning, use of antidepressant medications for young people with depression plummeted. 

This brings me to another important point, which is that there are serious risks to not treating depression in young people as well. Like I said before, suicidal thoughts are common among individuals with depression. So common in fact that between 2 and 15% of individuals with untreated depression complete suicide. Yes, I said complete. Thus, we are brought to the second, less often considered sentence of the black box warning which reads, "Anyone considering the use of [Insert established name] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need." In fact, we can see the unintended negative consequences of this black box warning over time. Between 1990 and 2000 adolescent suicide completion rates were steadily declining, and have been steadily increasing since 2004 when the black box warning was added. Click here for a figure of these suicide rates.  

To summarize, youth with depression are likely already experiencing suicidal ideation, and the risk of the teen completing suicide is highest when untreated. Obviously, treatment decisions are extremely personal and there will always be pros and cons of every treatment decision. However, we know that the most effective way to treat depression is a combination of weekly CBT and antidepressant medication, and risks are most effectively managed by mental health professionals who specialize in child and adolescent mental illness. For more on depression and it's treatment, click here


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