The third leading cause of death for adolescents is suicide, behind injury and homicide, respectively, arguably making it something of a crisis (Basco, 2006). When you take into account that death by injury and accidents are fairly rare for teenagers, and that even some of those (such as car crashes), could actually be suicides not labeled as such, the problem becomes even more pressing (Basco, 2006).
Girls would seem to be at especially high risk, as the rates of depression after the onset of puberty is twice as high for girls as for boys (Bonati and Clavenna, 2005). A history of abuse, particularly sexual abuse, has also been shown to increase the risk of suicide (Basco, 2006), and teenagers with conduct disorders combined with mood depressive disorders were at the highest risk (Basco, 2006).
Popular belief hypothesizes that bringing up the subject of suicide with an adolescent whom you suspect is suicidal will “give them ideas” and place the thoughts in their head. But talking to a possibly suicidal adolescent and frankly asking them if they are planning to kill themselves does not, in itself, precipitate suicide; in fact, it has been shown to be an effective tool in fighting suicide. Most suicidal patients simply want someone to pay attention to them and acknowledge their pain, in addition to the fact that acknowledgement can increase social support (Basco, 2006). And if an adult, or even another teenager, suspects someone of being suicidal, chances are the one being suspected has, indeed, already considered it, and the person bringing it up would not be placing any novel ideas in their head.
But how serious is teenage suicide? According to the World Health Organization (WHO), in 2005 in the United States, there were over 30,000 suicides, approximately 2,000 of them occurring in the fifteen to nineteen year-old age group (Basco, 2006). Roughly 90% of that number suffers from a serious mental illness, depression being far and away the most common (Basco, 2006). So what do these figures tell us about teenage suicide? What are the most common factors that precipitate a suicide in an adolescent? Are antidepressants the answer to solving the problem of teenage depression and suicide, or do they exacerbate an already complicated time when cognitive therapy might be more helpful and useful?
For some reason, the rate of teenage suicide increased dramatically in the latter half of the twentieth century (Steinberg, 2005). Many different and varying explanations are given for this dramatic increase, including diminished contact between adolescents and adults, more divorce, more pressure to “grow up” faster, and a more violent society, but none have proven to be satisfactory in explaining this phenomenon (Steinberg, 2005). However, through various systematic studies, 4 distinct risk factors have been identified and isolated as confident predictors of teenage suicide: psychiatric problems such as depression; genetics, or having a history of suicide in the family; external stress, typically social in origin; and severe familial stress or rejection by parents (Steinberg, 2005). A previous suicide attempt is the leading predictor, however, in whether or not a teenager will try to take their life again (Steinberg, 2005).
In the 1990’s, suicide rates in most Western countries declined significantly, and this decline directly correlates with the drastically increased use of selective serotonin reuptake inhibitors (SSRI’s) in depressed adolescents (Rey & Dudley, 2005). Since such a large number of adolescent suicides occur in the midst of a severe mood disorder, it will be helpful to look at treatment options and how those options are affecting suicide rates.
Most teenagers who commit suicide don’t do so in a vacuum, contrary to universal belief. Most seek some sort of professional help in the month prior to their taking their life (Gibbons, Hur, Bhaumik, and Mann, 2006), but at the time of death, only approximately 2% of suicides are taking any sort of medication (Gibbons, Hur, Bhaumik, and Mann, 2006). But teenagers must become, and remain, active in their own care to make it effective. A study of 49 adolescents who had committed suicide in Utah showed that 24% had been prescribed antidepressants, but not a single one of them tested positive for SSRI’s in their systems during autopsy (Gibbons, Hur, Bhaumik, and Mann, 2006).
The first SSRI approved in the United States for the treatment of a major depressive disorder (MDD) was fluoxetine, in 1987 (Kratchvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). By 1991, the USFDA was already holding public meetings about the safety of fluoxetine and its possibly contributing to suicidal behavior in adults, but 17 double-blind clinical trials later found no significant difference in the risk of suicide by those taking fluoxetine over a placebo (Kratchvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). Not until 1997 did these same studies begin to start happening on the efficacy of fluoxetine in children and adolescents (ages 7-18 years), but when they did, 56% of the fluoxetine subjects had improved in eight weeks, as opposed to only 33% in the placebo group (Kratchvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). After practice guidelines for the American Academy of Child and Adolescent Psychiatry (AACAP) were changed to recommend SSRI’s as valid therapy for youths, the number of adolescents receiving an antidepressant at the onset of a new depression rose from 5% to more than 37% in 2002 (Kratchvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). Although numerous studies were performed on placebo-controlled trials of drugs like paroxetine, sertraline, and citalopram, and most found little to no differentiation between any SSRI and a placebo, fluoxetine is still the only drug FDA-approved for pediatric use (Kratchvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006).
In 2004, an FDA clinical trial showed a relative suicide risk of 2% over a placebo for minors currently taking 10 different antidepressant drugs (Kratochvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). Based on these findings, the FDA took four actions that same year: a “black box” warning on all antidepressants that use in children came with accompanied risk of suicidality; they required a medication guide to accompany all pediatric prescriptions; they proscribed strict guidelines for monitoring of patients on any and all antidepressants; and lastly, they incorporated warning and explanation packaging in every single prescription of an antidepressant that was filled, regardless of the duration of use by the patient (Kratochvil, Vitiello, Walkup, Emslie, Waslick, Weller, Burke, and March, 2006). The reasons for the possibly increased suicidality of teenagers taking antidepressants is unclear, but likely result from a varied and highly complex interactions in both biological and social factors (Rey and Dudley, 2005). SSRI’s often induce extreme side effects in their users, including agitation, irritability, an inability to sit still or concentrate, and insomnia (Rey and Dudley, 2005). Like any other medication, SSRI’s can also trigger manic mood swings with higher suicide risk, and withdrawal can also set off many of these same symptoms (Rey and Dudley, 2005).
In 2005, the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health in London, England, released new guidelines stating that antidepressants should be used on adolescents and children suffering from depression only as a last resort, and not at all on sufferers of only mild depression (Mayor, 2005). Furthermore, it declared that once depression had been diagnosed, the patient should immediately be put on a specific psychotherapeutic track, such as cognitive behavioral therapy or family therapy, in conjunction with antidepressants, and that their drug intake should be closely monitored for any signs of negative affects (Mayor, 2005). Fluoxetine was the only drug recommended for use in adolescents and children (Mayor, 2005).
Other factors have since then been found to affect both efficacy of antidepressants, and the rate of suicides in adolescents taking antidepressants. The suicide rate for teenagers on antidepressants (not just SSRI’s, but all antidepressants) is significantly higher than for those teenagers not on medication, but this has more to do with the fact that only much more severe cases of MDD are generally put on medication in the first place, and even then, it’s often too late (Rosack, 2005). Of the 24, 119 adolescents in a recent clinical study marked as having a major depressive episode, 17, 313 of them had no antidepressant filled within six months of their diagnosis (Rosack, 2005), which led the researchers to conclude that if anything, MDD’s are grossly underdiagnosed (Rosack, 2005). Additionally, the suicide rate for teenagers, after going up for 40 years, finally began to hold steady and even drop slightly in the 1990’s, while the prescribing of SSRI’s to depressed teenagers increased significantly in that same time period, rendering the increased risk of suicide argument negligible, at least from an epidemiological standpoint (Basco, 2006).
Suicide is an unpredictable and mysterious climax to often torturous afflictions in all age groups. There are known treatment methods and approaches to the problem, some more useful and valid than others. While antidepressants in general, and SSRI’s in particular, have proven to be an effective treatment method for depression and other major mood disorders, which are the leading causes of suicide, they must be accompanied by a rigorous psychotherapeutic treatments and in-depth scrutiny. The two together (pharmaceuticals and therapy) have shown to be more useful than either alone, especially cognitive therapy (Tonkin and Jureidini, 2005). Teenagers, especially depressed teenagers, can often be hostile, moody, unmotivated, and lack insight, rendering cognitive therapy alone often useless or futile (Rey and Dudley, 2005). With carefully monitored use of fluoxetine (in severe cases), teenager’s moods can often be stabilized enough to get them to actively participate in their own therapy and healing process (Rey and Dudley, 2005).
The use of any medication for MDD’s on teenagers or children remains a controversial idea, especially given how much misinformation, skepticism and uncertainty exist in the professional (psychiatric and medical) world regarding the topic. Ultimately, every decision regarding administering medication should be made on a case-by-case basis, with a careful, ongoing benefit and risk analysis (Rey and Dudley, 2005).
The cost of doing nothing to help alleviate the symptoms of devastatingly isolating mood disorders in adolescents is too great to not be taken very seriously. Just in the last 15 years, major advancements in the study of both psychotherapy and the use of psychotropic medications has yielded tremendous and hopeful results, but not without their setbacks and caveats. The medical and psychological fields must keep striving to provide ever more and effective treatments for an insidious and crushing disorder, not only of the mind, but also of the spirit.
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