WHAT TO TELL YOUR PATIENTS

Do SSRIs cause teen suicide?

The jury's still out but experts agree that young patients
need extra monitoring

By Jadzia Jagiellowicz

A national newspaper runs the headline "Ottawa warns of suicide risk for teens on anti-depressants." Their parents are coming in frantic, worried the medication their moody teens are taking might have horrific consequences. As a general practitioner, what do you tell them? On February 3, 2004, Health Canada issued an advisory telling patients under 18 who are currently being treated with an a Selective Serotonin Reuptake Inhibitor (SSRI) or Seratonin/Norepinephrine Reuptake Inhibitor (SNRI) to consult their physician to confirm that the benefits of the drugs still outweigh its potential risks. The advisory listed the antidepressants citalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline and venlaflaxine. It appears these antidepressants, not indicated for use in children and adolescents, are being prescribed "off-label."

The advisory cited "recent safety concerns," but didn't mention the "s" word, suicide. However, according to Health Canada spokesperson Jirina Vlk, concerns of an increased risk of suicide with some of the SSRIs are not new. In the summer and fall of 2003, Health Canada sent out letters warning healthcare professionals of suicide-related events in children and adolescents using paroxetine and venlaflaxine. The manufacturer of paroxetine also changed the Canadian product monograph to contraindicate its use in this age group.

Health Canada recently requested that the manufacturers of the newer anti-depressants provide a thorough review of the worldwide safety data for their drug when used in children under 18. An independent expert advisory panel of psychiatrists will review the manufacturer's data, as well as international reports linking these drugs to an increased risk for suicide-related events.

"Once the advisory panel has made its recommendations, Health Canada will make any necessary changes to the Canadian product monograph and patient package information for these drugs," says Ms. Vlk.

"The jury's still out," says Dr Marshall Korenblum, Chief Psychiatrist at the Hincks-Dellcrest Centre for Children in Toronto. "What is necessary is a risk-benefit analysis."

Other medical professionals out-and-out disagree with the Health Canada advisory. An American College of Neuropsychopharmacology task force concluded that SSRIs don't increase teen's risk of suicidal thinking or suicide attempts and that they are effective in treating depression. There are also few alternatives to the new antidepressants for young people. Older tricyclic antidepressants, the only pharmacological alternative, were not effective in young people, stated the task force. Cognitive-behavioural therapy, a non-drug therapy that has proven effective in adults, has not been well tested in depressed adolescents, nor is it always readily available. The task force did note that clinicians should ask depressed patients about suicide, suicidal thinking and plans for suicide.

Depressed patients are unhappy, and there is always a risk of these patients being suicidal, was the consensus of GP Michael J Golbey of Kelowna, BC and Dr Korenblum, a Toronto psychiatrist.

"Patients on antidepressants should be monitored for akathisia," says Dr Korenblum, adding that they should also be told to expect this side effect. According to Dr Korenblum, if a patient knows to expect agitation and knows that it will pass in time, "it's not dangerous."

Dr Golbey has been reviewing the use of the newer antidepressants with his older adolescent patients. "They are happy to continue on the SSRIs," says Dr Golbey, "because they feel better when taking them."