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Letter to the Editor

Editor, – The editorial 'Suicide and antidepressants in children' (Aust Prescr 2005;28:110-11) is potentially misleading. It stated that there was a 'small but significant increase in suicide risk'. This is not so.

Analysis of the UK General Practice Research Database found no suicides among the 6976 people aged 10-19 years who had been prescribed one of two selective serotonin reuptake inhibitors (SSRIs) or two tricyclic antidepressants between 1993 and 1999; however, 15 people in that age group who died by suicide had not received an antidepressant.1 Similarly, a toxicological review of 14 857 suicides between 1992 and 2000 in Sweden detected no SSRIs in the 52 suicides under 15 years of age. In the 15-19 years age group those taking SSRIs had a lower relative risk of dying by suicide than those taking other antidepressants.2

Clinicians with responsibility for children and adolescents can be reassured by these data, and by the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association guidelines3 which have been endorsed by over a dozen United States organisations comprising a 'national coalition of concerned parents, providers, and professional associations'. Similar guidance has been provided by the Australian/Australasian Colleges of General Practitioners, Physicians and Psychiatrists.4

In view of the strong association between child and adolescent mood disorders and suicide,5 it does not appear prudent to withhold antidepressant medication in young people with severe depression if non-pharmacological measures are ineffective.

Robert D. Goldney
Professor of Psychiatry, University of Adelaide
Adelaide

Professor Goldney has received honoraria and research grants from a number of pharmaceutical companies for presentations and research on depression.

Authors' comments

Dr Jon N. Jureidini and Professor Anne L. Tonkin, authors of the article, comment:

Analysis by the US Food and Drug Administration (FDA) shows a statistically significant doubling (from 2 to 4%) in suicidal thinking and acts in randomised controlled trials. It is true that increased suicidal thinking and acts need not lead to completed suicide, but Professor Goldney seems unduly reassured by the fact that none of the 4000 individuals in those trials completed suicide. Based on 2003 Australian figures of 1.2 completed suicides/100 000 in people under 18 years old,6 a cohort 100 times greater is required to expect to see a single completed suicide in the time frame of these trials. While Professor Goldney is reassured by apparently favourable associations between antidepressant use and completed suicide, the data are inconclusive.7

In appealing to authority, Professor Goldney prefers the American Psychiatric Association and Academy of Child and Adolescent Psychiatry to the findings of US and British regulatory authorities cited in our paper. Inaccurate claims made by these organisations include 'a large number of clinical research trials † have clearly demonstrated the effectiveness' of antidepressant medications for children and adolescents with depression.8 It seems that these organisations are subject to wishful thinking that things cannot be as bad for antidepressants as the evidence suggests.9 Further, unlike Professor Goldney, the report of the various professional colleges10 does not provide information about potential conflicts of interest.

General practitioners who find non-pharmacological means ineffective should be consulting with colleagues expert in child and adolescent mental health rather than prescribing unproven, potentially dangerous drugs.

References

  1. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA 2004;292:338-43.
  2. Isacsson G, Holmgren P, Ahlner J. Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides. Acta Psychiatr Scand 2005;111:286-90.
  3. American Psychiatric Association and American Academy of Child and Adolescent Psychiatry. The use of medication in treating childhood and adolescent depression: information for patients and families. http://www.parentsmedguide.org/parentsmedguide.htm [cited 2006 Mar 8]
  4. Royal Australian and New Zealand College of Psychiatrists, Royal Australian College of General Practitioners, Royal Australasian College of Physicians. Clinical guidance on the use of antidepressant medications in children and adolescents. http://www.racgp.org.au/downloads/pdf/20050509antidepressantguidelines.pdf [cited 2006 Mar 8]
  5. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 1996;53:339-48.
  6. Australian Bureau of Statistics. Canberra: ABS; 2005.
  7. De Leo D, Evans R. International suicide rates and prevention strategies. Washington, DC: Hogrefe & Huber; 2004.
  8. American Psychiatric Association and American Academy of Child and Adolescent Psychiatry. The use of medication in treating childhood and adolescent depression: information for patients and families. http://www.parentsmedguide.org/parentsmedguide.htm [cited 2006 Mar 8]
  9. Tonkin A, Jureidini J. Wishful thinking: antidepressant drugs in childhood depression. Br J Psychiatry 2005;187:304-5.
  10. Royal Australian and New Zealand College of Psychiatrists, Royal Australian College of General Practitioners, Royal Australasian College of Physicians. Clinical guidance on the use of antidepressant medications in children and adolescents. http://www.racgp.org.au/downloads/pdf/20050509antidepressantguidelines.pdf [cited 2006 Mar 8]