Adolescent Patients Caught Between Suicide and Anitidepressants
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SUSAN DENTZER: Chris Drell knows what it’s like to be a child in despair, since that’s exactly what he used to be.
CHRIS DRELL: I was diagnosed with bipolar disorder when I was 11 years old. I had my first manic episode, I had a lot of trouble sleeping, and got to the point of paranoia and couldn’t sleep, and I was hospitalized at that age of 11 years old.
SUSAN DENTZER: Drell’s now 24. But from ages 14 to 19, his condition, also called manic depression, drove him to attempt suicide eight times. Usually he overdosed with sleeping pills and other drugs. Once he swallowed bleach.
CHRIS DRELL: All I can see at that moment when I’m feeling depressed is the problems and how I’m unhappy right now, and it seems like it’s not worth it. So it makes sense at that time when I’m in that mind state to just end life as soon as possible.
SUSAN DENTZER: With psychotherapy and medication, Drell’s disease is now under control. But now some antidepressant drugs like those that helped Drell have come under attack.
SPOKESMAN: The FDA encourages you, the open public hearing speaker…
SUSAN DENTZER: At a recent meeting sponsored by the Food and Drug Administration, more than a dozen parents whose children had committed suicide blamed the drugs for their deaths.
SARA BOSTOCK: My daughter Cecily had only been taking Paxil for two weeks before she died, during which time her condition greatly worsened.
SUSAN DENTZER: Sara Bostock’s daughter, a young Stanford graduate, had been given Paxil by a psychiatrist for racing thoughts and anxiety.
SARA BOSTOCK: She stabbed herself twice in the chest with a large chef’s knife. Her autopsy revealed she had a very high blood level of Paxil, which reflects poor metabolization and is a feature common to many of these suicides.
SUSAN DENTZER: Bostock and other families whose children killed themselves after taking antidepressants have called on the FDA to ban or stiffen warnings about the drugs. And a newly published analysis in the journal The Lancet suggests that four particular antidepressants– Paxil, Zoloft, Effexor and Celexa — should not be used to treat depression in children. The authors wrote that the risk of suicide-related behaviors and other adverse reactions could outweigh the benefits. But the FDA and many psychiatric experts say there is not yet any clear evidence that antidepressants alone cause suicides in kids. Dr. Robert Temple is the FDA’s associate director for medical policy.
DR. ROBERT TEMPLE: It’s tempting to believe that if a person didn’t commit suicide and then got the drug and did, that it must be the drug that did it. But you can’t know that.
SUSAN DENTZER: Dr. Adelaide Robb is a child psychiatrist at the Children’s National Medical Center in Washington, D.C. She’s treated Chris Drell for years. She says for the most part it’s the underlying mental illness that causes suicide.
DR. ADELAIDE ROBB: Major depression has a rate of suicide as high as 10 percent. So untreated, if you just had a bunch of teenagers that weren’t on any medicine and weren’t on any therapy, up to 10 percent of them would attempt to or succeed in killing themselves.
SUSAN DENTZER: But whether or not antidepressants cause suicide by themselves, it’s long been known that they can contribute to them. That’s because putting people on antidepressants can prompt a response called the rollback phenomenon.
DR. ADELAIDE ROBB: One of the things that we’ve always been taught is that if you have a very depressed unhappy person and you start them on medicine, the first one or two weeks on therapy when they’re feeling a little better is when they’re at highest risk of wanting to kill themselves. And the reason is they finally have enough energy to get out of bed and go to the store and buy the Tylenol or the razor blades, not because the medicine makes them worse, but because the medicine makes them well enough to finally do it.
CHRIS DRELL: Your energy will come back first before your mood comes back, and that’s how people can do that, where it can give you the energy to act out on the suicidal thoughts that you have.
SUSAN DENTZER: Dr. Robb says the rollback phenomenon is now being seen in some children on antidepressants, in part because millions of kids are now on newer classes of these drugs. But the FDA worries that many doctors and the families of depressed kids and adults aren’t sufficiently aware of the rollback problem. So in March it asked manufacturers of nine popular antidepressants to strengthen their warnings about it on the package inserts. The FDA also warned doctors and families that medication may need to be discontinued if it produces symptoms linked to suicidal behavior, like anxiety or severe restlessness. Dr. Lawrence Diller is a California pediatrician; he specializes in behavioral issues.
DR. LAWRECE DILLER: The take-home message to the family is a critical one here that is different from the previous one. If a child is started on this medicine and is doing worse, whether or not they’re acting erratically or having new thoughts about killing themselves or killing their classmates, in the past the doctor would have said just stay on that medicine a little bit longer. I think the message now should be “let’s stop the medicine for two or three weeks.” If necessary we’ll put the child in the hospital on no medicine just to see what happens.
SUSAN DENTZER: The rollback phenomenon is one issue. Now the FDA is also examining a separate concern: Whether there is a link between some antidepressants and a range of thinking and behavior called suicidality.
DR. ROBERT TEMPLE: What we generally mean is… is thinking about suicide in a way that contemplates that you might actually do it– someone walking near a ledge or something, and did that or toyed with a gun and played Russian Roulette; those are all things you’d worry a lot about.
SUSAN DENTZER: Much of the FDA’s scrutiny has focused on Paxil. It’s long been one of the most widely prescribed antidepressants in children. However, recently disclosed studies show that Paxil is no more effective than a dummy pill in treating kids with depression. The study also suggests that children on Paxil have three times the rate of suicidal thinking and suicide attempts as kids on dummy pills. As a result, last year the FDA recommended that Paxil not be prescribed for depression in children. The FDA has now broadened its inquiry to examine suicidality in eight other drugs as well. In sifting through studies of all these drugs the agency has found that unlikely range of behaviors and thinking in kids have sometimes been classified as suicidal.
DR. ADELAIDE ROBB: One of the things that was reported as a suicide attempt in the Paxil study was an eight-year-old who was upset and hit himself in the face and said, I want to die. That was coded as a suicide attempt. Another case that was coded as suicide attempt was a teenager who scratched on the back of his hand with a paper clip and said, i want to die. Scratching your hand with a paper clip doesn’t kill you. But that was coded as a suicide attempt.
SUSAN DENTZER: The FDA has now asked experts at Columbia University to examine all these studies, to determine which reactions in children really should be classified as suicidal. Meanwhile, one congressional committee is looking into whether one FDA official, Dr. Andrew Mosholder, was muzzled by his superiors. Mosholder believes the evidence linking the drugs to suicidality is strong enough to warn against using almost all of them in children. That is the stance that regulators in Britain took last year after reviewing the same data as the FDA. That nation’s medicines and healthcare products regulatory agency said the link to suicidality was so disturbing that only one widely studied drug, Prozac, should be used to treat depression in kids. In the view of some experts, like Diller, the caution shown by british authorities may be warranted.
DR. LAWRENCE DILLER: I hear the british looked at the very same data that the FDA had came up with very different conclusions. A culture clash.
SUSAN DENTZER: Who’s right?
DR. LAWRENCE DILLER: Well, you know me, i prescribe these medicines all the time but I’ve real respect for them and a real concern that we move too quickly and over use these medicines all the time.
SUSAN DENTZER: But the FDA says it’s premature to warn against use of antidepressants in children. Since many are clearly deemed helpful by patients and doctors alike. For now, the agency is awaiting the Columbia expert’s review, expected to be completed by the summer.