Drugged and Confused

The Wall Street Journal, September 10, 2004

By Sally Satel

Do such commonly prescribed antidepressants as Celexa, Paxil and Zoloft cause suicide in children? A recent FDA report on an analysis conducted by suicide experts at Columbia University has parents worried. The report got sensational coverage — one AP headline read: “New FDA Analysis Backs Continuing Antidepressant-Suicide Concern.” Yet a closer look at the 131-page study shows how tenuous this claim is.

The Columbia experts were asked to determine whether instances of self-harm that occurred during clinical trials were truly suicide attempts. No child actually killed himself during the trials but there were incidents ranging in seriousness from a hanging attempt to a girl who slapped herself in the face. But the experts found relatively little cause for alarm: In the 15 clinical trials of depression, youngsters on selective serotonin reuptake inhibitors, or SSRIs, were no more likely to experience an “emergence of suicidality” than those on placebo, nor was there a discrepancy between the groups with respect to “worsening of suicidality.”

What the report did find was that youngsters on medications for other conditions (e.g., anxiety, or obsessive-compulsive disorder), as well as for depression, were 1.78 times as likely as those on placebo to exhibit “definitive suicidal behavior/ideation.” It was this finding that sparked the media attention. But not mentioned in the coverage was that this elevated risk emerged only when two discrete categories, “suicidal behavior” and “suicidal ideation,” were combined to make a third, composite category called “definitive suicidal behavior/ideation.” Separately, neither of the two categories showed a statistically significant elevation for subjects on medication. Combining data from separate categories is not necessarily a problem, but since the original results were inconclusive in the first place, the finding is less than convincing.

Parents of children whose physicians recommend an SSRI should not fear the medications. What should concern them is whether the child has been properly diagnosed for depression by a skilled clinician and is monitored frequently in the first weeks after starting medication. We must also ask how many suicides the drugs have prevented. Epidemiologic trends raise the possibility that antidepressants have actually helped. While their use climbed over the 1990s, suicide rates declined 25% between 1992 and 2001. This isn’t definitive proof — and there are no simple answers. What’s clear is that authentic major depression in children is a serious matter. Accurate diagnosis and careful treatment will save many more lives than might be lost through the use of these drugs.

Dr. Satel is a resident scholar at the American Enterprise Institute.