Different antidepressants associated with similar suicidality risk in children

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1. When compared to fluoxetine, a selective serotonin reuptake inhibitor (SSRI) and the current FDA-recommended antidepressant for children with major depressive disorder, no significant difference in risk of medically treated suicide attempts was observed between those treated with other SSRI antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs).

2. A significant, increased risk of suicidal behavior was noted among patients on multiple antidepressant medications when compared to those taking fluoxetine alone.

Evidence Rating Level: 2 (Good)   

Study Rundown: The pharmacologic treatment of major depressive disorder in children and teens is complicated by the potential link between antidepressants and suicidal behavior. Prior evidence has suggested that the risk may vary depending on the antidepressant. This study compared the risk of suicidal behavior among pediatric users of different antidepressant classes including serotonin-norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs) to fluoxetine, an SSRI and the current FDA-recommended antidepressant for pediatric patients. No significant difference in risk of medically treated suicide attempts between those taking fluoxetine and antidepressants other than fluoxetine were observed. Researchers did find a significant increase in risk of medically treated suicide attempts associated with the use of multiple antidepressants when compared to individuals on fluoxetine treatment alone. It is noted, however, that this finding may be biased as those on multiple medications also had higher rates of prior suicide attempts and psychiatric hospitalizations than those on fluoxetine monotherapy. Although limited by the use of medically treated suicide attempts as the only representation of suicidal behavior and by its retrospective design, this study may encourage physicians to consider a broader range of antidepressants in children.

Click to read the study in Pediatrics

Relevant Reading: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders

In-Depth [retrospective cohort study]: Researchers reviewed the medical records of 36 842 children (mean age = 14 years, 53% female, 15.9% African American) enrolled in Tennessee Medicaid and who were newly prescribed antidepressants during 1995-2006. A total of 47.4% of participants were diagnosed with major depressive disorder. “New users” were identified as those with no prior prescription of antidepressant for 365 days. Potential participants were excluded if diagnosed with a mental illness apart from major depressive disorder. Medically treated suicidal behavior, determined by hospital record review was the primary endpoint investigated. No significant difference in risk of suicidal behavior was seen between fluoxetine and the other antidepressants studied.  However, a significantly increased risk of suicidal behavior was seen among those on multiple antidepressants when compared to those on fluoxetine monotherapy (RR = 1.70, 95% CI 1.10-2.62).

By Laurel Wickberg and Leah H. Carr

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