Other Considerations Antidepressants and Suicidal Ideation

In 2004 the FDA added a black-box warning to all antide-pressants indicating that the use of antidepressants in children, adolescents, and young adults under 25 years of age increased the risk of suicidal thinking and behavior. The warning on antidepressants was based on an analysis of 372 clinical trials involving 11 antidepressant medications, noting an increase in the number of patients who experienced an increase in suicidal ideation and behavior, although no increase in actual suicides was observed. Further analysis of the FDA data revealed a strong age-dependent relationship, such that the greatest risk was in patients younger than 25. In clinical terms, four additional patients in 1000, age 18 to 24 years, would be expected to experience suicidal ideation or behavior as a result of taking antidepressants, and an additional 14 patients in 1000, under age 18, would be expected to experience worsening. Patients older than 30 showed a reduction in suicidal ideation as a result of taking antidepressants, with a reduction of 6 patients of 1000 in adults over 65. The net effect of antidepressant use in patients age 25 to 64 seems moderately protective against suicidal ideation and more strongly protective for adults age 65 and older (Levenson and Holland, 2006). Antidepres-sants should be used cautiously in patients under age 25, with close monitoring for worsening of mood or thoughts of suicide, particularly in the days and weeks after the drug is initiated. For the majority of depressed patients, the beneficial effects of antidepressants greatly outweigh the risks (Libby et al., 2007).

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