A highlight from Duty to Warn: Antidepressants in Children and Adolescents
For nearly seventeen years since the fda black box warning about suicide audi with antidepressants our community has been quoting data. That downplays this concern. We were wrong. We were deceived. Antidepressants can be lifesaving. But there really is a duty to warn in this episode. Doctors martha eagles ski. And glenn spielman talk with us about what went on and how to talk about it with our families. Welcome to the car psychiatry podcast. This is a special episode from the child. Psychiatry team. i'm dr josh. Fader the editor in chief of the car latte child. Psychiatry ford and co author of the child medication fact but for psychiatric practice. And i'm mira government a licensed clinical social worker in southern california with a private practice and i'm also regional director at positive development institute. So let's get right into it. The sound were using from this episode is an interview. I did with doctors. Martha ign- izzy a fellow at the university of california san francisco and dr glenn spielman a professor of psychology at metropolitan state university in saint. Paul minnesota glenn started by giving us the background. Let's start with where it began. So of course the two thousand four black box warning was based on a higher rate of treatments emergent suicidality anti-depressants than placebo and pretty shortly after that some researchers lane that this black box warning ended up resulting in fewer kids taking antidepressants. And then that's ledge more suicides. One line of logic so i think among a lot of people that this those arguments really gathered some currency and have really become accepted wisdom but the research evidence actually really supports the black box warning pretty well. This black box warning was and still is a big deal for those of us working in child and adolescent mental health. What are your thoughts on it mira. I recently attended an online suicide conference. And here's some really interesting things that i learned. According to the world health organisation every forty seconds a life is lost to suicide a hundred and fifty six percent. More people killed themselves than were murdered by others in twenty eighteen. The american association of suicide oncology said the number to cause of death in the sixteen to twenty four age group was suicide and that number was six thousand two hundred eleven in the twenty five to thirty four age group. The second cause of death was suicide and that was eight thousand and twenty another really interesting. Statistic is that in twenty fifteen in high school students. One male and two females have probably attempted suicide. so i'd say yacht. This is a really big problem and a big concern especially in the time of pandemic that we have to discuss an address with our clients. We're having it at our practices mayor. And i were just talking a few minutes ago before we started recording. This episode about a family were working with where somebody you know had an dose and it's in the context of certainly all the difficulties families have but on top of it as you say the pandemic is making it even worse there are aspects of this. We definitely need to understand better first of all is there really a correlation between antidepressant use than suicidality feelings team dug into the studies. And here's some important nuance to our understanding of this issue. Exactly here's what he had to say about the data surrounding the black box warning anyway. Antidepressant prescriptions for kids have been increasing so and also suicides among kids have been increasing. Now i don't really think that you can make much of a conclusion based on that i think um and this is something we got into. Our paper is that you know you can look at the population suicide rate and you can look at the population rate of prescriptions. And you can look at how those things relate to each other. But i think it's pretty unwise to draw conclusions based on that. There's all sorts of variables that influence suicide as clinicians. Now so you've got and what's going on with the economy in terms of unemployment You've got sue drug use by the kids. You've got drug use either parents. You've got parental military deployments which can influence suicide rates stutter. You got all of those sorts of things and many others going on at any given point in time. So the best way to examine jew into your presence. You know. 'cause suicide in some cases is to look at controlled trials which is the foundation for the Black box warning in the first place. So i think a lot of the studies that came out and looked at these population. Wide studies Our population data. I think can be misleading first of all the decrease in antidepressant prescriptions for kids in the usa was relatively modest And depending on the source and the timeframe that you look at it was either a modest drop in prescribing or just really slowing down the rapidly upward trajectory in antidepressant prescriptions that was occurring before ends so in the late nineteen ninety s early two thousands of is a really big increase in the number of anti-depressants that were prescribed. And this you know this leveled off and decrease to an extent but it wasn't it didn't plummets in the united kingdom. The prescribing rape plummeted and there was no increase in suicides. There by the way. Why would the u k show different trends doctors yeoman's attributes that to potentially cherry-picked data on us suicide -ality One other thing. We looked at was that. Sometimes you can just cherry pick certain years so a very influential paper In two thousand seven by robert gibbons and his team look at a one year relationship there was a over like a one year time period. There was a decrease antidepressant prescriptions and an increase in suicides. It was a time series of one year. Which is ridiculous to draw conclusions from every year there will be in the data with more or less suicides. More or fewer antidepressant prescriptions. So papers incited hundreds of times. It's it's a meaningless paper and that wasn't the only problem found with gibbons research another paper from the Robert gibbons team claimed that the prozac studies show that there was not an increase in suicide risk. But what they used to measure suicide risk. Was if you're familiar with the children's depression reading scale it's used a measure treatment effects. Nate the one item that measures suicide of that measure and they said that based on that there's no increase in suicide. Risk problem is the. Fda says that's not a good measure of suicide breast and glaxosmithkline's analysis analysis also found that it's not a good measure suicide risk because most prescribers are aware that ferocity axel showed pretty substantial increase in suicide related adverse events relatives placebo. If you use the child depression rating scale to assess suicide rescue. Don't see that so you see more. Actual events of that rating scale doesn't detect.