Major depression is one of the most common mental health problems in the U.S., affecting approximately 2.8 million adolescents from ages 12 to 17 years. Several different types of antidepressant medications — including selective serotonin reuptake inhibitors (SSRIs), and serotonin and norepinephrine reuptake inhibitors (SNRIs) — are commonly prescribed to treat depressive disorders. These medications act on certain brain chemicals called neurotransmitters — particularly serotonin, norepinephrine and dopamine.
Large pharmaceutical companies including GlaxoSmithKline (GSK) have marketed antidepressants such as Paxil as safe and effective for treating adolescents with depression despite studies that showed potential dangers — including thought disturbances and suicidal behaviors in clinical trials evaluating the use of antidepressants in youth. While preliminary data suggests that the SSRI (i.e., Paxil) was effective and well-tolerated for treating adolescents with major depression, a re-evaluation of the data (Restoring Study 329) revealed that suicide attempts were significantly higher than what the original study had reported and that other unreported serious adverse effects had occurred in patients. Contrary to the original study, the Restoring Study 329 reported that Paxil was not more effective than the placebo for alleviating symptoms of depression in young people.
There is limited knowledge regarding the use of antidepressants in youth, although it has been suggested that the risk for suicidal thoughts and attempts is greatest among adolescents, particularly within the first 30 days of starting treatment. Children and adolescents had a heightened risk for death, suicidal thoughts and attempts, aggression and akathisia, an extreme form of restlessness or agitation, according to a recent study published in the BMJ. Children and adolescents had double the risk for suicidality and aggressive behaviors when taking antidepressants.
Serious risks associated with antidepressants
In the systematic review and meta-analysis of 70 clinical trials that included more than 18,000 patients (a total of 10,258 patients who were taking antidepressants and 6,832 patients who received a placebo), Tarang Sharma, a Ph.D. student, and colleagues, from the Nordic Cochrane Centre and the University of Copenhagen in Denmark, evaluated the serious harms (i.e., mortality, suicidality, aggression and akathisia) associated with the use of five specific types of SSRIs and SNRIs in adults, and in children and adolescents, namely: duloxetine (Cymbalta), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and venlafaxine (Effexor).
The researchers found support for the dangers associated with the use of antidepressants for treating depression in young people. In particular, children and adolescents had twice the risk for suicidality and aggression when taking antidepressants. Of all clinical trials, the following outcomes were associated with antidepressant use among patients:
The findings of this study indicate that the risks of suicidality and aggressive behavior were doubled with the use of antidepressants for patients of all ages, although these findings were not statistically significant for adults. On the other hand, children and adolescents who were taking antidepressants had double the risk for suicidality and aggression compared to children taking the placebo.
The researchers noted that many of the clinical trials they evaluated appeared to misclassify, mislabel or misreport deaths and suicidal events in individuals taking antidepressants. In addition, more than half of the suicides and suicide attempts were coded as “emotional lability” or “worsening of depression,” which the authors concluded was an effort to downplay the seriousness of side effects associated with antidepressants.
Antidepressants and suicide risk
Published material from Zoloft trials only reported one suicidal act among children, although the FDA later revealed that antidepressants were associated with a much greater risk for suicidal thoughts, behaviors and attempts than previously thought. About 4 percent of children taking SSRI medications were found to experience suicidal thinking or behavior — these children had twice the risk for suicide compared to children taking a placebo.
Following a review of the controlled clinical trials of antidepressants in children and adolescents, the Federal Drug Administration (FDA) issued a public warning about an increased risk of suicidal thoughts or behavior (i.e., suicidality) among children and adolescents treated with SSRIs. All antidepressant medications now carry a black box warning to inform the public about the increased risk of suicidal thoughts or attempts associated with taking antidepressants, especially among children, adolescents and young adults under 25 years old.
Antidepressants and aggression
Not only do antidepressants increase the risk for suicidal behavior, children and adolescents taking antidepressants are also at an increased risk for aggressive and violent behaviors compared to those who were not taking these drugs. More than 35 school-related shootings and acts of violence have been linked to the use of antidepressants among young people who were either currently taking or withdrawing from psychiatric medications such as antidepressants.
Studies have found that young adults prescribed antidepressant medications were more likely to have violent crime convictions compared to those who were not taking an antidepressant. Earlier studies have found a link between antidepressants and aggressive behavior (e.g., hostility, assault) in adults. For the first time, the use of antidepressants was also associated with a heightened risk for aggressive behavior in young people.
Dangers of prescribing antidepressants to youth
SSRIs are not recommended for use in young patients due to evidence for increased self-harm and suicidal thoughts among these individuals. Despite the growing recognition of an increased risk for suicidal and aggressive behaviors, antidepressants are still commonly used to treat children and adolescents with depression. Collectively, these studies suggest that young people respond differently than adults to antidepressants, something that needs to be considered when treating youth with depressive disorders.
Sharma and colleagues highlighted some of the serious harms associated with antidepressant use in children and adolescents, including the risk for death, suicide, aggression and akathisia. The fact that children and adolescents taking antidepressants are at twice the risk of suicide and aggression suggests the need to utilize other treatment options (e.g., psychotherapy, cognitive behavioral therapy) for young people.
Depression is a debilitating mental disorder that leads to persistent feelings of sadness or loss of interest, which can affect a person’s ability to function in his or her daily life. The Sovereign Health Group offers comprehensive behavioral health treatment services to patients with mental health disorders, including depression, as well as substance abuse and co-occurring disorders. For more information on the evidence-based treatments available for treating depression at Sovereign Health, please contact our 24/7 helpline for more information.
About the author
Amanda Habermann is a writer for the Sovereign Health Group. A graduate of California Lutheran University, she received her M.S. in clinical psychology with an emphasis in psychiatric rehabilitation. She brings to the team her background in research, testing and assessment, diagnosis and recovery techniques. For more information and other inquiries about this article, contact the author at firstname.lastname@example.org.