Antidepressants and Youth

Behavioral Health Update
BHSI Newsletter Vol. 3, No. 1
Bart Main, M.D.

Much attention has been paid in the media recently to the possible adverse effects of antidepressants in youth, especially in regard to suicidal risk. Our clinics have received many questions about this, and so we publish this article of clarification.?


Suicide is the second leading cause of death in youth between 12 and 21 years of age (behind accidents). Of course, suicidal behavior occurs in the context of depression. Depressed youth, medicated or not, are far more likely to think about or attempt suicide than their non-depressed counterparts. But, the more seriously depressed or suicidal a youth is, the more likely he or she is to be prescribed an antidepressant medicine. Therefore, perhaps the prescription of antidepressants is not the cause of suicidal thinking or behavior as much as it is the result of suicidal risk appropriately recognized.

The American Academy of Child and Adolescent Psychiatry (AACAP) reviewed the European literature on which the FDA based the current “black box” warning for antidepressants. Five studies were involved summarizing the treatment of 4000 youths. In the youth who were depressed but not treated with antidepressants the incidence of suicidal thoughts during the study period was 2%. In the medicated depressed youth the incidence was 4%. It is important to note that there were no suicides in either group. The FDA concluded (and the AACAP concurs) that there may be an increase in suicidal thoughts in depressed youth as a result of antidepressant treatment.

Although antidepressants may pose a risk for some depressed youth, it is important that we not lose sight of the fact that untreated depression is far more dangerous, and that antidepressants are one part of effective treatment of depression. In a recent study of 439 depressed adolescents (JAMA, August, 2004), 29 percent had some suicidal thinking prior to treatment, and after a 12 week course of psychotherapy and antidepressant medication that rate dropped to 10%.


It has long been known that antidepressants pose special risks to people who have bipolar affective disorder (AKA manic depressive illness). If unaccompanied by a mood stabilizing agent such as lithium, antidepressant medication can stimulate dramatic mood swings in a person who is genetically predisposed to the highs and lows of bipolar illness. When a person experiences the despair of depression and the energy of mania close together in time, the result can be suicidal or other dangerous behavior.

Bipolar disorder is often difficult to recognize in young people, because of the relative brevity of life history. Perhaps a youth with latent bipolar illness has demonstrated depressive symptoms, but has not (yet) shown any tendency toward mania. If that youth is treated with an antidepressant only, the latent manic pole may become actualized.


Those who prescribe antidepressants should be skilled in identifying bipolar potential and early signs of mania.

Frequent monitoring of the response to antidepressants, especially early in treatment, must be part of the contract between the treatment team and the families of depressed youth. School personnel can provide important observations and feedback to parents and care providers.

The AACAP suggests that those prescribing antidepressants to persons under 18 years of age provide written warning to patients' guardians about the potential risks of antidepressants.

In addition to antidepressant medication, treatment of depression in youth typically involves practical problem solving in the life of the youth, and concurrent psychotherapy and/or family therapy. Such a combined approach has proven to be far more robust than medication or psychotherapy alone.