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Antidepressant use in children and adolescents has been associated with a twofold increase in risk for suicidal behavior. To further assess both efficacy and risk for suicidal thoughts and behaviors in the pediatric population, researchers conducted a meta-analysis of data from 27 randomized, placebo-controlled clinical trials of antidepressant treatment (mostly selective serotonin reuptake inhibitors [SSRIs]) for major depressive disorder (MDD, 15 trials), obsessive-compulsive disorder (OCD, 6 trials), and other anxiety disorders (6 trials) in pediatric patients.
The pooled differences in response for antidepressant groups compared with placebo groups were 11% for treatment of pediatric MDD, 20% for OCD, and 37% for other anxiety disorders. The differences in risks for suicidal behavior were 1.0%, 0.5%, and 0.7%, respectively. Overall, the authors calculated that a clinician would have to treat 143 patients to see suicidal behavior in a single patient. No completed suicides were reported.
Bridge JA et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. JAMA 2007 Apr 18; 297:1683-96.
Comment
This meta-analysis is the largest to date to examine efficacy and risk of antidepressant use in children and adolescents. Its importance for pediatricians is twofold: First, pediatricians may be surprised at the modest improvement in patients with depression and OCD. This finding serves as a reminder that cognitive behavioral therapy should be a part of treatment with or without medication and that SSRI medications are most effective in patients with non-OCD anxiety disorders. Second, in contrast with previous meta-analyses, this study assessed risks associated with the three disorders separately; these results point out that the risk association is with suicidal thoughts and behaviors, not completed suicides. Pediatricians can feel confident in prescribing SSRI medications for children and adolescents with specific mental health disorders as long as side effects are monitored appropriately (in particular, agitation and increasing sadness and isolation during the first month after starting or increasing the medication).