Data on Antidepressants and Suicide1
Clarifying Suicidal Ideation and Treatment
August 3, 2015
In 2003, there were troubling case reports, involving Teenagers, and Antidepressants.
Patient testimonies indicated, in the first weeks to months of Antidepressant Medication treatment, for Depression, some Adolescents developed Suicidal Ideation.
Any number of case reports, when it comes to Suicide, are concerning.
The FDA learned of these concerns, and placed a Black Box Warning, specific to Children and Adolescents, using Antidepressant Medication.
Before we get into that Box, let me entertain a brief discussion about Antidepressants, Suicidal Ideation, and Depression.
When I refer to Antidepressants, in this essay, I mean as they are used to treat Depression only. Antidepressants, despite their name, are used as First Line Agents in Anxiety Disorders as well.
Functional Imaging studies have demonstrated that Depression and Anxiety have a huge overlap, in which areas of the brain are involved, as well as which neurotransmitters (chemicals).
One of the most important in both Depression and Anxiety, is SEROTONIN.
Suicidal Ideation is the collection of thoughts, or fantasies one may have, involving themes of suicide.
It is not concerning, to occasionally have fleeting thoughts about suicide.
Or to think about it, when feeling intense emotions, or during severe stressors.
It becomes alarming, when these thoughts occur repetitively, or so intensely, that one feels compelled to escalate into action.
While I did just say that fleeting suicidal thoughts are not concerning, they can be, in life situations involving high stress, recent losses, or when mixed with drugs or alcohol
Alcohol is, by far, the most dangerous substance, to mix with violence.
40% of all Homicide victims have alcohol in their system, at the time of their death.
It is estimated, that 40% of Homicide perpetrators have used alcohol close to the time of the crime.
Drinking is especially common among perpetrators of specific crimes, including murder, sexual assault, and intimate partner violence.
People engaging in Suicidal behaviours are often intoxicated, or at least affected by alcohol, at the time of their death.
22%, of all completed Suicide victims, are found to be legally intoxicated, during autopsy.
This percentage accounted for about 7500 completed suicides, in the United States, in 2012.
Passive Suicidal Ideation may entail a 1 second thought, about Suicide.
This contrasts the other bookend, of this definition.
At the other side, are intense and unrelenting thoughts and images about Suicide, that balance on the brink, almost tipping over, into making definitive plans about how to do it.
Active Suicidal Ideation involves making preparations for Suicide, by creating a plan of some sort, and deciding on a method.
Time and place may not be decided at the same time, although the person may be looking for opportunities.
The Suicide Attempt is the culmination of this spectrum of thoughts; going from Pre-Contemplation, to Contemplation, and finally, Action.
The LETHALITY of the Suicide Attempt, is related to the method chosen. The more lethal strategies involve dying quickly, such as hanging, or using a car or gun.
Less lethal means entail more drawn out ways, such as overdoses, depending on the substance involved. It may also include cuts, in places where it would take a long time to bleed out, and attempts where there is a great likelihood of being discovered.
Every single suicide attempt and act of harm, to self or others, demands action by caregivers, or kind strangers, to ensure the person is assessed as soon as possible, by a Mental Health Professional.
Suicidal Ideation occurs, during the course of severe Depression, in some sufferers.
It is difficult to fully understand, how someone could develop suicidal ideation, when they were supposedly being ‘treated’ for it.
Or, at least its apparent cause is being treated: Clinical Depression.
But here are a few guesses, before we continue our story.
Every illness that is undergoing treatment, from Diabetes, to cnacer, commonly follows one of only a few trajectories.
There are those people, that have a fairly good, or ‘rapid’ response.
In the case of Adolescents with Depression, a good medication response occurs about 40-60% of the time.
The other trajectories involve less than optimal responses, which prompt Doctors to consider many other possibilities.
‘Did I get the diagnosis correct, in the first place’
‘Did I choose, and deliver, the appropriate treatment’
‘Did the patient comply with the treatment, as I prescribed it’
If you were treating a patient with unstable Diabetes, and were in the first few weeks of treatment, using Insulin, what would you think if Blood Sugars actually became even more unstable?
It is well known that Teenagers struggle, even more than most Adults, to stick to a prescribed regimen; whether that involves chores around the house, school assignments, or medication schedules.
It is also noted, that many Teenagers are, simultaneous to fighting an illness, navigating the complex developmental roles inherent to teens.
The occupation of Teenagers is to learn the skills necessary, to establish a feeling of independence.
This is the end result of successfully navigating what Margaret Mahler referred to as Separation-Individuation. These same principles are related to the growth of the dependent Teen, into the independent adult.
When your teenager actively defies you, or resists following your advice, they are merely practicing, what their genes are preaching.
Anything you want them to do is ‘your way’.
The last thing any ‘individual’ wants, is to follow someone else’s orders.
They define their independence from you, by actively ensuring they engage in behaviors that you will not agree with.
And when it comes to Adolescents with Diabetes, it is well known that there are many struggles with appropriate meal and exercise planning, as well as the need to often change Insulin dosing, and times.
What complicates this further, especially for Teenagers, is that they are also testing Grandiose fantasies about death, and immortality.
Many Teenagers, who are unconsciously fearful, regarding bodily harm or even death, use the defence mechanism of GRANDIOSITY.
This leads to an individual exhibiting unhealthy BRAVADO, in the face of dangerous situations, to see if they are truly immortal.
Such Counter-Phobic behaviours have been seen many times in Football Players with enlarged spleens, who try to ‘get back in the game’, even after they are told that ‘one hit may kill them’.
It is also seen in Teenagers with Anaphylactic reactions to specific foods.
It is not uncommon, while in a group of other adolescents, to test how severe an allergy is, by licking a peanut (much the same way teens dare each other to lick batteries or frozen metal poles).
This same pattern of RESISTANCE, to Evidenced Based Treatments prescribed by Doctors, is seen in Diabetes, and many other illnesses teens unfortunately encounter.
What makes poor compliance with treatment even more likely, when it comes to Adolescent Depression, involves both STIGMA, and the symptoms of Depression themselves.
Stigma and judgment can lay dormant in a family for years, especially if there is no circumstance that would reveal it.
Spike Lee’s Jungle Fever, is a nice example of a type of unconscious oppression, which people may not even appreciate is there, until it is in front of them, in black and white.
Many families have a history of mental illness, dating back many generations. These painful life stories are very difficult to retell, and measures are taken, to keep some of them secret.
When they are discussed, it is often in whispers, legends, and half tales.
Sometimes lines are drawn in the sand between Parents themselves, and they may disagree whether Depression exists at all, or whether medications are safe, or even effective.
These are all good questions to ask the Doctor, and if satisfactory answers are not found, I would recommend you seek a second opinion.
When Parents fight over how to treat Teen Depression, the Adolescent themselves can internalize the conflict.
They may blame themselves for having Depression, and burdening their Parents with the stress of their symptoms.
They may feel the stigma, of being ‘that person’, in the current family generation.
The one to exhibit symptoms, a specific Parent remembers, all too well, from a long almost forgotten past.
These types of family wounds, can fuel the Teenager to become ambivalent about wanting their Depression treated at all.
It may also contribute, to thoughts such as, ‘Maybe they would all be better off, if I was no longer around’.
With a reluctance to want to become involved in something they do not agree with, or understand, Parents may also leave it up to the Depressed Adolescent themselves, to administer the daily doses of pills.
Many healthy Teenagers lose or forget things, even when things are going well.
With poor energy, little motivation, and decreased concentration, all typical symptoms of clinical Depression, the risk of missed meds is high.
The point of this discussion, just prior to highlighting the actual data, related to Teens, Antidepressants, and Suicide, can be summarized with the following points:
All Teenagers, may feel some resistance, to any help or treatment advice, from Adults, because they are trying to practice their independence. It is unfortunate when they pick such unsafe playgrounds, to practice these much needed developmental skills.
It is helpful to negotiate with Teenagers, giving them more freedom in some other areas, in exchange for military compliance, when it comes to treating medical conditions.
Many treatments do not work especially well, in the first few days to weeks, especially if there are many complicating factors involved.
Some Teenagers are afraid to show signs of happiness, even when they are having a better day, because they fear their Parents will think they are cured.
When Depression lifts, they will advertise their happiness, openly.
Those Teenagers newly diagnosed with Diabetes, can struggle for months, to coordinate Insulin Injections, meal planning, and scheduling exercise.
Struggling to find this new balance, especially in the beginning, can actually lead, at times, to even more unstable blood sugars. We would likely not conclude, with multiple case reports, that Insulin causes unstable blood sugars.
Family factors, especially attitudes of the Parents, can play a strong role in how the Adolescent handles the illness AND treatment.
Ensuring that the teenager doesn’t feel like a burden is vital.
Providing education, in the Parent’s own words, about Depression and Treatment is helpful. If a parent is using their own words, it allows for a discussion, which may highlight areas where further information is needed.
Helping the Teenager to stay organized and motivated enough to participate in their own recovery is necessary.
When it comes to Depression, ensuring the Adolescent has taken scheduled medications with caring supervision, is paramount.
Suicidal Ideation is a symptom of Depression itself, and could occur at the same time as the treatment was being initiated.
It takes at least 6-8 weeks, at the right dose, for a specific Antidepressant to show a reasonable facsimile of its ‘full effect’.
In the first several weeks, even in eventual successful treatment, the Depressed Teen may show little, if any, positive response.
The Teenager may also have had difficulty concentrating prior to treatment, and as they begin to improve in their thinking, they may finally be able to articulate suicidal thoughts that were present for days or longer, prior to starting treatment.
They may finally have the energy, in early recovery, to act on these thoughts as well.
There are some RECEPTOR EFFECTS, at the neuronal level, that may also cause agitation, perhaps leading to Suicidal thinking, which we will discuss in the next chapter.
So I hope you come back again, to read part 2, Data and the FDA.
Simon Trepel, MD
Simon Trepel, MD FRCPC, is a practicing Child and Adolescent Psychiatrist, in Winnipeg, Canada. He is an Assistant Professor, at the University Of Manitoba, in the Faculty of Medicine, and the Co-founder of the GDAAY Clinic. He is, more importantly, the proud Father of 2 beautiful Daughters. He writes in his spare time about things he knows something about, and occasionally about things he doesn’t; like Yoga, and Italian flavored coffees. He was not referring to coffee that tastes like an Italian person.
Check out his Blog, called Simon Says Psych Stuff, at