by Harvey Widroe, M.D.
American Reporter Correspondentj
July 25, 2007
KIDS AND SUICIDE: THE ANITDEPRESSANT LINK
ORINDA, Calif. -- A growing debate about whether antidepressant drugs increase or actually cause suicidal thinking in adolescents has in recent months led many doctors to become more reluctant to prescribe them. The sad result has been an increase in the adolescent suicide rate because depressed adolescents may not have received the very medications that could have saved their lives, or may have recently stopped taking them.
Along with other practicing psychiatrists, I sometimes hear reports of increased suicidal thinking from some of our adolescent and adult patients of any age who are taking certain antidepressant medications. But the history, the presence, or the possibility of suicidal thinking should not be taken as a signal for physicians to stop prescribing antidepressant drugs.
In fact, inicidents of young people under a psychiatrist's care who stop taking medications and suddenly become suicidal or violent are common; there may be a link between rage suppressed by such medications and episodes of suicide and violence when they are abruptly discontinued. That was again the case with the suspect in the Virginia Tech shootings, and with several other other famous rampages.
But used properly, these drugs can alleviate misery and actually avoid help
suicide. The problem of suicidal thinking increased or caused by
antidepressant medication is avoidable or, if encountered, readily fixable.
The confusion about the issue can be cleared up by recognizing that not all depressive illness is the same, and that not all antidepressant medications are equally indicated for treating all types of depressive illness. In most cases patients quickly, often within a day or two, achieve relief from the anguish and despair that often leads to suicidal wishes.
Such relief is typically provided with the use of a rapidly-acting, mood-stabilizing medication (not an antidepressant) along with an antidepressant drug. Antidepressants alone usually take at least a week to begin having a positive effect.
Depression is not the same as the day-to-day variations of mood we all experience. Most depressive illness falls into either of two very different categories. Apathetic depression is characterized by a depressive mood, especially low energy to the point of lying in bed with excessive sleep, loss of interest in almost everything, social isolation, little motivation, and inability to enjoy anything. Patients with this type of depression are not suicidal. They improve when given energizing antidepressants. They do not improve or else improve very slowly when given more sedating antidepressants.
Jenny recalled that she had had this problem before, back in high school, the difficulty getting out of bed in the morning to get to class. She had no energy, and couldn't get up for a shower or to brush her teeth. When she felt like this, she didn't even change her clothes. Everything was an effort.
Her roommate brought in fast foods and junk foods. Pizza or Chinese food delivery was almost the rule. Jennie's appetite wasn't great, but stuffing herself seemed to help to feel better, at least for awhile. Her thinking had slowed down somehow. She couldn't concentrate on anything, mostly because she really didn't care. She didn't submit her papers or take her quizzes. She knew she was destined to flunk out but felt helpless to do anything about it. Yet even though she felt that her life was "a total drag", she was never suicidal.
Her parents, realizing that something was seriously wrong, urged her to seek help at the student health center.
Jenny saw a counselor who referred her to a psychiatrist for medication in addition to her psychotherapy. She was prescribed Wellbutrin, one of a number of energizing antidepressant medications, and within a week she noticed some improvement, especially sleeping less and getting out of bed more easily. She described it as the "lifting up of an iron blanket." It took a month and several medication adjustments for her to feel almost normal.
Agitated depression is a very different illness. Patients with agitated depression suffer from anxiety, anguish, despair, poor sleep, poor concentration, high irritability, and frequent suicidal thinking. Sufferers from this type of depression may experience an increase in many or all of their symptoms, including suicidal thinking, if given energizing antidepressants. But these very same patients respond positively if given a sedating antidepressant enhanced by a rapid-acting, mood-stabilizing drug.
Amy couldn't describe her pain. It wasn't like a toothache or back ache. It was a kind of hurting all over, especially when she woke up. Her sleep was poor, with many awakenings and a number of grisly nightmares. Her mood was agitated and anguished. She felt like she was in a black hole with unbearable anxiety. No one could understand how terrible she felt. She obsessed about how trapped and hopeless she felt. Either jumping off a bridge or driving her car into a telephone pole seemed like a great way out.
Her primary care doctor prescribed Prozac, the antidepressant he used for all of his depressed patients. Within a few days her level of agitation and despair increased, and her suicidal thinking became a preoccupation. Her parents, fearing for her life, insisted that she see a psychiatrist, and Amy was hospitalized for her own protection. The Prozac was stopped and she was given Risperdal, a mood stabilizing medication.
Within a day the suicidal thinking was almost gone. Her sleep improved, as did her sense of pain and despair. The relief from her anguish gave her a sense of hope. An antidepressant medication, Celexa, was added to her regimen.
Within a week she was discharged from the hospital and felt well on the road to recovery, although she didn't feel like her normal self for several months. At this stage the idea of suicide had become totally foreign to her. Looking back she said, "It was like I was somebody else".
Used properly, antidepressant medications are a miracle for alleviating the misery of depressive illness. Administered thoughtfully and carefully, we not only have little to fear but many lives can be saved.
Harvey Widroe, a longtime practicing psychiatrist, is the author of the recently published "Smart Dieter's Cheating Guide: Eat and Watch Pounds Melt Away," with Ron Kenner (Outskirts Press, 2007).