Highly publicized government warnings that antidepressants could cause suicidal thoughts in adolescents may have scared off parents and doctors alike, meaning fewer depressed children are being diagnosed, U.S. psychiatrists say.
The warnings, starting in 2003, were followed by the biggest one-year spike in suicide rates in 15 years among U.S. children and young adults, according to figures released last week by the U.S. Centers for Disease Control and Prevention.
Psychiatrists say the 8 percent increase in youth suicides in 2004 is the inevitable byproduct of those warnings, and caution that the trend may continue.
"Parents became very concerned," said Dr. Louis Kraus of the American Academy of Child and Adolescent Psychiatry and a psychiatrist at Rush University Medical Center in Chicago.
While the U.S. Food and Drug Administration's "black box" warnings on antidepressants were not recommended until late 2004, they were preceded by a series of public health warnings in both the United States and Europe.
"Most of my patients remained on medication but it took a lot of discussion," Kraus said in a telephone interview. "The majority of kids that were on antidepressants did not have the luxury of having a child psychiatrist."
Most pediatric antidepressant prescriptions are written by primary-care physicians and the warnings affected them as well, he said.
"Pediatricians became very wary of this and many opted not to prescribe antidepressants anymore," Kraus said.
Depression is the leading cause of suicide, which is the third-biggest killer of children and young adults between the ages of 10 and 24.
Dr. Andrew Leon of Cornell University in New York, who served on the FDA panel that approved the black box advisory, said it is too early to link the warnings and the spike in suicides. But the build-up to the warnings may be playing a role.
Fear of Lawsuits
"Parents read in the paper that there is a risk and they might not want to give their kids antidepressants," Leon said.
"Physicians might be concerned about litigation."
Leon said trial lawyers were at the 2004 hearings leading up to the black box warnings on antidepressants for pediatric patients, and again last December during FDA hearings on whether to extend the warnings to young adults.
"Trial lawyers were almost advertising themselves," he said.
Robert Gibbons of the University of Illinois at Chicago, who also served on the FDA scientific advisory panel, said he voted against the pediatric warnings.
"I was very concerned that rather than more carefully following up their patients, doctors would decide not to prescribe antidepressants," he said in a telephone interview. "I think we are starting to see the effects of that."
Gibbons this week published a study in the American Journal of Psychiatry that found a 22 percent decrease in youth antidepressant prescription rates between 2003 and 2005 in both the United States and the Netherlands.
Suicides climbed 14 percent among U.S. children and teens 19 and under in 2004 and were up 49 percent in the Netherlands between 2003 and 2005.
In real numbers, Gibbons said there were about 250 additional suicides in the United States in children aged up to 19. "I think that is a lot of dead kids," he said.
Gibbons is waiting for 2005 figures from the United States, which he expects by the end of this year.
"Will we the see the same thing in the 2005 data? I don't know. But I think we are really at the point now where people have to take a very serious look at this."
The FDA's Dr. Tom Laughren said the agency will follow the issue and see if rates continue to climb. But Dr. David Fassler of the University of Vermont College of Medicine was not satisfied.
"If we saw an increase like this in the death rate for cancer in a single year, there'd be a public outcry," he said.