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NEWS FROM CAMBRIDGE HEALTH ALLIANCE
For Immediate Release December 5, 2005

TEEN SUICIDE AND ANTIDEPRESSANTS:
HARVARD PSYCHIATRISTS REVIEW BLACK BOX WARNING

Cambridge, Chelsea, Everett, Medford, Revere, Somerville, Winthrop, MA…. Imagine your teenager over several weeks has no energy, is unable to get out of bed, and there are family members who have suffered from debilitating depression. Or you have an adolescent who made a suicide attempt by taking an overdose after a prolonged period of irritability and slipping grades with little interest in anything. Of course, a thorough evaluation and therapy is the first line of defense-trying to come to an understanding of why things are so difficult for your child. But, at some point, doctors, families, and patients may consider a trial of an antidepressant to see if it helps teenagers to function and in a more critical situation or in more critical cases help teenagers to endure. Often when a child or adolescent persistently thinks about killing themselves, it is compared to an untreated fever. The urge for self harm is not a state of wellbeing.

In this current climate, with the recent FDA warning about the use of antidepressants with children and adolescents, doctors and patients are more cautious about treating youth with antidepressants. Parents and doctors are challenged to make a balanced assessment of risk and benefits. Dr. Rappaport, Dr. Jefferson B. Prince, and Dr. Jeff Q. Bostic of the psychiatry department of Harvard Medical School in their article in the December issue of The Journal of Pediatrics "Lost in the Black Box: Juvenile Depression, Suicide and the FDA's Black Box" encourage clinicians to pay careful attention to identify and address modifiable risk factors for suicide that include treating depression/ anxiety, storing guns safely, and treating substance abuse. Important risk factors for suicide include depression, stressful life events, substance use/abuse, irritability, agitation, and impulsivity.

The authors detail the FDA concern about the possible association between selective serotonin re-uptake inhibitors (SSRIs-a class of antidepressants) and worsening of suicidal thoughts and/or new onset of increased suicidal behavior. In the FDA review of suicidal data, there are limitations; many of the patients seen in the office of pediatricians and psychiatrists were excluded from the 24 studies (patients who were very sick with depression and were significantly suicidal, and patients with other disorders present such as ADHD). The FDA examined past records of the patients (rather than interviews), and it was difficult to identify /assess and classify the suicidal intent of the patients. Interestingly, examining large databases between 1990 and 2000 for the changes in antidepressant prescription and adolescent suicides showed that geographical areas where SSRI prescriptions increased, there were reductions in adolescent suicide. In another study, Valuck identified 24,119 adolescents diagnosed with depression and/ or receiving antidepressants. Adolescents treated for longer periods with antidepressants (more than 180 days) were less likely to make suicide attempts than those treated for less than fifty-five days.

With Dr. Rappaport's experience as a doctor working with high risk adolescents at school-based health centers and assistant professor of psychiatry at HMS, she was asked about guidelines for parents dealing with depressed teenagers: " It is key that they know that they are not alone, and that probably one of the most stressful problems for parents is to deal with a teenager who has an 'invisible disease'-major depression-that can make it hard for their adolescent to function or want to be alive. Given the recent events pediatricians and child psychiatrists, families, and patients need to weigh the risk and benefit of treatment to promote growth and avert the debilitating impact of juvenile depression. Medication may be one important aspect (consideration) of treatment," said Rappaport.

Dr. Rappaport is director of school programs at Cambridge Health Alliance, and she sees patients at Cambridge Health Alliance's Teen Health Center. She is also consulting child and adolescent psychiatrist to the Cambridge Public School system. She is an assistant professor of psychiatry at Harvard Medical School, and was selected in 1999 by the American Academy of Child and Adolescent Psychiatry as one of the writers of Clinical Parameters, the national guidelines for school consultation. Her previous publications and presentations have focused on school violence, school-based mental health care, assessing and managing violent and aggressive students, and in translating psychiatric concepts for teachers.

THE JOURNAL OF PEDIATRICS
The Journal of Pediatrics is a primary reference for the science and practice of pediatrics and its subspecialties. This authoritative resource of original, peer-reviewed articles oriented toward clinical practice helps physicians stay abreast of the latest and ever-changing developments in pediatric medicine. The Journal of Pediatrics ranks 3rd of 70 pediatric journals receiving the most citations (Science Citation Index). The Journal is published by Elsevier, a leading global publisher of scientific, technical, and medical journals, books, and reference works. It is a member of the Reed Elsevier plc group. URL: www.jpeds.com

CAMBRIDGE HEALTH ALLIANCE
Cambridge Health Alliance is an innovative, award-winning health system that provides high quality care in Cambridge, Somerville, Everett, Revere, and Boston’s Metro-North communities. It includes three hospitals, more than 20 primary care practices, the Cambridge Public Health Department, and the Network Health plan. With this unique model, the Alliance is able to offer the finest health services, a diverse working environment, and a premier training experience in community-based medicine.

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