Can antidepressants contribute to suicidal tendencies? The jury is still out, but concern is high enough that the FDA issued a public health advisory, warning that certain antidepressants might worsen depression and cause agitation, anxiety, and hostility in some patients. Psychologist Patricia Farrell, Ph.D., joined us with an expert look at this news.
MODERATOR: Welcome to WebMD Live, Dr. Farrell. This public health advisory has been all over the news the last couple of days, and it's sure to create a lot of confusion. Can you explain what this means for those who are using antidepressants or have a family member who takes them?
FARRELL: Antidepressant medications have been one of the greatest advances in the psychiatric arena in the past 50 years. They are extremely helpful, but like any medication, and that includes aspirin, they must be taken thoughtfully. The patient must be aware of the potential side effects and a qualified physician must be monitoring their use of it.
The FDA advisory is really just a prudent reminder that people who are depressed may become suicidal. This does not mean, necessarily, that the FDA believes these medications cause increased incidences of suicide.
MEMBER QUESTION: It seems notable to me that this issue has been forwarded to the FDA. Why must the FDA intervene in such an issue that would seemingly be left in the hands of the "experts?" Have the doctors dropped the ball on this issue?
FARRELL: The FDA has wisely entered into this debate, because of two reasons: Number one, these medications are very widely prescribed. They are used for a great variety of disorders, not just depression, and secondly, many physicians prescribing these medications are not psychiatrists. This last consideration is of great concern, because general practitioners do not usually receive specialized training in recognizing and treating psychiatric illnesses. It seems wise, therefore, that the FDA advises everyone about its concerns.
MEMBER QUESTION: If one of these drugs is dangerous, if you are taking two of them at the same time are you more likely to have problems?
FARRELL: This is really a question for your prescribing physician. Many times, more than one of these medications will be taken at the same time, since it is believed that one medication can actually increase the efficacy of the other medication. They work together in a number of patients.
MEMBER QUESTION: What antidepressants are they saying do this? I ask because the one I am on seems to do the same.
FARRELL: Here's the list:
- Prozac (sold generically as fluoxetine)
- Zoloft (sertraline)
- Paxil (paroxitine)
- Luvox (fluvoxamine)
- Celexa (cetalopam)
- Lexapro (escitalopram)
- Wellbutrin (bupropion)
- Effexor (venlafaxine)
- Serzone (nefazodone)
- Remeron (mirtazapine)
MEMBER QUESTION: Zoloft has been wonderful for me (anxiety and panic disorder). I have never thought I was depressed but did not enjoy social situations. Zoloft has changed my life totally for the better. I'm calmer and not suspicious but engaged in social situations. I have not peaked out on my dosage (75 milligrams now). What should I expect to experience if medication is not working but causing a problem?
FARRELL: Most of these medications, when you first begin therapy, may cause increased anxiety or agitation or insomnia. When this happens, you should discuss this with your doctor. These side effects generally abate within the first week. If they don't, again, talk to your doctor. If you start having unusual thoughts that are not normal for you, thoughts of either hurting yourself or anyone else, if you start becoming extremely impulsive, please call your doctor right away.
MEMBER QUESTION: I believe there was a study done in October of 2003 that produced statistics that these types of drugs do, indeed, increase suicidal tendencies primarily in youth. Are you saying that these statistics/reports are false?
FARRELL: As a professional, I question every study that is done, because I know there is no study that is done that does not contain either some problem in methodology or in interpretation. Therefore, I would say if you can't read these studies directly yourself and understand them, that means that someone else is interpreting them for you, and in any interpretation there is a selective process that goes on, which may miss some important details. So please don't just accept the studies as reported by someone else.
FARRELL: Classically, we think of suicidal people as doing a number of things:
They may have decreased interest in things. They may start giving away personal items that they have special love for. This may include pets, clothing, jewelry, poetry, etc. They may begin isolating themselves. They generally will give some indication by what they say, and this may include statements such as, "What's the use?" "Why bother going on?" "This will all be over soon."
However, sometimes, suicidal people do not engage in the typical behaviors. They may, instead, seem happier, seem more at peace with themselves and the world, and may actually tell you about plans they have for the future. This does not mean, however, that they are not suicidal.
So it is very difficult for even professionals, sometimes, to discern the suicidal from the nonsuicidal person.
MEMBER QUESTION: Initially I heard that suicidal tendencies were increasing in children and teens and to avoid prescribing these drugs to them. Are the FDA and/or doctors now saying it is increasing the tendencies in adults taking these drugs as well?
FARRELL: The FDA has included adults in their advisory. I think that that is because, as I said before, children, adolescents, and adults at the beginning of this type of pharmocotherapy may exhibit some unusual behavior, agitation, or impulsivity. I don't think that the drugs, per se, as the FDA has indicated, are pushing people to suicidal ideation.
MEMBER QUESTION: Why is this warning issued now, since these drugs have been on the market for so long?
FARRELL: I think the information that was coming out of studies in England was the prime mover for having the FDA take a closer look at these drugs. This is not unusual, because we have seen this in the past; either the British or the medical authorities in the Netherlands have taken action against certain anti-anxiety drugs or drugs used for insomnia and the FDA has then taken a closer look.
MEMBER QUESTION: Are they saying that these drugs will cause suicidal ideation, even if the person has never had any in the past? I am taking Zoloft for anxiety and feel much better, now I am scared to death. I don't feel suicidal at all? So should I worry?
FARRELL: From what I have been reading in the professional journals, and from what I have been hearing from psychiatrists, there are certain pre-existing psychiatric conditions where the person would have a tendency to suicide, and these are the individuals who are at greatest risk. I think it's safe to take your drug, but I would recommend you speak to your doctor.
MEMBER QUESTION: Does it have to be a certain dose before this kind of reaction?
FARRELL: I believe this is really on an individual basis, and I haven't seen any references to certain dosage levels being more problematic than others. It appears that it is related to the energizing effect of the medications.
MEMBER QUESTION: Are we talking about the drugs making you more depressed and leaning towards suicide or do they make you feel better, or well enough, to think of suicide?
FARRELL: That is correctly and very well phrased. The belief is the drugs may energize you sufficiently to put in place a plan to suicide. In fact, some people, when placed on these particular medications, will experience a level of energy they have never had before, and this can place them at risk for impulsive self-harm, as can drinking alcohol when you're on these drugs.
MEMBER QUESTION: So you are saying that the drugs do not cause the thoughts of suicide; it would be the person who does? And these drugs give them the energy to carry it out; therefore those of us who have never thought of such a thing are not at the high-risk level?
FARRELL: I don't think we can make any definite statements about whether or not these medications would cause suicidal thinking, but it must be given careful consideration. I don't think there's reason for alarm here, but there is reason for concern of an appropriate nature. Your prescribing physician should be discussing this with you because of the new packaging requirements of the FDA.
MEMBER QUESTION: My daughter is 15 years old. She has been a cutter for more than two years and recently attempted suicide. She was prescribed Zoloft. Is she at a greater risk now?
FARRELL: I believe that the Zoloft was prescribed for the cutting behavior that you have mentioned. I don't believe she is necessarily at greater risk; however, I would urge you to bring this to the prescribing physician's attention.
MEMBER QUESTION: My mother is on Serzone. When she is having a bad, depressing day she sometimes takes more than the prescribed amount. Could this cause the suicidal tendencies?
FARRELL: I would be very concerned if anybody were to, on their own initiative, change their dose of any of these medications without their doctor's approval. I would also look into our drugs and herbs section on WebMD to see more about this particular drug, which, if I am recalling correctly, can have liver problems associated with it. Therefore, excessive doses could place the person at higher risk. Please have her talk to her doctor.
Let me add an addendum: Many times patients confuse two classes of drugs and how they work. One class is the anxiolytics and the other is the antidepressants. Anxiolytic drugs work usually on a PRN (as needed basis) and antidepressant drugs work on raising blood levels of that particular drug. Therefore, while the antianxiety drugs can be taken when needed, the antidepressant drugs must be taken only as prescribed. You cannot take more of the antidepressants and get an immediate better effect. As a matter of fact, you can get yourself into serious trouble.
MEMBER QUESTION: I'm taking Effexor XR for anxiety and Trazadone to help me sleep. I've been feeling depressed for the past week which is very abnormal for me. I've been taking this medication for four months now. Could it be the Effexor that is causing this? I told my doctor and he has increased it again. I'm a bit worried after hearing the FDA warning. As a psych nurse, I do know warning signs and just wondered what your opinion was.
FARRELL: Once again, you might want to speak to your doctor or get a second opinion. I don't know if it could be related to the dose of medication you're taking. As a medical professional, you are obviously aware of the fact that sometimes, rather than increasing a dose of a medication, the dose should be reduced.
MEMBER QUESTION: Do you feel antidepressants should be prescribed to children?
FARRELL: I have great concerns, unless the person who does the prescribing to the child is a pediatric psychiatrist and all behavioral interventions have been tried first. Sometimes this is a phase of life that the child may be going through, or it could be related to something that is happening either in the home or in school or both.
MEMBER QUESTION: Is it a sign of depression to think about suicide, but know you will never do it because of how it will affect you family?
FARRELL: This is a common thought that a number of people have, even those who do not suffer from depression. If it concerns you, then I suggest you talk to a mental heath professional, because there might be something in your life that needs attention. This does not necessarily mean you need medication.
MEMBER QUESTION: What are the signs to look out for in teenage depression and suicide?
FARRELL: In teenagers, there are so many factors involved that it could be difficult to see signs that would definitely point to suicide; however, depression may manifest itself by:
Sudden changes in mood, sleeping habits, or eating behavior Irritability Social isolation Dramatic change in either grades in school or behavior related to school or going to school Some form of self medication, and by this I mean over-the-counter cough medicine, alcohol, or street drugs
Any of these should be an issue for discussion with the teen.
MEMBER QUESTION: My 11-year-old son takes one pill of Celexa each night. He seems fine, but in light of this report should I have some concern for his safety?
FARRELL: Whoever is doing the prescribing should be the person you call about this. As I've said before, if he's been on it for awhile there shouldn't be a problem, and the problems don't appear to be dose related, so that this would not be a problem. But please talk to the prescribing healthcare professional.
MEMBER QUESTION: Nine years ago my husband committed suicide after taking Prozac for seven days. He was only mildly depressed and within those seven days lost weight, was anxious, etc. At the time the doctors indicated that they felt that the increased level of depression was caused by the medication. My question is if the doctors were aware of the problem nine years ago why haven't warnings been issued long ago? Is this another case of drug companies just not wanting to admit to the side effects of the medication that they manufacture? Also, is there a place where I can register to become part of the data collected for a study?
FARRELL: On the FDA.gov site they list all sorts of trials that are looking for people who would wish to enter them. You may find one that is appropriate for you, or you can do a search of the site for the National Alliance for the Mentally Ill, at www.nami.org, where you will probably find a lot of helpful information on this subject.
I think that although there have been instances where people have committed suicide on these drugs, no one can say for sure that it was the drug that caused it, and therein lies the problem. It is so individual and so difficult to prove either way. That is the reason we have heard very little on this until now.
MEMBER QUESTION: Why do so many people need treatment with these drugs in the first place?
FARRELL: To my mind, and I could be giving you a biased opinion on this because I am a psychologist, I believe that there are a number of things in people's lives that could be disruptive to normal happy functioning. I do not believe that they should be handled immediately with medication. I also believe there are many people who need medication, but my concern is that the medical model is overtaking a more reasonable approach to life's stresses. Medication will never be able to teach you anything, but it may make you more receptive to learning something.
So it would seem more useful to use both approaches, therapy and medication, when appropriate. But I believe that therapy, if appropriate, should be sought first.
MODERATOR: Do you have any final words for us, Dr. Farrell?
FARRELL: I would suggest that anybody who is interested can easily sign up at the FDA site to receive alerts on medication clinical trials or medical devices. This way, you can be sure that you will be receiving the information in a timely fashion, and you can take whatever action you believe you need to take.
MODERATOR: Thanks to Patricia Farrell, pH for sharing her expertise with us. For more information and advice on this topic, be sure to visit the WebMD message boards, including Depression and Anxiety: Medications and Treatments and Anxiety and Panic Disorders: Patricia A. Farrell, pH , where you can post your questions and comments for our in-house experts, as well as your fellow WebMD members.