“Will the inevitable decrease in prescriptions ultimately lead to more teenage suicides?” asks The New York Times Magazine. Readers of FmH know I have covered the controversy over antidepressants and suicide in detail. I won’t belabor the points I have already made, except to summarize that, even though they do sometimes make their users more uncomfortable, any excess suicidality in users of the antidepressants should not be attributed to the drugs but to the way they are prescribed. Part of the art of prescribing is monitoring and managing side effects; we do not restrict ourselves only to medications that are trouble-free, but weigh the relative risks and benefits with our patients in making the decision to prescribe a given medication and following the patient once they are taking it. All well and good, if everyone has access to accurate data on the effects of a medication, but drug company minimization and concealing adverse information from both consumers and prescribers has made that impossible. The pharmaceutical manufacturers sitting on top of this cash cow have marketed the drugs as trouble-free and persuaded prescribers that little care was necessary to follow those taking the drugs under their supervision. Over the past two decades, this marketing strategy succeeded by shifting the bulk of SSRI prescribing from the psychiatrists who have traditionally followed depressed patients, have the training to assess the subtleties of antidepressant side effects and the subtleties of assessing suicidality, and the time to do so in their patient visits, to generalists, internists and primary care clinicians who have none of those assets.

The ‘black box’ warning about suicide risk in pediatric use of these medications was premature and unwarranted. Most data shows that antidepressants not only do not enhance suicide risk but that they decrease it. Here is a Google Scholar search into whose citations you can drill down if you have further interest. One of the effects of the cavalier attitude about prescribing the new generation of antidepressants has been a tremendous expansion of the indications for which they are used and a lowering of the threshold for using them, especially in children. Many speculate that the adverse publicity will make many parents skittish about having their children on antidepressants. With any luck, this reluctance will take its toll primarily on the more dubious uses of the medications and not on the most severe childhood depressions for which the medications remain urgently necessary, justifying any added risk if used carefully, and without which use there would be an expansion of childhood and teenage suicides. While I am not a child psychiatrist, given my strong interest in this issue I have had many conversations with my child-psychiatrist colleagues, including some of the most authoritative and well-respected pediatric psychopharmacologists in the Boston area, with whom I am privileged to collaborate at times. The good news is that they are not seeing the feared chilling effect; parents seem no more reluctant to approve antidepressant therapy for their children in need than before the furor began. Of course, they may not be a representative sample of antidepressant prescribers. By and large, the child psychiatrists I have queried are not the ones who would be prone to prescribe in a cavalier manner, with inadequate followup, or for dubious indications. But the premise of the Times Magazine‘s article — that there will inevitably be a decline in antidepressant prescribing since the FDA warnings — is not at all a given, as I see it.