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Am Fam Physician. 2008;77(5):678

Background: Much attention has been focused on the risk of suicide in children receiving antidepressant medications. A meta-analysis conducted by the U.S. Food and Drug Administration found an increase in suicidal behaviors (attempts and ideation), but no increase in suicides. This study represents an update of the risk-benefit analysis of antidepressants in the treatment of depression, obsessive-compulsive disorder (OCD), and non-OCD anxiety disorders.

The Study: Bridge and colleagues included randomized, placebo-controlled trials that studied selective serotonin reuptake inhibitors (SSRIs) and second-generation agents. Target populations were children and adolescents 19 years of age or younger with a diagnosis of major depressive disorder (MDD), OCD, or non-OCD anxiety disorders. Outcome measures included symptom changes based on assessment scales (to measure the benefits of antidepressants) and suicidal ideation and attempts (to measure the risks).

Results: In patients with MDD, the risk difference between patients receiving an anti-depressant and those receiving placebo was 11 percent (95% confidence interval [CI], 7 to 15), with a number needed to treat (NNT) of 10 (95% CI, 7 to 15). The pooled risk difference for suicidal ideation/attempt was 1 percent (95% CI, −0.1 to 2.0), with a number needed to harm (NNH) of 112. For treatment of patients with OCD, the pooled risk difference between those receiving an SSRI and those receiving placebo was 20 percent (95% CI, 13 to 27), with an NNT of 6 (95% CI, 4 to 8); the pooled risk difference for suicidal ideation/attempt was 0.5 percent (95% CI, −1 to 2), with an NNH of 200. For patients with non-OCD anxiety disorders, the pooled risk difference (after excluding a small pilot study) between treated and untreated groups was 30 percent (95% CI, 19 to 41), with an NNT of 4 (95% CI, 3 to 6); however, there was significant heterogeneity among the studies. Suicidal behavior risk was low, similar to the other disorders analyzed. Age, duration of depression, and the number of sites in the treatment trial were significant moderators of efficacy outcomes in the depression trials.

Discussion: The greatest response to antidepressants occurred in patients with non-OCD anxiety disorders; effectiveness in patients with OCD was intermediate; the lowest response was in patients with MDD. However, all conditions studied showed response to antidepressants, particularly in older ages. There was a small increase in suicidal behavior, but no completed suicides occurred in the trials reviewed.

editor's note: A landmark study found that when unpublished studies were factored into the assessment, the risks of prescribing SSRIs for children and adolescents outweighed the benefits, suggesting publication bias.1 Since the results of that study, other reviews have acknowledged that there may be a small increase of suicide risk among children and adolescents only early in the initiation of therapy. Ecological studies do not support an important association between the use of SSRIs and suicidality.2 Most children and adolescents who attempt or complete suicide are not under pharmacologic treatment. Prescribing antidepressants for this population remains controversial. Although this study suggests that the benefits outweigh the risks, especially for some psychiatric conditions, antidepressants are not a panacea.—c.w.

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