Children and antidepressants

The parent on the phone is frightened. "What are these pills doing to my child? She says she wants to die."
I'm on call, covering for a colleague (there are no children in my practice). I've seen the news reports about the FDA warnings. Is her child more likely to die with the pills, or without? I try to figure out what else is upsetting the parent and child, and then I say something like this: that meds can affect behavior, that her child needs close monitoring, that her child should be assessed in ER.
Later, I debrief with some child psychiatrists. It turns out that different drug companies have had different definitions of "suicidal behavior," and it's been hard to sort out risks. And studies are sorely lacking. Some symptoms may increase impulsive behavior (I'm thinking of anxiety, panic, increased energy, and restlessness), and sometimes those symptoms are side effects of meds.

A depressed, impulsive, panicky patient may be at more risk of suicide. But untreated patients have increased risk of suicide. The take-home point: suicide is more likely in untreated patients. For most patients, the benefits of the meds outweigh the risks. But treated patients need really close surveillance.