Do SSRIs increase the risk of suicide in those diagnosed with clinical depression?
By Skye-Ali Johnson, Amora Campbell, Heaven Pete and Selah Hart with Josephine Chu, Urban Health Media Project
Artwork by Pooja Singh, Graphics & Social Media Coordinator
July 21, 2020
Antidepressants present a counterintuitive challenge.
The most popular ones have been dogged for decades by claims they can actually increase the risk of suicide, particularly for children. This link is described most often for the class of drugs known as selective serotonin reuptake inhibitors or SSRIs.
For every study that purports to prove a link, there’s one countering it. So what’s a concerned parent to do? We researched the topic, reviewed medical journal articles and interviewed experts on every side of the debate.
Our conclusion: The increased risk of suicidal thoughts in children exists, but it shouldn’t dissuade the parent of a suicidal youth from considering SSRIs if recommended by a trusted psychiatrist who will monitor symptoms.
Dr. Bhavin Dave, a child and adolescent psychiatrist at the Children’s National hospital in Washington, D.C., called antidepressants a “life-saving medication in some cases.”
After all, he points out, untreated depression can also lead to a higher risk for suicide. The lowest percent risk for untreated depression - 2.2% - is greater than the risk of suicidal thoughts in patients who take SSRI’s, or 0.7-2%, Dave noted. That’s not to say antidepressants are for everyone, but some type of treatment should be.
It is a critical time for the discussion as Black youth suicides are rising faster than for whites, suicides are increasing overall and racial disparities are in stark focus. That underscores both the problem and the challenge. Racism, including the use of law enforcement on people with mental illness, perpetuated stigma surrounding treatment as has medical bias, experimentation on African-Americans and what many call the structural racism underpinning the entire health care system.
COVID-19, which already disproportionately sickens and kills African Americans, is predicted to lead to tens of thousands more suicide deaths due to unemployment, isolation and uncertainty. Major depression, like hypertension, is a “silent killer” of African American men.
Risks do exist, however.
“Antidepressants are serious mind altering drugs and have risks and shouldn’t be taken lightly,” said Kim Witczak, an advertising industry consultant and consumer representative on the Food and Drug Administration’s Psychopharmacologic Advisory Committee. “There should be a discussion about the potential harms and an exit strategy as these drugs were never meant for more than short term use.”
Witczak’s husband died by suicide five weeks after his doctor prescribed him the antidepressant Zoloft to treat his sleep problems. She has been a drug safety advocate ever since and helped to get the most serious “black box” warning - which alerts to serious, potentially life threatening risks - required for these antidepressants.
The risk of suicidality necessitates an “informed conversation with your doctor about the real risk short-term, long-term and what to look for,” Witczak said.
Preventing or causing suicide?
Dr. Frank Fortunati, who heads the Yale’s Psychiatric Hospital, believes a phenomenon known as activation is likely responsible for reported upticks in suicide. As the concept goes, antidepressants improve patients’ moods enough to give them the wherewithal to act on suicidal urges.
Here’s a look at the research:
- A 2016 study in The Pharmaceutical Journal found SSRIs and the class known as serotonin-norepinephrine reuptake inhibitors double the risk of suicidality and violence in healthy adults with no signs of a mental disorder.
- An analysis of studies looking at the black box warning cited recent data increasing antidepressant prescriptions are related to more suicide attempts and completed suicides among American children and adolescents.
- However, a 2007 study in the American Journal of Psychiatry found that in the U.S. and the Netherlands, when SSRI prescriptions for children and adolescents went down, suicides rates went up. Seven years later, a study in Acta Psychiatrica Scandinavica found the black box warning may have increased the number of suicides by leaving a number of suicidal youth without antidepressant treatment.
But Dave said the numbers are at least concerning enough to warrant warnings and careful consideration of antidepressant pros and cons for children.
Christine Conoboy, an executive assistant in the Washington, D.C., area, saw firsthand how important it can be to question doctors and change medications when something isn’t working. Her three daughters have clinical depression and two of them were prescribed Paxil by their pediatrician years apart.
It made them “zombie-like,” and they had to wait two weeks before they were able to change the dosage of the medication, Conoboy said.
Tamara Ince, a licensed clinical social worker in Washington, D.C., said many people can be misdiagnosed due to insufficient evaluation, so it’s important to regularly monitor a patient’s behavior. A 20-minute survey during a doctor's visit often isn’t enough to truly understand what is going on in the patient’s life.
If you recently lost a friend or had a life-changing accident, for example, it is normal to feel depressed, Ince explained.
“In a sense we all have a certain level of anxiety,” she said. “Sometimes life events give volume to our brain’s response.”
However, Ince said there are some who need medication to “stabilize their mental health” or they “won’t fit well with societal rules.” She suggests discussing with primary care physicians, as well as mental health specialists to first understand and accept a diagnosis before deciding on a treatment.
“I always believe that you should pause to see if there are other things you should do before you take antidepressants,” Witczak said.
Making that pause permanent, however, carries its own risks. Dave said it’s not uncommon for him to get a new patient, especially young men, who have never had therapy or any mental health treatment until a behavioral incident at school or with law enforcement prompts the visit. By that point, antipsychotic medications - which carry more risk - are often needed because unhealthy, often antisocial, coping mechanisms developed to compensate for anxiety, inattention or anger problems.
Blacks and mental health treatment: a painful past
African Americans have a long history of discrimination and exploitation in the healthcare system. In the Tuskegee syphilis study, men who were mostly poor and illiterate sharecroppers were enrolled in a study of syphilis. Hundreds were not given penicillin when it was found to be a cure, dozens died, and countless others were infected.
A lack of racial representation - only 5 percent of physicians are black - adds to their distrust and reluctance to speak openly with doctors. Studies also show blacks are half as likely as whites to seek mental health help in the first place.
As a result, blacks trust word of mouth over medical professionals and are more likely to turn to churches for support.
Nichole Pete, 45, said the medical industry can be “a little sketchy sometimes.”
“I trust them but I feel like if there’s a little thing they can do to get some extra money they will,” she said.
Claressa Campbell, 47, has long struggled to find a doctor she trusts. She called the healthcare system “incompetent,” saying physicians would have to “go against what they’re taught in order to treat you like an individual.”
Many African Americans have had bad experiences with prescription drugs, which makes them feel like doctors aren’t listening to them and don’t have their best interests at heart.
Symea Johnson, 46, started taking a generic form of Lipitor after a series of strokes in 2018, but this drug, meant to decrease the risk of future strokes, has actually left her with a slew of side effects including chronic stomach ulcers and digestive issues.
“With prescription drugs, you’re not winning, you just find yourself with a cabinet full of medication,” she said.
Campbell has a hard time getting the medication she knows would work best for her. She also struggles to find a doctor she trusts.
“They want you to take something that makes you feel sick,” she said. “You tell them it makes you feel sick and they say, ‘well why don’t you take it for another three to four months?’”
Campbell says she is stuck in a vicious cycle where she runs out of medicine and then she is unable to book an appointment with her doctor or get a new doctor when the ones covered by her Medicaid plan change.
African-Americans, already far more resistant to prescription drugs, are more likely to fear suicidal side effects from antidepressant medication. The black box warning issued by the FDA says the drug may increase the risk of suicide.
Antidepressants, among other prescription drugs, are also known to have scary withdrawal symptoms.
Mikiya Brown, 18, said she heard antidepressants can cause suicidal thoughts and may increase the risk of suicide. Isaiah Henson, 24, said he prefers natural remedies because “people think antidepressants are the cure, but they actually lead to anxiety, more depression and body issues.”
Reimagining mental health care in the black community
After decades of stigma surrounding mental health treatment in and out of the black community, many believe it is time to acknowledge that a wide range of treatment is needed and that the health care system needs to better accommodate people of all colors with care that’s integrated into primary care doctors’ offices.
“There is no shame in having a mental illness and having to take antidepressants just like there is no shame in having a physical illness like a stroke or diabetes,” said Dr. Georges Benjamin, executive director of the American Public Health Association.
Witczak stressed the importance of a strong doctor-patient relationship, especially when it comes to teens and antidepressants. Teens suffer from bullying, peer pressure, self-esteem and sometimes even abuse, which makes them more likely to be prescribed antidepressants.
She doesn’t believe “throwing a pill at something is for everyday stresses,” she said.
Dave said doctors should listen to their patients and create an environment where patients feel comfortable “communicating everything they possibly can to you about their experience with the medications.”
Before deciding whether antidepressants will be a part of the treatment plan, Dave has patients complete a full risk assessment and a full psychosocial assessment. He also stressed physicians’ role as educators responsible for informing families and individuals about antidepressants.
“I’m asking someone for a tremendous amount of faith in me when I am asking them to put some kind of born chemical into their body,” he said.
Darryl Webster, a special education social worker in the District of Columbia Public Schools system, is a strong advocate for mental health support and treatment options in schools. He refers children to psychologists instead of recommending antidepressants, because he supports parents and children having an open discussion about mental health.
Webster faced devastating anxiety, depression and agoraphobia as a young adult. He avoided prescription drugs for a long time out of fear of side effects, but when his anxiety got to a point where he couldn’t have a face-to-face conversation without running away, he decided it was time to give in. After about five years, he developed enough coping strategies to function well without medication.
He urged people not to be deterred by one bad experience with one particular medication.
“Sometimes you have to go through multiple drugs to see which one chemically suits your body,” he said.
Webster added that there are countless treatment options, from meditation to medication, and people have to make those choices for themselves. No matter what the choice, medication alone is never the answer.
“If you truly need and are prescribed antidepressants, you should be surrounding yourself in environments that are stress-free, drug and alcohol free, and safe in order to improve your health positively in the near future outside of the doctor’s office,” Benjamin said.