With all the recent concern about SSRIs and suicidality, what advice should be given to the practising clinician regarding the management of a depressed young person?

Publicity has surrounded the issue of selective serotonin reuptake inhibitors (SSRIs) and suicidality since the publication of the case report by Teicher et al in 1990 (Am J Psychiatry 1990;147:207–10). It gained momentum last year with the recommendation of the Committee on Safety of Medicines in the United Kingdom that the use of SSRIs in children and adolescents should not be permitted, except for fluoxetine. This was based on a review of studies suggesting that there may be an increased incidence of agitation, behavioural changes and ideation akin to suicidal tendencies in these patients.

Following this, the US Food and Drug Administration and the Therapeutic Products Directorate in Canada each convened advisory groups from government and industry to provide guidance to physicians on the issue. The Canadian and US regulatory agencies did not recommend the complete withdrawal of SSRIs. This is largely because the studies they reviewed featured ill-defined indicators of suicidality and small numbers of subjects. In spite of this, there was sufficient evidence to alert physicians to the potential risk of suicidality and to remind them of the limited role of SSRIs in the overall treatment of depression.

Practitioners may rely too heavily on the anticipated effectiveness and on the much-vaunted innocuousness of the new antidepressants. This is particularly trouble-some regarding children and adolescents in whom the efficacy of these drugs has not been well demonstrated in randomized clinical trials. It is worth reminding clinicians that the “hit and run” approach to treating depression with a prescription rarely works and does not deal with the psychologic aspects of the illness. It also may not deal with the risks involved in the normal course of improvement of depression; for example, the risk of suicide does not necessarily decrease as the depression improves but may, in fact, increase at certain stages of the process of recovery. Drug therapy may also lead to adverse events. Each of these factors may be associated with fluctuations in levels of anxiety, agitation and mood swings often associated with suicidal tendencies. The unwanted effects of SSRIs may be different and more tolerable than those of the older antidepressants, but they are nevertheless significant.

Although the evidence for increased suicidality is weak, it must not be disregarded. It is not clear whether this tendency would be a direct effect of the medication, an epiphenomenon of the drug treatment or a feature of the improvement of the illness.

The treating physician is not advised to stop the use of SSRIs in the treatment of depression, especially when the patient’s condition is improving, but to be alert to the potential of suicidality, either in the patient’s thoughts or behaviour. Should this arise, and a link to the antidepressant be suspected, treatment with the drug should stop, with a gradual tapering of the dose. Close monitoring for discontinuation symptoms such as malaise and myalgia is recommended.

Once the patient has been successfully tapered off the suspected drug, should there be a continuing need for an antidepressant, fluoxetine may be an appropriate choice. It has a better record of effectiveness and of fewer incidents of associated suicidality in children and youth than the other SSRIs. Nonetheless, in all cases of depression, especially with a risk of suicide, continued vigilance and monitoring of the patient should remain in effect until complete recovery. This entails regular visits and social and family intervention when indicated.