Long-Run Trends in Antidepressant Use Among Youths After the FDA Black Box Warning

Effect of the FDA Black Box Suicidality Warnings for Antidepressants on Suicide Rates in the USA

Background: Some authors claimed that the US Food and Drug Administration (FDA) black box warning on treatment-emergent suicidality with antidepressants in adolescents (issued 2004) and young adults (issued 2006) led to an increase of suicides, based on the analyses of ecological data with debatable assumptions about putative changes in suicide rates. Aims: To explore if putative changes in suicide rates in adolescents and young adults at the time of the FDA warnings is a detectable signal in the data or compatible with random fluctuations. Method: We applied different changepoint analyses for adolescent and young adult suicide rates from 1981 to 2019 in the USA. Results: Changepoint analysis did not support a detrimental effect of the FDA black box warnings. The downward trend of suicides reversed several years after the warning in adolescents (2007-2009) and many years before in young adults (1999-2001). Limitations: Our analyses cannot rule out detrimental effects of the FDA warnings. However, even if there was such an effect, it was likely small and indistinguishable from random fluctuations in the available suicide data. Conclusion: There is no detectable change of trend in adolescent or young adult suicide rates in line with a detrimental effect of the FDA black box warnings on treatment-emergent suicidality.

Depression treatment preferences by race/ethnicity and gender and associations between past healthcare discrimination experiences and present preferences in a nationally representative sample

BACKGROUND

Depression treatment disparities are well documented. Differing treatment preferences across social groups have been suggested as a cause of these disparities. However, existing studies of treatment preferences have been limited to individuals currently receiving clinical care, and existing measures of depression treatment preferences have not accounted for factors that may be disproportionately relevant to the preferences of disparities populations. This study therefore aimed to assess depression treatment preferences by race/ethnicity and gender in a representative community sample, while accounting for access to healthcare, provider characteristics, and past experiences of discrimination in healthcare settings.

METHODS

We conducted a nationally representative study of individuals with depression in and out of clinical care. Treatment preferences (medication versus talk therapy) were elicited through a discrete choice experiment that accounted for tradeoffs with factors related to access and provider characteristics deemed relevant by community stakeholders. Past discrimination was assessed through questions about unfair treatment from medical providers and front desk staff due to personal characteristics (e.g., race, gender). We used conditional logit models to assess treatment preferences by race/ethnicity and gender and examined whether preferences were associated with past experiences of healthcare discrimination.

RESULTS

Non-Hispanic white respondents (OR-here, the odds of a talk therapy preference over the odds of a medication preference: 0.80, 95% CI: 0.64, 0.99) and men (OR 0.76, 95% CI: 0.60, 0.96) preferred medication over talk therapy, while non-Hispanic black respondents, Hispanic respondents, and women did not prefer one over the other. Past discrimination in healthcare settings was associated with lower preferences for talk therapy and greater preferences for medication, particularly among non-Hispanic black respondents and women respondents.

CONCLUSIONS

Addressing previous methodological limitations yielded estimates for depression treatment preferences by race/ethnicity and gender that differed from past studies. Also, past discrimination in healthcare settings was associated with current treatment preferences.

Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified

The United States Food and Drug Administration issued a Black Box warning in October 2004 after placebo-controlled trials of antidepressant medications found an increased risk of suicidal thoughts and behaviors among children and adolescents taking antidepressant medications relative to placebo. Subsequently, some researchers have concluded that the Black Box warning caused severe unintended consequences; specifically, they have argued that the warning led to reduced use of antidepressants among youth, which led to more suicides. In this paper, we critically examine research regarding the Black Box warning's alleged deleterious consequences. One study claimed that controlled trials did not actually find an increased risk of suicidality among youth taking fluoxetine relative to those taking placebo, but its measure of suicidality is likely invalid. We found that ecological time series studies claiming that decreasing antidepressant prescriptions are linked to higher rates of suicide attempts or actual suicides among youth were methodologically weak. These studies exhibited shortcomings including: selective use of time points, use of only a short-term time series, lack of performing statistical analysis, not examining level of severity/impairment among participants, inability to control confounding variables, and/or use of questionable measures of suicide attempts. Further, while some time-series studies claim that increased antidepressant prescriptions are related to fewer youth suicides, more recent data suggests that increasing antidepressant prescriptions are related to more youth suicide attempts and more completed suicides among American children and adolescents. We also note that case-control studies show increased risk of suicide attempts and suicide among youth taking antidepressants, even after controlling for some relevant confounds. As clinical trials have the greatest ability to control relevant confounds, it is important to remember such trials demonstrated increased risk of suicidality adverse events among youth taking antidepressants. The Black Box warning is firmly rooted in solid data whereas attempts to claim the warning has caused harm are based on quite weak evidence.

Liability and Patient Suicide

Suicide is one of the leading causes of liability against a psychiatrist treating adult patients. Reducing the risk of liability entails understanding the phenomenology of suicide, approaching suicide risk assessment from a clinical perspective, conceptualizing how malpractice cases unfold, examining the issues of foreseeability and proper risk assessment, and developing a risk management approach to mitigate against the potential for a bad outcome. The use of various suicide screening risk assessments in certain clinical contexts is a potentially useful first step in identifying the need for further risk assessment. In conducting a more detailed review of a patient's risk, nonsuicidal self-injury is typically distinguished from suicidal intent and action, although morbidity and mortality can also be associated with any deliberate self-injury. Understanding the concepts of means reduction and risk management planning are essential elements to assist in helping reduce risk. Special attention to risk reduction related to firearms has received increased attention in recent years. Proper assessment, and documentation thereof in clinical records can assist in reducing liability. This article reviews these basic elements for the general practitioner of adult psychiatry related to suicide risk, assessment, and liability surrounding patient suicide.

Targeting Serotonin Transporters in the Treatment of Juvenile and Adolescent Depression

Depression is a serious public health concern. Many patients are not effectively treated, but in children and adolescents this problem is compounded by limited pharmaceutical options. Currently, the Food and Drug Administration approves only two antidepressants for use in these young populations. Both are selective serotonin reuptake inhibitors (SSRIs). Compounding matters further, they are therapeutically less efficacious in children and adolescents than in adults. Here, we review clinical and preclinical literature describing the antidepressant efficacy of SSRIs in juveniles and adolescents. Since the high-affinity serotonin transporter (SERT) is the primary target of SSRIs, we then synthesize these reports with studies of SERT expression/function during juvenile and adolescent periods. Preclinical literature reveals some striking parallels with clinical studies, primary among them is that, like humans, juvenile and adolescent rodents show reduced antidepressant-like responses to SSRIs. These findings underscore the utility of preclinical assays designed to screen drugs for antidepressant efficacy across ages. There is general agreement that SERT expression/function is lower in juveniles and adolescents than in adults. It is well established that chronic SSRI treatment decreases SERT expression/function in adults, but strikingly, SERT expression/function in adolescents is increased following chronic treatment with SSRIs. Finally, we discuss a putative role for organic cation transporters and/or plasma membrane monoamine transporter in serotonergic homeostasis in juveniles and adolescents. Taken together, fundamental differences in SERT, and putatively in other transporters capable of serotonin clearance, may provide a mechanistic basis for the relative inefficiency of SSRIs to treat pediatric depression, relative to adults.