Re: Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports
Dear Editor,
Re suicide and antidepressants in children: BMJ press release and Sharma et al, 352:i65, 2016
We are writing to express our concerns regarding the editorial process involved in the publication of the above article. As outlined below, the article is fundamentally flawed in presentation and logic, and the results have been further misrepresented by the BMJ in its own press release. The BMJ is highly regarded and anything published by the BMJ is likely to be taken as fact by journalists and the public. It is therefore crucial that the BMJ operates with the highest levels of peer review scrutiny and editorial comment.
Depression in young people is under-diagnosed (1) and under treated. Parents often may feel conflicted or guilty. Suicide is a highly emotional topic and the claim that anti-depressants increase suicide in young people is likely to cause untold worry and potential harm to young people. It is likely that some young people will stop taking their medication and thus increase the risk of harm, and that others will not start taking anti-depressant medication because they believe it will do more harm than good.
To limit this damage we ask the BMJ to review their press release headline, and publish a statement to correct the factual errors that have been made.
We note a number of specific instances where the peer review process apparently failed to identify errors and inconsistencies in the research report. Of particular note we highlight two problems:
1. The term ‘suicide’ is used in the discussion when in fact the data concerned refer to ‘suicidal behaviour’. This is a hugely important difference. The data presented shows there were no instances of suicide in children or adolescents.
2. The authors state that it is known that anti-depressants increase the risk of suicide in children and adolescents, which is not factually correct. The references cited do not support this.
In addition to problems with the paper itself the BMJ press release then presented the research in a misleading way, stating that the study showed that anti-depressants doubled the risk of suicide in children.
Neither the paper itself or the editorial provided important contextual information which is critical to an interpretation of the study. Of particular importance is that fact that of the five antidepressants mentioned in the article, only two (fluoxetine and sertraline) are currently recommended by NICE (the National Institute for Health and Care Excellence) for the treatment of depression in young people. Two of the five (paroxetine and venlafaxine) have been contra-indicated for use in children and adolescents by NICE since 2005.
There appears to be little in this paper that is new. Numerous meta-analyses have commented on the poor quality of available data, and also expressed concerns that we do not have data on the most severely depressed and suicidal young people who have been excluded from trials (e.g. (2, 3)). They have also noted the small increased risk of suicidality with SSRIs consistent with previous analyses, and NICE guidelines appropriately recommend close monitoring.
It is well established that under-treating depression in children and young people is linked to suicides. For example, a review of 574 youth suicides reported that only 1.6% had been exposed to antidepressants (4). Young people need access to a range of individualised evidence based treatments. The possible risks of harm from antidepressants (or psychological therapy) must always be balanced against the benefits of treatment and the elevated risk of suicide in severe, untreated depression.
We fully support the call for transparent data and better monitoring of adverse events in all trials including psychological treatment trials. These trials have not been held to the same degree of scrutiny, despite evidence that psychotherapy may also cause harm (5, 6).
Dr Bernadka Dubicka
Adolescent psychiatrist and honorary senior lecturer
University of Manchester and Lancashirecare Foundation Trust
Dr Alys Cole-King
Clinical Director Connecting with People
Consultant Liaison Psychiatrist (Betsi Cadwaladr University Health Board)
Dr Shirley Reynolds
Director Charlie Waller Institute
Professor of Evidence Based Psychological Therapies
School of Psychology and Clinical Language Sciences
University of Reading
Dr Paul Ramchandani
Reader in Child and Adolescent Psychiatry & Deputy Head
The Centre for Mental Health
Imperial College London
1. Fitzpatrick C, Abayomi N-N, Kehoe A, Devlin N, Glackin S, Power L, et al. Do we miss depressive disorders and suicidal behaviours in clinical practice? Clinical Child Psychology and Psychiatry. 2012;17(3):449-58.
2. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents [Systematic Review]. Cochrane Database of Systematic Reviews. 2012;11:11.
3. Dubicka B, Hadley S, Roberts C. Suicidal behaviour in youths with depression treated with new-generation antidepressants: Meta-analysis. British Journal of Psychiatry. 2006;189:393-8.
4. Dudley M, Goldney R, Hadzi-Pavlovic D. Are adolescents dying by suicide taking SSRI antidepressants? A review of observational studies. Australasian Psychiatry. 2010;18(3):242-5.
5. Wolpert M, Deighton J, Fleming I, Lachman P. Considering harm and safety in youth mental health: A call for attention and action. Administration and Policy in Mental Health and Mental Health Services Research. 2015;42(1):6-9.
6. Nutt DJ, Sharpe M. Uncritical positive regard? Issues in the efficacy and safety of psychotherapy. J Psychopharmacol. 2008;22(1):3-6.
Competing interests:
No competing interests
31 January 2016
Bernadka W. Dubicka
adolescent psychiatrist and honorary senior lecturer
Shirley Reynolds, Paul Ramchandani, Alys Cole-King
University of Manchester and Lancashirecare Foundation Trust
The Junction Adolescent Unit, Scotforth, Piccadilly, Lancaster LA1 4PW
Rapid Response:
Re: Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports
Dear Editor,
Re suicide and antidepressants in children: BMJ press release and Sharma et al, 352:i65, 2016
We are writing to express our concerns regarding the editorial process involved in the publication of the above article. As outlined below, the article is fundamentally flawed in presentation and logic, and the results have been further misrepresented by the BMJ in its own press release. The BMJ is highly regarded and anything published by the BMJ is likely to be taken as fact by journalists and the public. It is therefore crucial that the BMJ operates with the highest levels of peer review scrutiny and editorial comment.
Depression in young people is under-diagnosed (1) and under treated. Parents often may feel conflicted or guilty. Suicide is a highly emotional topic and the claim that anti-depressants increase suicide in young people is likely to cause untold worry and potential harm to young people. It is likely that some young people will stop taking their medication and thus increase the risk of harm, and that others will not start taking anti-depressant medication because they believe it will do more harm than good.
To limit this damage we ask the BMJ to review their press release headline, and publish a statement to correct the factual errors that have been made.
We note a number of specific instances where the peer review process apparently failed to identify errors and inconsistencies in the research report. Of particular note we highlight two problems:
1. The term ‘suicide’ is used in the discussion when in fact the data concerned refer to ‘suicidal behaviour’. This is a hugely important difference. The data presented shows there were no instances of suicide in children or adolescents.
2. The authors state that it is known that anti-depressants increase the risk of suicide in children and adolescents, which is not factually correct. The references cited do not support this.
In addition to problems with the paper itself the BMJ press release then presented the research in a misleading way, stating that the study showed that anti-depressants doubled the risk of suicide in children.
Neither the paper itself or the editorial provided important contextual information which is critical to an interpretation of the study. Of particular importance is that fact that of the five antidepressants mentioned in the article, only two (fluoxetine and sertraline) are currently recommended by NICE (the National Institute for Health and Care Excellence) for the treatment of depression in young people. Two of the five (paroxetine and venlafaxine) have been contra-indicated for use in children and adolescents by NICE since 2005.
There appears to be little in this paper that is new. Numerous meta-analyses have commented on the poor quality of available data, and also expressed concerns that we do not have data on the most severely depressed and suicidal young people who have been excluded from trials (e.g. (2, 3)). They have also noted the small increased risk of suicidality with SSRIs consistent with previous analyses, and NICE guidelines appropriately recommend close monitoring.
It is well established that under-treating depression in children and young people is linked to suicides. For example, a review of 574 youth suicides reported that only 1.6% had been exposed to antidepressants (4). Young people need access to a range of individualised evidence based treatments. The possible risks of harm from antidepressants (or psychological therapy) must always be balanced against the benefits of treatment and the elevated risk of suicide in severe, untreated depression.
We fully support the call for transparent data and better monitoring of adverse events in all trials including psychological treatment trials. These trials have not been held to the same degree of scrutiny, despite evidence that psychotherapy may also cause harm (5, 6).
Dr Bernadka Dubicka
Adolescent psychiatrist and honorary senior lecturer
University of Manchester and Lancashirecare Foundation Trust
Dr Alys Cole-King
Clinical Director Connecting with People
Consultant Liaison Psychiatrist (Betsi Cadwaladr University Health Board)
Dr Shirley Reynolds
Director Charlie Waller Institute
Professor of Evidence Based Psychological Therapies
School of Psychology and Clinical Language Sciences
University of Reading
Dr Paul Ramchandani
Reader in Child and Adolescent Psychiatry & Deputy Head
The Centre for Mental Health
Imperial College London
1. Fitzpatrick C, Abayomi N-N, Kehoe A, Devlin N, Glackin S, Power L, et al. Do we miss depressive disorders and suicidal behaviours in clinical practice? Clinical Child Psychology and Psychiatry. 2012;17(3):449-58.
2. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents [Systematic Review]. Cochrane Database of Systematic Reviews. 2012;11:11.
3. Dubicka B, Hadley S, Roberts C. Suicidal behaviour in youths with depression treated with new-generation antidepressants: Meta-analysis. British Journal of Psychiatry. 2006;189:393-8.
4. Dudley M, Goldney R, Hadzi-Pavlovic D. Are adolescents dying by suicide taking SSRI antidepressants? A review of observational studies. Australasian Psychiatry. 2010;18(3):242-5.
5. Wolpert M, Deighton J, Fleming I, Lachman P. Considering harm and safety in youth mental health: A call for attention and action. Administration and Policy in Mental Health and Mental Health Services Research. 2015;42(1):6-9.
6. Nutt DJ, Sharpe M. Uncritical positive regard? Issues in the efficacy and safety of psychotherapy. J Psychopharmacol. 2008;22(1):3-6.
Competing interests: No competing interests