Letters Suicidality and aggression during antidepressant treatment

Paper on suicidality and aggression during antidepressant treatment was flawed and the press release was misleading

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i911 (Published 16 February 2016) Cite this as: BMJ 2016;352:i911
  1. Bernadka Dubicka, adolescent psychiatrist and, honorary senior lecturer, University of Manchester1,
  2. Alys Cole-King, clinical director, Connecting with People, and consultant liaison psychiatrist2,
  3. Shirley Reynolds, director, Charlie Waller Institute, and, professor of evidence based psychological therapies3,
  4. Paul Ramchandani, reader in child and adolescent psychiatry and deputy head, Centre for Mental Health4
  1. 1Lancashirecare Foundation Trust, Junction Adolescent Unit, Lancaster LA1 4PW, UK
  2. 2Betsi Cadwaladr University Health Board, UK
  3. 3School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
  4. 4Imperial College London, London, UK
  1. Bernadka.Dubicka{at}manchester.ac.uk

We have concerns about the editorial process involved in the publication of Sharma and colleagues’ article.1 The article is fundamentally flawed in presentation and logic, and the results were further misrepresented by The BMJ press release. The BMJ is highly regarded and anything it publishes will probably 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 underdiagnosed and undertreated.2 Parents often feel conflicted or guilty. Suicide is a highly emotional topic and the claim that antidepressants increase suicide in young people is likely to cause untold worry and harm to young people. Some young people may stop taking their drugs, thereby increasing the risk of harm, and others might not start taking antidepressants because they think they 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.

The peer review process apparently failed to identify several errors and inconsistencies in the research report. Of particular note we highlight two problems:

  • The term “suicide” is used in the discussion when the data concerned refer to “suicidal behaviour.” This is a hugely important difference. The data presented show there were no instances of suicide in children or adolescents

  • The authors state that antidepressants are known to increase the risk of suicide in children and adolescents, which is not factually correct. The references cited do not support this assertion.

In addition to problems with the paper itself the press release was misleading, stating that the study showed that antidepressants doubled the risk of suicide in children.

Neither the paper itself nor the editorial provided the important contextual information needed to interpret the study. Importantly, of the five antidepressants mentioned in the article, only two (fluoxetine and sertraline) are currently recommended by the National Institute for Health and Care Excellence for the treatment of depression in young people. Two (paroxetine and venlafaxine) have been contraindicated for use in children and adolescents by NICE since 2005.

Little in this paper seems to be new. Numerous meta-analyses have commented on the poor quality of available data and expressed concerns about the lack of data on the most severely depressed and suicidal young people, who have been excluded from trials.3 4 They have also noted the small increased risk of suicidality with selective serotonin reuptake inhibitors consistent with previous analyses, and NICE guidelines appropriately recommend close monitoring.

It is well established that the undertreatment of depression in children and young people is linked to suicide. For example, a review of 574 youth suicides reported that only 1.6% had received antidepressants.5 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 increased 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.6 7


  • Competing interests: None declared.


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