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Clinical Review State of the Art Review

Suicide in young people: screening, risk assessment, and intervention

BMJ 2023; 381 doi: (Published 24 April 2023) Cite this as: BMJ 2023;381:e070630

Rapid Response:

Depression drugs have been shown to double the risk of suicide in young people and should not be used

Dear Editor

In their comprehensive article (6425 words) about suicide prevention in young people (1), Hughes et al. mention some risk factors, e.g. “Living in a home with firearms is associated with a threefold to fourfold increased risk of suicide.” They do not mention treatment with depression drugs even though this is an important risk factor, as acknowledged in package inserts for depression drugs.

Later, under “Pharmacological interventions,” Hughes et al. say that selective serotonin reuptake inhibitors might increase suicidal thinking and behavior” referring to the 2004 black box warning, but they do recommend against using these drugs for young people with depression or anxiety. They recommend “increased monitoring by the prescribing physician during initiation, titration, and discontinuation of these drugs.” We know that this doesn’t work, just like it doesn’t work to warn against the firearms in people’s homes. Many children on depression drugs have killed themselves shortly after their parents thought they were totally okay (2).

Hughes et al. say that the trial data “showed a statistically significant, but small, risk difference of 0.7% for suicidal ideation or suicide attempt comparing drug with placebo.” However, they immediately downplay this fact in the next sentence: “Data from more recent pediatric antidepressant trials have not shown differences between drug and placebo, perhaps because newer studies have included suicide specific measures rather than adverse event reporting alone.”

The review they use to downplay the suicide risk is a poor one (3). Particularly when studying rare events, it is very bad methodology to lose statistical power by including only “recent” trials and not all trials in a systematic review. Furthermore, five of the seven included trials were conducted by the drug industry, and the review only included published trial reports, even though we know that the industry has omitted many suicide attempts and suicides in their published trial reports (2,4-6).

David Healy and I used the clinical study reports Eli Lilly had submitted to the drug regulators for our restoration of the two pivotal trials of fluoxetine that led to approval of this drug for depression in children and adolescents (6). We found that suicide attempts on fluoxetine were not only missing in the publications but even in the clinical study reports. Adverse events definitely predisposing to violence against self or others leading to discontinuation occurred in 11 patients on fluoxetine and in only 3 on placebo (out of a total of 157 vs 158 patients). We also found that fluoxetine doesn’t work. The efficacy outcomes were biased in favour of fluoxetine by differential dropouts and missing data. But even so, the efficacy on the Children’s Depression Rating Scale-Revised was only 4% of the baseline score, which is not clinically relevant and patient ratings did not find fluoxetine effective.

My research group has furthermore found that, compared to placebo, depression drugs double the occurrence of FDA defined precursor events for suicide and violence in healthy adult volunteers (7); they increase aggression in children and adolescents 2-3 times (8); and they increase the risk of suicide and violence by 4-5 times in middle-aged women with stress urinary incontinence, judged by FDA defined precursor events (9).

A review of suicide prevention in young people should say the obvious: Depression drugs should not be used at all. Indeed not for anyone, as they also seem to double the risk of suicide in adults (10,11) while their clinical effect is lower than what is clinically relevant (2).

1 Hughes JL, Horowitz LM, Ackerman JP, Adrian MC, Campo JV, Bridge JA et al. Suicide in young people: screening, risk assessment, and intervention BMJ 2023;381:e070630.

2 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.

3 Ignaszewski MJ, Waslick B. Update on randomized placebo-controlled trials in the past decade for treatment of major depressive disorder in child and adolescent patients: a systematic review. J Child Adolesc Psychopharmacol 2018;28:668-75.

4 Healy D. Let them eat Prozac. New York: New York University Press; 2004.

5 Le Noury J, Nardo JM, Healy D, Jureidini J, Raven M, Tufanaru C, AbiJaoude E. Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ 2015;351:h4320.

6 Gøtzsche PC, Healy D. Restoring the two pivotal fluoxetine trials in children and adolescents with depression. Int J Risk Saf Med 2022;33:385-408.

7 Bielefeldt AØ, Danborg PB, Gøtzsche PC. Precursors to suicidality and violence on antidepressants: systematic review of trials in adult healthy volunteers. J R Soc Med 2016;109:381-92.

8 Sharma T, Guski LS, Freund N, Gøtzsche PC. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ 2016;352:i65.

9 Maund E, Guski LS, Gøtzsche PC. Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports. CMAJ 2017;189:E194-203.

10 Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: a re-analysis of the FDA database. Psychother Psychosom 2019;88:247-8.

11 Hengartner MP, Plöderl M. Reply to the Letter to the Editor: “Newer Generation Antidepressants and Suicide Risk: Thoughts on Hengartner and Plöderl’s Re-Analysis.” Psychother Psychosom 2019;88:373-4.

Competing interests: No competing interests

26 April 2023
Peter C Gøtzsche
Institute for Scientific Freedom, Copenhagen