18 Apr What Recent Studies Reveal About Antidepressants and Suicidality Risk

In October 2020, a ground-breaking study was published online that sought to address the long-term effects of severe black box warnings on antidepressants. These warnings are familiar to anyone who has ever taken antidepressants or discussed them with a doctor or mental health clinician.

These black box warnings were rolled out by the Food and Drug Administration (FDA) in the early 2000s, after a series of meta-analyses discovered that younger individuals taking antidepressants were twice as likely to have suicidal thoughts or behaviors, compared to similar patients who were receiving a placebo. 

This increased risk was most prevalent in children, teens, and young adults under the age of 24. The risk was negligible in adults aged 25 to 65, while antidepressants had a clear protective effect in older adults.  

This rise in suicidality and suicidal behaviors was extremely concerning to the FDA, who immediately implemented black box warning labels that indicated a particular medication was associated with an increased risk for suicidal thoughts, ideations, and behaviors in young people.  

However, in the years since those warnings were implemented, researchers and mental health clinicians have developed grave concerns that these black box warnings are actually doing more harm than good. 

What Recent Studies Reveal About Antidepressants and Suicidality

Researchers have identified a few main issues that have resulted from antidepressant black box warnings.

• The original studies that purported to reveal an increased risk factor for suicidality in young people while taking antidepressants were inherently biased and flawed. They did not account for individuals who dropped out of the study and had no objective measure for determining the level of suicidal thoughts they were supposed to be tracking.
• These black-box warnings have been a significant contributing factor to elevated levels of mental health stigma. As these black box warnings became more prevalent, rates of mental health care declined and individuals were less likely to seek out treatment when they were feeling symptoms of depression. Currently, between 60-70% of young people who have major depression do not have any mental health care.  
• Suicide death rates actually increased following the release of these FDA warnings. This was likely due to the reduction in mental health and depression care following the roll-out of the black box warnings. These are “intermediate outcomes that predict suicide”, according to the lead study author. 
• Media coverage surrounding the introduction of these black box labels led to even greater stigmatization of mental health care and depression, causing many people to avoid these medications.

 
In the study’s conclusion, the researchers recommended switching the current black box warning to either be lifted entirely, or substituted for a more routine warning within the product label.

While the original intention behind the black box labeling system was positive, the unintended consequences continue to cause adverse effects, particularly among young patients with depression. 

Do Antidepressants Increase Suicidality? The Short Answer is No.

Ultimately, researchers discovered that these medications did not lead to an increase in suicidality and suicide deaths. Instead, these overly cautious black box warnings contributed to increased stigmatization of mental health care and antidepressant medication, making it more likely that someone with suicidal thoughts or behaviors would go untreated.

Tips for Clinicians to Help Shape More Productive Conversations about Antidepressants

Fortunately, clinicians can have a positive impact on this discussion, as we help our clients develop a more accurate and nuanced understanding of antidepressant medication and its role in fighting depression. Here are some suggestions for ways you can implement these changes within your practice.

Continue to educate your clients on the real and accurate risks or side effects of antidepressants. Many clients believe the narrative that antidepressants contribute to an increased risk for suicide, so sharing the latest research on this should help them make more informed decisions.

Share the potential dangers that can happen if clients don’t seek mental health care, especially if they are experiencing symptoms of depression. Some clinicians track their clients’ visits in their behavioral health EHR and may reach out after a set period of time if the client has not booked an upcoming appointment.

Be aware of which symptoms may indicate a contraindication and, continue to monitor clients who are taking antidepressants. Scheduling regular check-ins to evaluate how each particular medication is working will help ensure it performs as expected. There’s no one-size-fits-all approach to depression treatment, so getting to know each client and how they react to different treatment options will be extremely useful in navigating towards the right path.

Keep up on the latest research on available antidepressant medication options through research journals as well as educational and professional development opportunities. This allows clinicians to better explain the efficacy and function of each medication to clients. Many of the original antidepressant medications were discovered serendipitously, and researchers are still learning more about how and why they work.

Although the unintended consequences of these black-box warnings have been largely harmful, rather than helpful, clinicians are well-placed to work with their clients to help them use these medications safely and effectively. By building trust with clients and being open and honest about potential risks and benefits, we can help mitigate some of the negative stigmas of these medications.

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