The suicide rate of U.S. youth remains elevated after a decade of decline
that ended in 2003, according to a study in the September 3 Journal of the
American Medical Association.
In this study, researchers led by Jefffrey Bridge, Ph.D., a principal
investigator at the Research Institute at Nationwide Children's Hospital
and an assistant professor at the Ohio State University College of Medicine,
analyzed 1996-2005 data on suicide deaths of youngsters aged 10 to 19 and
found, after the spike in 2004, that the suicide rate dropped slightly but
remained significantly higher than the trend in previous years.
The estimated rate of suicide deaths in 10- to 19-year-olds was 4.49 per
100,000 in 2005, a small reduction from 4.74 per 100,000 in 2004 but still
significantly higher than the projected rate based on the steadily declining
trend from 1996 to 2003.
The analysis used data from the National Center for Injury Prevention and
Control, a division of the Centers for Disease Control and Prevention
After years of decline, the suicide death rate in youth rose in 2003 and
more sharply in 2004, according to the CDC's announcement last year
((Psychiatric News, October 5, 2007). The 18 percent increase from
2003 to 2004 had been the highest one-year jump in the previous 15 years. The
unexpected spike caused heated debates over its causes, and many, including
the Food and Drug Administration (FDA), were unsure whether this was an
isolated incident. The new study suggests that the elevated trend persisted in
2005 and thus may not be an anomaly.
The suicide death rate in 2005 was significantly higher than the 1996-2003
trend predicts in both male and female teenagers and in both the younger (10
to 17) and older (18 and 19)
Many experts have suspected a connection between the rise in suicide deaths
and the black-box warning on suicidal ideation and behavior in young patients
associated with antidepressant drugs that was imposed by the FDA in 2004 and
the accompanying publicity (Psychiatric News, October 5 and June 15,
2007). Studies have shown that the use of antidepressants declined or stopped
increasing, especially among children and adolescents, after the FDA issued
the warning (Psychiatric News, February 1). These observations have
raised concerns by psychiatrists and others about inadequate treatment for
depression in young patients that may pose a greater risk of suicide than the
antidepressant-triggered suicidal ideation and behaviors.
"The fact that the adolescent suicide rate remains elevated is very
disturbing," David Fassler, M.D., a pediatric psychiatrist and a
clinical professor of psychiatry at the University of Vermont and APA
secretary-treasurer, commented. "After over a decade of steady decline,
we're seeing a definite and sustained increase." Meanwhile,"
we've seen a significant reduction in prescriptions for young
people since the FDA imposed a black-box warning."
The temporal parallel, however, cannot prove a correlation between the
black-box warning and the rise in youth suicide rates. The study authors
proposed several possible explanations for the observed trend such as changes
in alcohol use or firearm access, influence of Internet social networks, and
increased suicide among military personnel in this age category, as well as
more patients with untreated depression after the black-box warning was
"Attention must now be directed toward understanding whether this
increase in the youth suicide rate... reflects an emerging public health
crisis," they wrote.
"It is very difficult to prove a causal relationship between the
increase in the youth suicide rate and the decrease of antidepressant
prescribing," Darrel Regier, M.D., M.P.H., director of APA's
Division of Research and the American Psychiatric Institute for Research and
Education, told Psychiatric News. "One finding is very
clear—the black-box warning did not reduce completed suicides, which
should have been the ultimate goal of the FDA action."
He pointed out that, because of ethical reasons, researchers cannot conduct
a randomized, controlled experiment to assess whether a link exists between
completed suicide and decreased availability of treatment. "One
possibility is to conduct a quasi-experiment and withdraw the black-box
warning to see if there is a subsequent reduction in suicide rate," he
Regier explained that the FDA had relied on relative rates of spontaneously
reported suicidal ideation or behavior from depressed people on medication
compared with those on placebo in clinical trials in the agency's
decisions about whether to require the black-box warning for
"Epidemiologists, FDA staff, and psychiatric experts have identified
many methodological problems of relying on spontaneous reports of suicidal
ideation in randomized clinical trials," Regier pointed out. "The
FDA now advocates using prospective systematic assessments of suicidal risk in
future clinical trials for all medications that may be associated with such
risks." However, the black-box warning for antidepressants remains
"In the recent FDA hearing on suicidal risks of antiseizure and
mood-stabilizing medications, we heard testimonies suggesting that the
societal effects of black-box warnings go beyond informing physicians for
better monitoring and vigilance, but may be more complex and unpredictable
than expected," Regier noted.
Earlier this year, the FDA intended to require a black-box warning for
antiseizure medications based also on spontaneous reports of suicidal ideation
and behavior in clinical trials (Psychiatric News, August 15). The
experts on the advisory committee, however, voted to recommend against a
black-box warning, citing concerns that patients' fear of taking these
medications would lead to far more deaths from untreated seizures and bipolar
disorder than from the possible drug-related suicidal ideation.
"Not all children and adolescents with depression need medication,
but for those who do, it can be extremely effective and even
lifesaving," said Fassler. He urged the FDA to monitor the consequences
of its regulatory decisions and modify its actions if evidence suggests it is
"The question now for the FDA is what epidemiological evidence would
be enough to prompt the agency to reconsider its previous decision about the
black-box warning because of these reported signs of unintended
consequences," said Regier.
"Suicide Trends Among Youths Aged 10 to 19 Years in the United
States, 1996-2005" is posted at<jama.ama-assn.org/cgi/content/full/300/9/1025>.▪