It is important to bring to the attention of clinicians and researchers who
are of a younger generation than my own (I practiced for more than 50 years)
that suicidality is a risk when very depressed patients begin to improve. I
believe that this risk occurs independently of antidepressants per se.
The severely depressed are too apathetic to activate suicide. In my
clinical generation, all very depressed patients were placed on suicide watch
as they improved. We used to tranquilize patients in the agitated stage, which
is a clinical phase. Antidepressants do not "cause" suicide; they
merely enable action.
For the last 10 years I was in charge of a large adolescent treatment
facility. Many patients who were diagnosed as just depressive and placed on
antidepressants were later found to be bipolar.
I believe that antidepressants activated their mania with symptoms of
agitated self-destructive attempts and threats. Antidepressants were falsely
accused of "causing" the suicidality.
It is best to regard all depressed teenagers as possibly or even likely
bipolar and monitor them very closely. Parents should be warned to watch for
signs of activation or excitement.