Can Antidepressants Cause Harm?

Antidepressants are not new, and have been used since the 1950’s without much controversy. All this changed in 1988, when the release of antidepressants with fewer side effects, such as fluoxetine (Prozac), meant that more people, and younger people, were able to take them. With so many taking these medicines, there soon came a few reports of bad reactions. At first was hard to tell if these reactions were caused by the drug or by the illness that was being treated. For example, some people with depression became violent or committed suicide while taking fluoxetine, but fluoxetine is often prescribed to people who are at risk for violence or suicide to begin with.

Although these questions have not been fully researched, clinical experience and the available studies do point towards some answers. Antidepressants do not directly cause violence; in fact, they are often used successfully to lower aggression, violence and suicidal behavior. However, they can cause several rare side effects which can be very uncomfortable: akathisia (restlessness), anxiety, agitation and mania.

Psychiatrists have known about these reactions for a long time because they happen naturally in people who aren’t on medicine. We know that they are treatable, and we know that they can sometimes lead to violence. They are described in more detail below:

1) Akathisia

This is a feeling of inner restlessness or agitation. People often feel that they can’t sit still and have to keep moving, and may get up and pace from their chair frequently.

2) Anxiety

Although antidepressants usually reduce anxiety, on rare occasions they can increase it. This “paradoxical anxiety” is more likely to happen in the first few weeks of treatment or if the dose is too high.

3) Bipolar or Manic Reactions

Some people with depression may actually have bipolar depression, which means that their mood can swing from sad and low to high, excited and agitated.

Antidepressants may cause mood swings in people with this condition, and if this “manic state” goes on too long it can lead to impulsive or aggressive behavior. Signs of mania include high energy, needing very little sleep, racing thoughts, extreme confidence or happiness, irritability or agitation, and reckless or impulsive behavior.  People with a family history of bipolar disorder are at a higher risk of this happening.

Reducing the risks

The Food and Drug Administration has recommended screening for bipolar disorder in all persons started on antidepressants to reduce the risks of harm.  This is important, as studies have found that 30-50% of people who visit a psychiatrist for depression have bipolar disorder.  There are many ways to screen for bipolar disorder, from family genetics to structured interviews for manic symptoms.  At the Mood Treatment Center, we use 6 different screening tests for bipolar disorder.

Antidepressants can also be raised slowly in people who may be at risk for bad reactions (e.g. those with anxiety).  Children and those under age 25 should be closely monitored when starting antidepressants (see below).

Antidepressants in Children and Adolescents

In 2003, news came of a slightly elevated suicide risk in children who take antidepressants [1].  Although the risk was small, and none of the children studied actually committed suicide, this problem may be real and seems to be related to hostility, mood swings and aggression in some children who take the medicine. If this reaction occurs, it is likely to happen in the first few weeks of treatment. 

The risk of suicidal thinking on antidepressants gradually lowers as people age into adulthood, so that there is no elevated risk after age 25.

This risk is very small, and there are also risks to not treating depression with antidepressants.  Depression itself can lead to suicide, and can be harmful to a child’s personal development.  Untreated depression can cause changes in the brain which make it more difficult to treat. There are risks, then, both in medicating and not medicating children with depression.

If you are thinking of stopping your child’s antidepressant, talk to your doctor first since abrupt stopping can cause withdrawal symptoms syndrome that include dizziness, nausea, tremors, and anxiety. These symptoms tend to be worse for paroxetine (Paxil).

Footnotes:

[1] In the first study, with paroxetine (Paxil), 1-2% of children on a sugar-pill (placebo) had suicidal behavior, as compared to 2-3.5% of children taking paroxetine (Paxil). The second study found that 2% of children and adolescents taking venlafaxine (Effexor) had thoughts of suicide, compared with none who took the sugar pill (placebo). A separate study was more reassuring: it turns out that when data from all antidepressant studies in children are combined and averaged, involving more than 2,000 children, there is no increased risk of suicide with antidepressants.  Other antidepressants have been studied in children with good results. Fluoxetine (Prozac) and sertraline (Zoloft) both have several placebo-controlled trials showing benefit for children with depression, and fluoxetine has been approved by the FDA for childhood depression.

References:

Wagner KD, et al. Efficacy of Sertraline in the Treatment of Children and Adolescents with Major Depressive Disorder: Two Randomized Clinical Trials. Journal of the American Medical Association (August 27, 2003): Vol. 290, No. 8, pp. 1033–41.

March, J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association (August 18, 2004) Vol. 292, No. 7, pp. 807-20.

American College of Neuropsychopharmacology, Preliminary Report of the Task Force on SSRIs and Suicidal Behavior in Youth. January 21, 2004.

Food and Drug Administration, Report on Pediatric Psychopharmacology, August 20, 2004.

—Updated 5/27/12 by Chris Aiken, MD