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Evidence summaries

Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment with Second-Generation Antidepressive Agents

Antidepressants appear to be more effective than placebo for children and adolescents with best benefits for non-OCD anxiety disorders, intermediate for obsessive-compulsive disorder (OCD) and modest for major depressive disorder (MDD). The benefits appear to be greater than the risk of suicidal ideation/suicide attempt, but the benefit-to-risk ratios vary. Level of evidence: "B"

A systematic review 1 including 27 studies with a total of 5 310 subjects was abstracted in DARE. Of these, 15 RCTs evaluated treatment effects in patients with major depressive disorder MDD (n=3 430), 6 RCTs evaluated patients with obsessive-compulsive disorder OCD (n=718) and 6 RCTs evaluated patients with non-OCD anxiety disorders (n=1 162). Studies in children and adolescents (aged less than 19 years) comparing selective serotonin re-uptake inhibitors (SSRIs) and other second-generation agents with placebo were eligible for inclusion.

MDD. Antidepressants were associated with a significantly increased treatment response rate compared with placebo, 61% versus 50%; the RD was 11% (95% CI: 7.1 to14.9; 13 trials) and the NNT was 10 (95% CI: 7 to 15). Antidepressants were associated with a non-statistically significant increased risk of suicidal ideation/suicide attempt compared with placebo, 3% versus 2%; the RD was 0.9% (95% CI: -0.1 to 1.9) and the NNH was 112.

OCD. Antidepressants were associated with a significantly increased treatment response rate compared with placebo, 52% versus 32%; the RD was 20% (95% CI: 13 to 26.6; 6 trials) and the NNT was 6 (95% CI: 4 to 8). Antidepressants were associated with a non-statistically significant increased risk of suicidal ideation/suicide attempt compared with placebo, 1% versus 0.3%; the RD was 0.5% (95% CI: -1.2 to 2.2) and the NNH was 200.

Non-OCD anxiety disorders. Antidepressants were associated with a significantly increased treatment response rate compared with placebo, 69% versus 39%; the RD was 37.1% (95% CI: 22.5 to 51.7; 6 trials) and the NNT was 3 (95% CI: 2 to 5). All studies showed benefit with antidepressant use but significant heterogeneity was found (p<0.001). Antidepressants were associated with a non-statistically significant increased risk of suicidal ideation/suicide attempt compared with placebo, 1% versus 0.2%; the RD was 0.7% (95% CI: -0.4 to 1.8) and the NNH was 143. There was an increased RD of suicidal ideation/suicide attempt across all trials and indications for drug versus placebo (RD 0.7%, 95% CI: 0.1 to 1.3; 27 trials). There were no completed suicides in any of the studies.

Comment: The quality of evidence is downgraded by review quality (incomplete reporting of the review methods).

    References

    • Bridge J A, Iyengar S, Salary C B, Barbe R P, Birmaher B, Pincus H A, Ren L, Brent D A. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 2007; 297(15): 1683-1696. [DARE]

Primary/Secondary Keywords