Newton has one of the highest per capita rate of psychiatrists and psychotherapists in the country. Massachusetts is famed for its educational prowess. Newton is also the site of three recent suicides in one of its high schools.
Can these facts be related?
Most would agree that suicide is the most feared outcome of any psychological problem. The majority of persons who commit suicide, according to commonly cited studies, experience depression at the time of death. This is not a light subject, nor one for easy opining. Questions should be asked, though, if we are ever to get progress on this last, worst, irreversible event in the chain of psychological pain.
Adolescent suicide is not unique to Newton, or to Massachusetts. About 8% of US adolescents make suicide attempts. But the recent local spate of suicides raises the question whether there can be any connection between our current approach to psychiatric treatment in children and suicide.
A link between antidepressants and suicide has been established in the most definitive scientific studies (randomized clinical trials), which led to a black box warning from the Food and Drug Administration and then a decline in antidepressant prescription in children. In contrast, amphetamine prescription continues to increase rapidly, with about 10% of all children in the United States currently receiving those medications. Many parents and students turn to prescription amphetamines for ADHD when schoolwork suffers, hence higher prescribing patterns are sometimes seen in academically competitive settings, as is the case in Newton. The third suicide seems at least partly related, according to a recent Boston Globe article, to academic stress.
Amphetamines are antidepressants; thus, they can share the same risks, including some increased risk of suicide. To appreciate this idea, a few logical and factual connections need to be explained:
For over a century, researchers have found that depression in adolescence occurs with manic-depression, a form of depressive illness that begins on average around age 19, with about one-third of persons having their first depression in adolescence. In contrast, simple depression (also called “major depressive disorder”) begins on average around age 30, far from childhood. Thus, the younger a depressed person, the higher probability of manic-depression. Prospective studies show that a substantial number (about 25-50%) of children with depression later develop manic episodes, meaning that they have manic-depression.
The relevance of this fact is that antidepressants can make manic-depression worse, especially by causing manic episodes. Mania means a state of heightened excitation and overactivity; but it frequently happen along with sadness of mood and anger and despair. This combination of mania with depressive symptoms, called “mixed” episodes, is highly associated with suicidality.
If amphetamines are given for ADHD, they could, like all antidepressants, cause mixed episodes in someone who has manic-depression, which could be a key factor in an increased risk of suicide.
This is not to say that amphetamines should not be given to children at all, nor that ADHD should not be treated with those agents. Rather, in those children with ADHD-like symptoms who also have depression, attention should be paid to the possibility that some of those children will have manic-depression, and, if given amphetamines, a few of them will get very much worse, rather than better.
As the many causes of the recent cases of adolescent suicide are discussed, this potential risk factor – which is preventable – should be explored and examined as well. It isn’t enough to educate ourselves about suicide if we won’t include all potential sources, especially those that we might be causing ourselves.