Clinician compliance to recommendations regarding the risk of suicidality with selective serotonin reuptake inhibitors in the treatment of children and adolescents

Abstract

Meta-analyses of randomized-controlled trials have established a heightened risk of suicidality for children and adolescents treated with selective serotonin reuptake inhibitors (SSRIs). The present study examined to what extent daily clinical practice complied with specific recommendations regarding the risk of suicidality when treating children and adolescents with SSRIs. All in-and outpatients aged 0-17 years at the Child and Adolescent Mental Health Services, Capital Region of Denmark with a prescription for SSRI on January 1st, 2016 were identified. Data were obtained for n = 365 patients regarding the level of clinician compliance to deliver pre-consent information about adverse effects, monitor for suicidality, and provide nonpharmacological interventions. 81.7% (n = 298) of patients received pre-consent information about adverse effects. 67.7% (n = 247) were monitored for suicidality within 6 weeks after SSRI initiation. Children (0-13 years) were less likely to be monitored for suicidality compared to adolescents (14-17 years) (49.6% vs. 77.5%, p < 0.001). Patients with depression as indication for SSRI treatment were more likely to be monitored for suicidality than patients with other indications (OR = 3.4, p = 0,002) and more likely to receive information specifically about suicidality (34.7% vs. 19.7%, p = 0.002). Respectively, 89.3% (n = 326) and 93.4% (n = 341) of all SSRI-treated patients were treated with non-pharmacological interventions prior to and in parallel with SSRI treatment. For the majority of cases, treatment of children and adolescents with SSRI complied with recommendations from clinical guidelines. However, patients of younger age and/or with indications for SSRIs other than depression were less likely to be managed according to recommendations.

Suicidality and self‐injury with selective serotonin reuptake inhibitors in youth: Occurrence, predictors and timing

“…Alternatively, the decline in suicidality is caused by other interventions offered in parallel with medication. In fact, the vast majority of the present sample received non‐pharmacological interventions prior to and in parallel with medication, 28 although patients who did not receive psychosocial interventions in parallel with SSRIs had lower risk of suicidality. Finally, the decline could simply be explained by natural variations in the occurrence of suicidality; the peak observed 2 weeks before SSRI initiation is an extreme, why the subsequent decline follows naturally.…”

“…In the present study, the majority of patients were treated with non‐pharmacological interventions prior to and in parallel with SSRIs. 28 Patients who were not treated with non‐pharmacological interventions in parallel with SSRIs were less likely to experience suicidality during SSRI treatment, but not in the 6‐week period immediately following SSRI initiation. This finding might suggest that clinicians are more inclined to intervene, when patients exhibit suicidality.…”

“…23,33 In this study, patients with depression as indication for SSRIs had a higher risk of suicidality in the first 6 weeks after SSRI initiation compared with patients receiving SSRIs for OCD, anxiety disorders or other indications. Patients with depression or depressive symptoms are more frequently monitored for suicidality during SSRI treatment than patients receiving SSRIs on other indications 28 why suicidality in other diagnostic groups might be underestimated, thus lessening the predictive value of depression for the risk of suicidality during SSRI treatment. NSSI has previously been described as an independent risk factor for suicide attempt.…”

“…In a published study of the present sample, we found that in a large majority of the 365 cases of children and adolescents treated with SSRI, the clinicians complied with recommendations from clinical guidelines regarding managing and monitoring the risk of suicidality. 28 We therefore decided that this large cohort of youths was suitable for further studying the risk of suicidality associated with SSRI treatment.…”

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“…Moreover, starting doses were guideline concordant in only 58% of the time for children, 31% for preteens, and 16% for teens. A Danish study found that less than a quarter of the parents were informed specifically about suicidality as possible adverse events of antidepressants [15].…”