A 19-year-old man is brought to the office by his mother due to sad mood and declining grades at college. Previously a straight-A student, he is now getting Cs and Ds, and his mother worries he will not complete his freshman year. The patient says, "I feel depressed and hopeless about the future." He has little interest in his classes, has difficulty concentrating on assignments, and abruptly decided to quit the soccer team. He refuses to answer any phone calls from his friends and keeps himself isolated at home. The patient feels that there is little point in living but has no suicidal intent or plan. He has tried alcohol at parties on 2 occasions but does not use illicit drugs. There is no history of mania. There is a family history of untreated depression in his mother and grandmother. Physical examination and laboratory values are normal. Major depressive disorder is diagnosed, and treatment is discussed. The patient is willing to take medication, but his mother is concerned that antidepressants can cause people to become suicidal. Which of the following is the most appropriate response to the mother?

Question

A 19-year-old man is brought to the office by his mother due to sad mood and declining grades at college.  Previously a straight-A student, he is now getting Cs and Ds, and his mother worries he will not complete his freshman year.  The patient says, "I feel depressed and hopeless about the future."  He has little interest in his classes, has difficulty concentrating on assignments, and abruptly decided to quit the soccer team.  He refuses to answer any phone calls from his friends and keeps himself isolated at home.  The patient feels that there is little point in living but has no suicidal intent or plan.  He has tried alcohol at parties on 2 occasions but does not use illicit drugs.  There is no history of mania.  There is a family history of untreated depression in his mother and grandmother.  Physical examination and laboratory values are normal.  Major depressive disorder is diagnosed, and treatment is discussed.  The patient is willing to take medication, but his mother is concerned that antidepressants can cause people to become suicidal.  Which of the following is the most appropriate response to the mother?

Quizplus · Accepted Answer

In 2007 the US Food and Drug Administration extended its warning that all patients age <25 should be informed about the small risk of becoming suicidal during initial antidepressant treatment. The warning was based on studies showing a slightly increased risk of suicidal thoughts and behaviors (not completed suicide) among a small group of child and adolescent patients treated with antidepressants compared with placebo (Choice D). Decisions regarding prescribing antidepressants for adolescents must weigh the risk of antidepressant-related suicidal thoughts and behaviors against the established benefits of antidepressants and the long-term risk of completed suicide in untreated depression. Although there is ongoing debate about the evidence for a link between antidepressants and suicidality, the consensus among experts and in practice guidelines is that the benefits of antidepressants for moderate to severe depression outweigh the risks. Antidepressant treatment should not be withheld due to this concern or limited to patients who have failed psychotherapy (Choice A). Physicians should closely monitor patients for increasing suicidal thoughts and behaviors, especially following initiation of antidepressant treatment. (Choice B) Although some antidepressants are avoided as first-line agents due to their adverse side-effect profile, there is no known or clear difference in the risk of suicidal thoughts or behaviors among different classes of antidepressants. All adolescents started on an antidepressant should be monitored closely. (Choice C) The warning is applicable to all patients under age 25 years, not just those under age 18. Educational objective: The slightly increased risk of antidepressant-related suicidal thoughts and behaviors in some children and adolescents must be weighed against the efficacy of antidepressants and the risk of completed suicide in depression. Patients should be carefully monitored for suicidality at the beginning of antidepressant therapy. References: Antidepressant drugs and the risk of suicide in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/24452997) Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. (http://www.ncbi.nlm.nih.gov/pubmed/24942789)

A 19-Year-Old Man Is Brought to the Office by His