Correspondence
Adolescent Depression
N Engl J Med 2003; 348:473-474January 30, 2003
- Article
To the Editor:
We disagree with the statement made by Brent and Birmaher (Aug. 29 issue)1 that overdoses of selective serotonin-reuptake inhibitors (SSRIs) are rarely toxic. Although overdoses of an SSRI (as the single ingested agent) are rarely fatal,2,3 toxicity sufficient to warrant specific treatment is well recognized, and ingestions of massive quantities may cause seizures and arrhythmias.
In addition, overdoses of a mixture of drugs that includes an SSRI are common. Simultaneous ingestion of an SSRI with other agents that affect serotonin release or reuptake, such as monoamine oxidase inhibitors, even in therapeutic doses, may produce serotonin toxicity.4 We believe that the authors' advice in relation to access to toxic medications should apply equally to SSRIs and that patients, especially those at risk for suicide, should be given only small amounts of any medication.
4 ReferencesPatricia McGettigan, M.D.
Newcastle Mater Misericordiae Hospital, Newcastle 2298, AustraliaGeoffrey K. Isbister, M.B., B.S.
University of Newcastle, Newcastle 2298, Australia
gsbite@bigpond.com Ian M. Whyte, M.B., B.S.
Newcastle Mater Misericordiae Hospital, Newcastle 2298, Australia1
Brent DA ,Birmaher B . Adolescent depression. N Engl J Med 2002;347:667-671
Full Text | Web of Science | Medline2
Kincaid RL ,McMullin MM ,Crookham SB ,Rieders F . Report of a fluoxetine fatality. J Anal Toxicol 1990;14:327-329
Web of Science | Medline3
Ostrom M ,Eriksson A ,Thorson J ,Spigset O . Fatal overdose with citalopram. Lancet 1996;348:339-340
CrossRef | Web of Science | Medline4
Neuvonen PJ ,Pohjola-Sintonen S ,Tacke U ,Vuori E . Five fatal cases of serotonin syndrome after moclobemide-citalopram or moclobemide-clomipramine overdoses. Lancet 1993;342:1419-1419
CrossRef | Web of Science | Medline
To the Editor:
The context of adolescents' depression is critical, since they are vulnerable to multiple environmental challenges. For example, undetected learning disorders, particularly attention difficulties and nonverbal learning disorders, result in poor performance in school. Subsequently, the adolescent can present in the doctor's office with trouble concentrating, irritability, and apathy. These symptoms can be mistaken for a mood disorder. A careful diagnostic assessment, including neuropsychological testing, might identify the learning disorder. In these situations, tutorial assistance, rather than medication, is appropriate.
Often, depressive symptoms precede substance abuse by four to five years. In one study,1 two thirds of adolescents who committed suicide had a history of substance abuse and mental disorder. It should be recognized that depression and substance abuse can be a lethal combination. Other research2 suggests that it is the combination of these factors that places gay teenagers at increased risk for suicide.
2 ReferencesNancy Rappaport, M.D.
Harvard Medical School, Boston, MA 02115
nrappaport@attbi.com 1
Shaffer D, Greenberg T. Suicide and suicidal behavior in children and adolescents. In: Shaffer D, Waslick B, eds. The many faces of depression in children and adolescents. Washington, D.C.: American Psychiatric Publishing, 2002:129-78.
2
Russell S ,Joyner K . Adolescent sexual orientation and suicide risk: evidence from a national study. Am J Public Health 2001;91:1276-1281
CrossRef | Web of Science | Medline
Author/Editor Response
McGettigan and colleagues correctly point out that ingestion of SSRIs, although they are considerably less toxic than tricyclic antidepressants, can result in serious toxic effects and even, rarely, in death. The risk of adverse outcomes is markedly increased if antidepressants are ingested in combination with other medications. Moreover, an overdose of venlafaxine can lead to dangerous increases in blood pressure and arrhythmias. We agree with the suggestion by McGettigan et al. that patients at risk for suicidal behavior should not have access to large amounts of antidepressants. For adolescent patients, it is best if parents maintain control of medications.
Rappaport notes that academic difficulties due to learning disorders could cause difficulty in concentration, poor performance in school, and demoralization and suggests that a careful diagnostic assessment, including neuropsychological testing, is needed. A careful history taking that documents difficulties in learning that antedate the onset of depressive symptoms might help to identify patients in whom a more detailed neuropsychological assessment is needed, particularly if their difficulties are not attributable to attention-deficit–hyperactivity disorder.
Rappaport also raises the issue of the frequently simultaneous occurrence of substance abuse and mood disorder and the association of these two coexisting conditions with suicide and suicidal behavior. These issues were raised in our article but bear repeated discussion. It is also true that gay young persons are at increased risk for suicidal behavior and have increased rates of substance abuse and mood disorder, but there may be other issues, such as rejection by family and victimization, that contribute to placing gay, lesbian, and bisexual young persons at risk for suicidal behavior.
David A. Brent, M.D.
Boris Birmaher, M.D.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15213-2593
