Is starting a patient on an antidepressant risky or beneficial in terms of reducing suicide risk? A 17-year-old male with a 3-year history of recurrent depression and a history of depression on his father’s side is struggling at his new school after having moved to the area 6 months ago. 

He has not tried antidepressants in the past, but he has had counseling. He would like a trial of an SSRI [selective serotonin reuptake inhibitor]. The patient has a medical history of asthma. — Della Ramirez, ARNP, Vancouver, Wash. 

SSRIs are first-line therapies for depressive symptoms in children and adolescents. However, this group of antidepressants has been implicated in clinical reports of increased risk of suicidality.

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Over the last two decades, the prescribing of tricyclic antidepressants (TCAs) has decreased due to their unfavorable side-effect profile. TCAs are regarded as being less safe in overdose compared with SSRIs, but an epidemiologic study by Donovan and colleagues published in The British Journal of Psychiatry (2000;177:551-556) found that acts of deliberate self-harm by persons aged 17 years and older occurred more often with the prescription for an SSRI, particularly fluoxetine, than with a TCA. 

On October 15, 2004, the FDA began requiring black-box labeling on all antidepressants regarding the increased risk of suicidal thoughts and behavior in children and adolescents (available at; accessed August 6, 2014).

It is important to monitor the patient closely during the initial phases of an antidepressant trial as there might be increased risk of suicidality. If there is considerably diminished social, occupational, or academic functioning, then a combination of counseling and antidepressants can provide optimal benefit for an individual who is diagnosed with depression. — Abimbola Farinde, PharmD, MS (190-2)

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