March 8, 2011

Emergency Department Visits for Drug-Related Suicide Attempts Involving Antidepressants by Adolescents and Young Adults: 2004 to 2008

Antidepressants commonly are prescribed by health care professionals to treat symptoms of depression. In the 1990s, health practitioners increasingly prescribed antidepressants, and many newer formulations were determined to be safe for use by children and adolescents. In fact, research has shown that suicide rates for youths have been decreasing, and some scientists have credited the widespread use of antidepressants for this decline.¹ However, in the past decade, concerns about the safety of antidepressants prompted the U.S. Food and Drug Administration to provide a warning label about the increased risk for suicidal thoughts and behavior among patients younger than 25.² Because suicide is the third leading cause of death for adolescents and young adults,³ a high-profile debate on the risks and benefits of antidepressant use in this population soon followed. However, suicides are difficult to study, and many clinical trials have been inconclusive.

National statistical studies shed light on suicide attempts in general among this younger population and provide some background about these attempts. Past year suicide attempts were reported by 6.3 percent of high school students, 0.9 percent of college undergraduates, and 0.3 percent of graduate students.^4,5 Of those who attempted suicide, 30 percent (approximately 300,000) of high school students, 19 percent (approximately 13,990) of college undergraduates, and 28 percent (approximately 1,874) of graduate students reported that they required medical attention for a suicide attempt.^4,5,6,7 Drug overdoses were involved in about half of suicide attempts among college students.⁸

Because suicide attempts often require emergency medical services, emergency department (ED) data can provide valuable information about this issue. Among ED visits for suicide attempts or intentional self-harm, adolescents aged 12 to 17 made an average of 60,885 visits per year between 2004 and 2008, of which 73.3 percent were made by females.³ There was an average of 85,452 such visits among young adults aged 18 to 24 between those same years, of which 56.0 percent were made by females.⁹ However, with respect to ED visits involving drug-related suicide attempts in particular, 2008 data show that adolescents made 23,124 visits and young adults made 38,036 visits; gender patterns were similar across these ED visits overall.^10,11

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related ED visits in the United States. To be a DAWN case, an ED visit must have involved a drug, either as the direct cause of the visit or as a contributing factor. DAWN includes only ED visits for suicide attempts that involve either drugs or alcohol in combination with drugs, so these suicide attempts are not limited to drug overdoses. If there is drug involvement in a suicide attempt by other means (e.g., a patient takes sleeping pills and alcohol and then deliberately crashes his or her car), the case is included as drug related. However, it should be noted that DAWN does not record all medications currently taken by patients but only records drugs that the ED staff believe were involved in the medical emergency that resulted in the ED visit. To the extent that antidepressants contribute indirectly to the likelihood that a person attempts suicide (e.g., having depression may increase the chance of suicide) but not directly to the medical emergency at hand, DAWN may understate the role of antidepressants.

This issue of The DAWN Report focuses on ED visits for drug-related suicide attempts involving antidepressants, focusing on adolescents (persons aged 12 to 17) and young adults (persons aged 18 to 24) by examining recent trends and reporting annual averages based on combined 2004 to 2008 data.

Among ED visits for drug-related suicide attempts in 2008, 23.0 percent (5,312 visits) of visits by adolescents and 17.6 percent (6,700 visits) of visits by young adults involved antidepressants. The overall trend data from 2004 to 2008 show no significant changes in the number of ED visits for all drug-related suicide attempts among young adults or adolescents (Figure 1). However, for young adults, there were statistically significant increases in the number of drug-related ED visits for suicide attempts involving antidepressants between 2005 and 2006 (3,807 vs. 6,010 visits) and between 2005 and 2008 (3,807 vs. 6,700 visits).

Figure 1. Number of Emergency Department (ED) Visits for Drug-Related Suicide Attempts Involving Antidepressants by Adolescents and Young Adults: 2004 to 2008

Between 2004 and 2008, there was an annual average of 9,660 ED visits for drug-related suicide attempts involving antidepressants by adolescents aged 12 to 17 and young adults aged 18 to 24. Between these years, females made up three fourths of visits by adolescents (74.7 percent) and two thirds of visits by young adults (65.2 percent).

Among ED visits for suicide attempts involving antidepressants, more than two thirds of visits by adolescents (68.4 percent) and more than three fourths of visits by young adults (78.0 percent) involved other substances in addition to antidepressants (Table 1). Other types of pharmaceuticals were the most common drugs used in combination with antidepressants for both age groups (58.8 percent of visits made by adolescents and 61.5 percent of visits made by young adults), and for each group, the most commonly found pharmaceuticals were pain relievers and drugs to treat anxiety and insomnia.

One tenth (10.2 percent) of visits by adolescents and nearly one fourth (22.6 percent) of those made by young adults involved antidepressants in combination with alcohol. Antidepressants in combination with illicit drug use were found in 8.9 percent of visits by adolescents and 14.9 percent of visits by young adults.

Among ED visits involving suicide attempts and antidepressants, 27.6 percent of adolescents and 17.3 percent of young adults were treated and released (Table 2). One third (32.9 percent) of visits made by adolescents and one half (49.4 percent) of visits made by young adults resulted in hospitalization. Of those admitted to the hospital, an annual average of 387 visits by adolescents and 1,154 visits by young adults required intensive or critical care, 428 visits by adolescents and 728 visits by young adults required an admission to the psychiatric unit, and 529 visits by adolescents and 867 visits by young adults were admitted to some other inpatient unit. A sizeable portion of visits made by adolescents (1,551 visits) and young adults (1,646 visits) resulted in the patients being transferred to a different health care facility.

Suicide prevention is essential for reducing one of the leading causes of death among young people. As noted earlier, the increased use of antidepressants by young people was accompanied by reductions in suicide rates; however, suicidal behavior in patients taking antidepressants as directed may still be a cause for great concern, and the debate continues regarding the appropriate use of antidepressants among adolescents and young adults. Further monitoring of drug-related suicide attempts is critical as treatment practices and pharmaceuticals treating mental health conditions evolve.^10,11 Similarly, continued tracking of adverse health effects related to antidepressant use will also be important for ensuring increased patient safety.

For both age cohorts, ED visits for suicide attempts involving antidepressants were more common among females than males. Further research will be needed to confirm whether or not gender differences account for differing susceptibility to suicidal behavior while taking antidepressants.

The majority of suicide attempts among adolescents and young adults that involved antidepressants also involved other drugs, some of which may have been used to deliberately overdose. Before prescribing antidepressants, health professionals can routinely inquire about other prescription medications and consider the potential for overdose, especially for drugs to treat anxiety and insomnia and pain relievers. It is also important to provide appropriate warnings about the dangers of mixing these drugs with alcohol or other drugs (including over-the-counter medications) and to educate parents/caretakers about the potentially harmful effects of antidepressants for this younger population.

This page was last updated on October 11, 2010.

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