Join the fight – learn how to help prevent suicide

The Pediatric Insider

© 2018 Roy Benaroch, MD

Suicide is among the most common causes of death of teens and young adults, and the rates are rising. Unfortunately, people at the most risk of suicide may not be able to get themselves the help and resources they need.

I’ve written and taped a short, 45 minute lecture series, A Practical Guide to Suicide Prevention, to help family and friends recognize the warning signs of suicide risk, and to help people learn the best steps to take when someone is in danger. It’s part of The Great Courses Plus streaming service, and you can watch or listen to the audio as part of a free trial.

If you do join The Great Courses Plus, please check out my other courses. I have three audio/visual series titled Medical School for Everyone. They’re all presented as medical mystery cases for laymen to figure out. While figuring out the mysteries, you’ll learn about medicine, physiology, therapeutics, and how doctors think through solving diagnostic mysteries yourself. The feedback has been great – I think you’ll enjoy the courses! You can watch them via the free trial on The Great Courses streaming service, or buy them individually (with a no-hassle money back guarantee) from The Great Courses. Links below!

Next year I have a new course coming out called A Skeptic’s Guide to Health, Medicine, and the Media. It’s going to be great – look out for it around February 2019.

My courses:

A Practical Guide to Suicide Prevention – via The Great Courses Plus

Medical School for Everyone: Grand Rounds Cases – medical mysteries for you to solve! From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Emergency Medicine – mystery cases from the Emergency Department. From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Pediatric Grand Rounds – mystery cases from the world of pediatrics! The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Is there a link between birth control pills and depression?

© 2016 Roy Benaroch, MD

A provocative new study from Denmark supports a link between hormonal contraceptive methods (like birth control pills) and depression. And the association seems to be strongest for adolescent girls.

Huge studies like this are based on huge datasets – in this case, relying the Danish medical system’s longstanding penchant for meticulous and integrated medical records. You just couldn’t do this kind of research in the USA, where medical records systems can’t talk to each other or combine their data in a coherent way.

The researchers started by reviewing the medical records of Danish women, age 15-34, from 2000 through 2013 (excluding women with a preexisting diagnosis of depression or related disorders.) To determine when women took hormonal contraceptives, they relied on a National Prescription Register, which included all prescriptions made and filled for combination contraceptives (these are the ones most commonly used) as well as other medicines and devices (like implants and injected progestin) that rely on hormones to prevent pregnancy. For the purpose of the study, women were considered to be on prescribed hormones for the period of time they filled these prescriptions, plus six months. Over a million women made up the final dataset, followed for an average of 6.4 years each. At any given time, 55% of the women were taking these kinds of contraceptive medications.

The researchers then figured out when all of these women had depression, relying on either their filling a prescription for an antidepressant medication, or when any medical facility made a diagnosis of depression. Overall, during the study period, a total of 133, 178 prescriptions for antidepressants were filled for about 23,000 diagnoses of depression (many of the patients with depression filled more than one prescription.)

Using the data including the timing of contraception usage and depression diagnoses, the study authors could then compare whether depression was diagnosed while the women were either taking or not taking these contraceptives. And it turned out the depression was more common during the on-contraceptive periods. Overall, the increased risk of depression during contraceptive use was about 20% for all women in the study. The increased risk rose to 80% when only adolescent young women from age 15-19 were evaluated. The elevated risks were seen among all the different kinds of hormonal contraceptives examined.

This doesn’t necessarily mean that the contraceptives caused depression. Observational cohorts like these only show a temporal association. It’s possible that women taking contraceptives are more likely to become depressed for reasons unrelated to the medication itself – perhaps relation to the kinds of relationships they were in. Contraceptives are prescribed for many reasons other than contraception, too – to improve menstrual symptoms, or to help with acne. It’s also true that antidepressant medications are prescribed for things other than depression, like anxiety disorders or some chronic pain syndromes.

Still – over a million women in the study, and the effect size (especially among adolescents) was significant. While this study does not mean that women shouldn’t take contraceptives, it does mean that prescribers and their patients should keep depression in mind as a possible side effect, and that women at risk for depression may wish to consider other, non-hormonal means of contraception.

 

 

The murky connection between maternal antidepressants and autism

The Pediatric Insider

© 2015 Roy Benaroch, MD

A new study of almost 150,000 Canadian children is sure to further worry parents. Does taking antidepressants during pregnancy really increase the risk of your baby developing autism by 87%? As usual, the details matter. And the truth is never quite as clear-cut as the press release.

First: what we already know. Autism is a complex disorder of social behaviors and language. It’s unlikely that we’ll ever know “The Cause” of autism, because (like cancer and obesity and many other things) there’s probably not just One Cause. Certainly, genetics plays a huge role—siblings and other relatives of people with autism are at an increased risk for autism spectrum disorders. And we know that many prenatal factors (like premature delivery or maternal health problems) increase the risk, too. Some children with autism have a known genetic variant or marker, and the proportion of those kids seems to rise every year as our testing gets better. Still, there’s a whole lot we don’t know about other influences on how the brain develops, and on what other factors might contribute.

Previous studies on antidepressants taken during pregnancy have had mixed results—some gave shown an increased risk of autism, and others have not. One of the difficulties in doing such a study is that we know maternal depression, itself, is a risk factor for autism. So is it the antidepressant medicines that cause the risk, or the depression itself, or some other factor? For instance, depressed moms may get less sleep, or are perhaps more likely to drink alcohol, or may just feel more stressed—any of these, or any combination of these, could be what really confers the risk to the unborn baby.

In the current study, the authors tried to control for these effects by looking at multiple covariates. There’s some heavy-duty math behind these statistical techniques, but the idea is to isolate one independent variable (taking antidepressants) from every other variable, so you only “see” the effect of what you’re looking for. Of course, you have to know all of those other variables beforehand, and how to measure them, and how they might contribute to your end-point—and that’s why it’s tricky, and that’s why it’s easier to write about a press release than it is to read an actual study and muck your way through the details. In this study, the authors “controlled” for maternal health and mental health issues (though not specifically for maternal autism), substance abuse, income, education level, whether the family received welfare, and many other variables.

The authors used registries of births along with child and maternal health records from Quebec, looking at all babies born in 1998-2009. They excluded premature babies and twins (because these are already known predictors of autism), along with babies with other health problems. Then they looked at the child and maternal health records. To see if mom took antidepressants during pregnancy, pharmacy records were reviewed for filled prescriptions.

The numbers, themselves, are interesting. Of 145,456 live-born babies eligible, 1054 (.7%) were diagnosed with autism during the study period (typically within the first 6 years of life). Of those 145,456 babies, 2532 had moms who took antidepressants during the 2^nd or 3^rd trimester, including 31 who developed autism. When all of the math was done and covariates accounted for, the proportion of autism worked out to be 87% higher among the moms who took antidepressants after the 1^st trimester (there was no increased risk during the 1^st trimester, only during the 2^nd and 3^rd, or the last 6 months of pregnancy.)

That 87% increased risk—that pops, and that’s what you’ll see in the headline. But there are some other things to notice about the study that are more subtle, but just as important. Of the babies whose moms took antidepressants, 1.2% developed autism—and 98.8% did not. The relative increase in risk looks high, but the absolute, actual risk is still quite low. And the whole conclusion of the study rests on those 31 of the 150,000 babies who developed autism after exposure to antidepressants. That’s not a very big number.

I also wonder about controlling for known maternal risks. Perhaps more-severe depression itself confers a higher risk of autism than mild depression—and if more severely depressed moms were more likely than mildly depressed moms to take medication, that would explain the different observed rates. And maternal autism, itself—a friend of mine pointed out that the authors didn’t control for that, and didn’t even try to measure it. But if a higher proportion of moms with autism were depressed (which, logically, makes sense), that would also explain this association, without implicating the antidepressant medication itself.

What should parents do about this? Maternal depression can be debilitating, and needs to be treated—but perhaps non-medical therapy should be the best, first option, especially in the last 2/3rds of pregnancy. But if medication is needed to help mom, I think it’s still a reasonable option, given the small risks that could be implied by this study. It’s also clear from this study that antidepressants in the beginning of pregnancy, through the first trimester, are not associated with increased risks. Women on antidepressants probably don’t need to stop taking them while trying to become pregnant, or early on in the pregnancy.

If your child was exposed to these kinds of medications prior to birth, it would also be sensible to keep tabs on Junior’s development, and refer early on if there’s a concern of autism. Early therapy can be very effective.

People want a clear answer –“This” causes autism. It’s not that simple. This study supports the idea that early influences during pregnancy (such as maternal depression, or maternal medications) can be at least one risk factor. But there’s a whole lot more to learn.

 

Note: after I wrote this, someone sent me this link to NPR’s review of the same study – they did a good job, and provided links to previous research. They also made the point that the lead author of this study has worked with plaintiff’s attorneys who are suing antidepressant manufacturers. Should that color how we look at results like these? You decide.

 

Is the FDA’s antidepressant warning killing people?

The Pediatric Insider

© 2014 Roy Benaroch, MD

In 2004, the FDA launched a program to “strengthen safeguards for children treated with antidepressant medication.” Among other steps, they started requiring manufacturers of several kinds of antidepressants to include a warning in their product labeling, a so-called “black box,” that explicitly and loudly proclaimed a risk for children taking these medications. The warning said that children taking these medications were at an increased risk of suicidal thoughts and behaviors. Later, the black box warning was expanded to include young adults. The warning was required to be added to the labeling of medications including Prozac, Zoloft, Celexa, Wellbutrin, and several other medications.

What prompted this action was an observation from studies of children taking these medications that in the weeks after starting them, there seemed to be increased thoughts of suicide. Not suicide attempts, and not deaths from suicide (there were actually no suicide deaths at all among the study groups), but self-reported thoughts about suicide.

Now, depression is a serious illness—and suicide is a very serious consequence of depression. People with major depression have about a 15% cumulative lifetime risk of death by suicide, so this is a very significant and serious problem not to be taken lightly. We know that people with depression often think of suicide, and are at grave risk for attempting suicide—is it possible that anti-depressant medications actually make this risk worse?

A June, 2014 study from The British Medical Journal has looked at the consequences of the FDA’s decision (and the ensuing broad media coverage.) Researchers examined data from a total of 2.5 million teens and young adults from 11 health care plans in the United States. After the warning, the use of these medications dropped by about 24-31% (depending on age grouping.) This was accompanied by an increase in the rate of suicide attempts, by 22-34%. The rate of deaths from suicide did not change at all—just the rate of attempted suicides.

So, no, the FDA’s warning, based on this study, didn’t increase actual deaths. But it did increase suicide attempts, which likely means it increased the rate and severity and consequences of depression. It certainly hasn’t done any good. The warning has scared many families and doctors away from one mode of therapy for depression. Antidepressant medications aren’t perfect—they do have important side effects, and they don’t always work, and they’re certainly not for everyone with symptoms of depression—but they can be one important part of the treatment of some depressed adolescents. It’s a shame that this misguided “black box warning” is doing more harm than good.

Breastfeeding and post-partum depression: A possible cure, a possible cause

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.

Depression in the family

The Pediatric Insider

© 2011 Roy Benaroch, MD

Beth posted, “As someone who has battled clinical depression since childhood, and whose husband has many of the same issues, I’m very curious about the risks my children face in this area. How much more likely are they to suffer from depression?”

Depression, as well as other mental illnesses, do run in families. The population risk of major depression—that is, the risk that someone will have depression at least once during their life—is probably about 5-10%. Add in the risk of an anxiety disorder, and you’ve probably got a lifetime risk in the 10-15% range. With one parent with problems with anxiety or depression, the risk for their children is about doubled, to 20-30%; with both parents, it’s somewhat higher than that (I couldn’t find an exact number.) So you’re right to be concerned about the risk in your kids.

We do know that there is more than genetics at work, though. Depression and anxiety are also influenced by environmental factors, including early childhood trauma, and exposure to parents and other loved ones with mental illness. If you and your husband are being successfully treated for depression,  it should reduce your own children’s risk—because they’re being raised by parents without symptoms (or with reduced symptoms) of mental illness.

The diagnosis of depression and anxiety disorders in children may be more difficult because kids do not necessarily have the same symptoms. While adults have anhedonia (lack of joy), children will more typically have irritability or chronic unexplained pain, trouble sleeping, or trouble with peers and in school.

If you’re worried about symptoms of mental illness in your kids, please bring them to your pediatrician. Be open about your own history of these problems. That can help the doctor come up with the best diagnosis. Though your kids are at elevated risk, that’s not to say that they’ll definitely—or even probably—have problems like these.

Early to bed

The Pediatric Insider

© 2010 Roy Benaroch, MD

“Early to bed and early to rise, makes a man healthy, wealthy, and wise.”

Maybe Ben Franklin* was talking about his teenager.

A study published in the January, 2010 issue of Sleep compared teenagers who had early bedtimes (before 10:00 pm) to teens who reported that their parents let them stay awake past midnight.

The authors found that the teens reporting the later bedtime had about a 24% increased incidence of depression, and a 20% increased risk of suicidal thoughts. Further analysis showed that the main way that the earlier bedtimes was protective was that the kids with later bedtimes got less sleep overall.

I speculate that the earlier bedtimes might also be more likely to be a rule in families where parents take a more “active” role in their teenagers’ lives, which probably also protects their teenagers against depression.

I don’t know about making a teen wealthy and wise, but one way to keep them healthy is by sending them to bed at a reasonable time. Teens need 8 or 9 hours of sleep a day– and catching up by sleeping until noon on weekends doesn’t count. If your teen is surly and hard to wake up in the morning, an earlier bedtime might be just the thing to improve everyone’s mood.

*The quote is often attributed to Benjamin Franklin, but apparently there were many earlier versions, like “Who soo woll ryse erly shall be holy helthy and zely.” This predated spell-check.



Early to bed

The Pediatric Insider

© 2010 Roy Benaroch, MD

“Early to bed and early to rise, makes a man healthy, wealthy, and wise.”

Maybe Ben Franklin* was talking about his teenager.

A study published in the January, 2010 issue of Sleep compared teenagers who had early bedtimes (before 10:00 pm) to teens who reported that their parents let them stay awake past midnight.

The authors found that the teens reporting the later bedtime had about a 24% increased incidence of depression, and a 20% increased risk of suicidal thoughts. Further analysis showed that the main way that the earlier bedtimes was protective was that the kids with later bedtimes got less sleep overall.

I speculate that the earlier bedtimes might also be more likely to be a rule in families where parents take a more “active” role in their teenagers’ lives, which probably also protects their teenagers against depression.

I don’t know about making a teen wealthy and wise, but one way to keep them healthy is by sending them to bed at a reasonable time. Teens need 8 or 9 hours of sleep a day– and catching up by sleeping until noon on weekends doesn’t count. If your teen is surly and hard to wake up in the morning, an earlier bedtime might be just the thing to improve everyone’s mood.

*The quote is often attributed to Benjamin Franklin, but apparently there were many earlier versions, like “Who soo woll ryse erly shall be holy helthy and zely.” This predated spell-check.