Antidepressants cut risk of hospital readmission for suicidal youth

December 17, 2009

COLUMBUS, Ohio - Suicidal adolescents who were prescribed an antidepressant medication during inpatient psychiatric hospital treatment were 85 percent less likely than others to be readmitted within a month after discharge, a new study found.

The results provide additional evidence that antidepressants may play a key role in helping improve the mental health of suicidal youth, said Cynthia Fontanella, co-author of the study and assistant professor of social work at Ohio State University.

The findings are especially important now, because antidepressant use dropped in 2003 after the Food and Drug Administration issued a black box warning that some antidepressants may increase the risk of suicidal behavior for pediatric patients. A black-box warning is the most serious type of warning in prescription drug labeling.

"We found that antidepressant treatment had a protective effect on readmission," Fontanella said. "Although the findings are preliminary, our results should be reassuring to child psychiatrists who may have been concerned about prescribing antidepressants since the FDA warning."

But another key finding from the study showed that hospitalized youth who were prescribed three or more medications from different drug classes for mental health issues had a 3-fold increased risk of being readmitted within a month of discharge.

Fontanella conducted the study with Ohio State researchers Jeffrey Bridge, assistant professor of pediatrics, and John Campo, chief of child and adolescent psychiatry. Both are also associated with the Research Institute at Nationwide Children's Hospital in Columbus.

The study appears in the December issue of The Annals of Pharmacotherapy.

The researchers did a retrospective study of 318 Medicaid-covered adolescents who were admitted to three major psychiatric hospitals in Maryland because of attempted suicide or suicidal behaviors.

They examined hospital medical records for the adolescents and recorded all medication changes - including additions, discontinuations and changed dosages that occurred during the hospital stay.

The researchers then identified which patients were readmitted to any hospital in Maryland within 30 days of their discharge.

Hospital readmissions within 30 days are considered an indicator of quality of care, Fontanella said. Most readmissions or post-hospitalization suicide attempts occur during that time period.

Fontanella said that this is the first study to investigate the effects of hospital medication changes and use of multiple medications on readmission of suicidal youth.

"We know little about how medication is being used to treat youth in inpatient care," she said. "This is a first step in figuring out what is effective and what is not."

The study found that 78 percent of the inpatients had one or more changes in their medication, typically the addition of an antidepressant, mood stabilizer or antipsychotic.

About a quarter of the adolescents were prescribed three or more medications from different drug classes. That's particularly concerning since those prescribed three or more drugs were 2.6 times more likely to be readmitted within 30 days, Fontanella said.

Fontanella emphasized that the study does not address the appropriateness of the medication prescriptions given to any individual patient in the study. However, she added that psychiatrists need to be "very judicious" in prescribing multiple drugs to adolescents, given the risks.

"What we're advocating is more quality monitoring and help for clinicians in hospitals to weigh the risks and benefits to putting adolescents on multiple medications," she said.

She noted that the researchers took into account a variety of clinical factors that may be related to the severity of illness for the adolescents in this study. That means youth who received multiple drug prescriptions weren't necessarily more likely to be readmitted within 30 days simply because they had more severe illnesses than did other patients.

While multiple medications presented clear dangers to adolescents in this study, the use of antidepressants was clearly helpful to most patients.

The message for psychiatrists is that they shouldn't dismiss the use of antidepressants for troubled youth, despite the FDA warnings, Fontanella said.

Beginning in 2003, several antidepressants have had to carry an FDA warning that states they may increase the risk of suicide for some users. Since that warning has appeared, the use of some antidepressants has fallen or leveled off, and the suicide rate among adolescents has risen.

"Our study suggests that many adolescents can really benefit from antidepressants, particularly those who are severely depressed," she said. "We have to be very careful before deciding not to use these medications."

One of the problems that hospital psychiatrists face is that they don't have time to adequately monitor how their medication changes are affecting their adolescent patients, according to Fontanella. The average stay for inpatients in this study was just 8 days.

"Because the treatment stays are so short, the psychiatrists and their teams are at a disadvantage. They aren't given the time to monitor the medications to see if they are safe and effective for the individuals," she said.

"We need better ways to monitor patients after they leave the hospital to look for possibly adverse effects and drug interactions, and to ensure the medications are effective."
The study was supported in part by The Center for Health Care Strategies, Inc., under tha Annie E. Casey Foundation's Children in Managed Care Initiative. Additional support came from the National Institute of Mental Health.

Ohio State University

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