Why Do Antidepressants Have Warnings About Suicidal Thoughts?

bottle of pills — The Food and Drug Administration requires a warning label on antidepressants that they may increase suicidal thoughts. Grace Cary/Getty Images

It's a common warning on the labels of antidepressant drugs: "may cause suicidal thoughts." Some people who are depressed may think about committing suicide. So, it seems counterintuitive that medications, which are specifically formulated to treat depression, could have this side effect. But why?

"The name 'antidepressants' is kind of a marketing term that makes the problem of suicidality less understandable," explains licensed clinical psychologist Dr. David Godot, with Psych Lab Psychology Center in an email. "Antidepressant medications do not actually reduce depression – they simply increase levels of certain neurotransmitters. Forty years ago, researchers imagined that depression was caused by a shortage of those neurotransmitters. However, research has not supported that hypothesis at all. The brain is much more complicated than that."

Indeed, it's a field where the brain seems to be constantly flipping the script. As a result, reactions to certain medications and treatments don't always make a lot of sense and vary widely from person to person. "As depression lifts, it can make a person feel more motivated. The vast majority of the time, this is a good thing," says Louis Laves-Webb, a psychotherapist in Austin, Texas. "It means they're motivated to engage in activities that make their life happy and meaningful. Unfortunately, this isn't always the case and, due to mechanisms we have yet to comprehend, a small minority of patients find the motivation not to play but to make a suicide plan."

It's a phenomenon that holistic healing blogger Esther Louise knows all too well, having used antidepressants to successfully manage her lifelong battle with depression and anxiety. The benefits haven't come without some pitfalls, however.

"I have been through the process of starting the SSRIs [selective serotonin reuptake inhibitors, a common form of antidepressant] on three occasions now, and each time I have found it to be very difficult. When starting the medication I tend to experience an increase in the severity of my symptoms for a short time before they slowly start to get better," she recalls. "In my experience, this means that for about a week after starting the antidepressants I will feel very depressed and experience suicidal thoughts, even if I had not been suffering with them before starting the medication."

She says that she still finds this experience to be very alarming, even though she's aware of what's going on. "During this time, I feel very out of character, more impulsive and not as stable," she explains. "It can be incredibly scary to feel like you are out of control in this way. However, I try to remind myself that it is only temporary and these feelings will go away soon – in my case, they always have."

This reaction probably occurs because it takes time for antidepressants to really kick in. "When you take Prozac, your serotonin levels will increase within about a half hour. But therapeutic benefits are not expected for at least two weeks," Dr. Godot explains. "Why? Because something else has to happen in the brain and body, in response to the elevated neurotransmitter levels. And frankly, no one in the world knows exactly what that something is."

Good Outweighs Bad

Despite the risk of suicidal thoughts, antidepressant use seems to be a case of the good outweighing the bad, as research has shown that antidepressants typically have a protective effect against suicide. A 2017 journal article also pointed put that toxicological reports of depressed people who died by suicide showed that it's more common for suicide to occur in patients who were not taking an antidepressant, than in those who were.

It also appears that the risk of suicidal thoughts is far greater in children and adolescents taking these medications than those over the age of 25. A 2003 review of 23 clinical trials using SSRIs in children and adolescents with depression found that there was a 4 percent risk for suicidal thoughts when using SSRIs versus a 2 percent risk when on a placebo. Although no one committed suicide during these trials, the Food and Drug Administration determined that a warning that antidepressants may increase suicidal thoughts was appropriate to add to the drugs' labels. But later research appears to

"In number, it is only a small percentage," Laves-Webb says. "[But] to parents of any child lost to suicide due to antidepressants, the problem is enormous and inconceivable."

Since awareness of this issue has risen, prescribing doctors have added risk of suicidal thoughts to their patient education checklist. "Providing the patient with information about this process is crucial so that they too can look for signs," says therapist and author Lauren Cook. "By normalizing conversation around suicide, a patient is that much more inclined to share if they are thinking about hurting themselves."