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Neurological entanglements: The case of paediatric depressions, SSRIs and suicidal ideation

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Abstract

This article explores the neurological entanglements that are the stuff of depressive states in treatment. My particular concern is the use of selective serotonin reuptake inhibitors in depressed paediatric populations. The use of antidepressants to treat childhood and adolescent depressions has become more frequent in recent years, and more controversial. My ambition is not to intervene into these debates directly, but to push some of our thinking about the substrata of depression in new directions. I am interested in what philosophies of the body and what theories of mind the psychological literatures about paediatric depression lean on, and silently promote. Drawing on neurological and clinical trial data, the article argues that depressive states are neither caused nor cured by singular events (a gene; a pharmaceutical); rather they are complex, non-deterministic sedimentations of pharmaco-affective, ideo-chemical and neuro-social affiliations.

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Notes

  1. Black box warnings are printed on the insert to be found inside the packaging of prescription drugs sold in the United States. The name ‘black box’ refers to the black border around the text that issues the warning about possible serious adverse responses to the drug. Black box warnings are the highest level of notification that the FDA can issue.

  2. SNRI refers to a serotonin–norepinephrine reuptake inhibitor. These drugs (for example, venlafaxine/Effexor) act on the transmitter norepinephrine as well as serotonin. In the United States, SNRIs are FDA-approved for the treatment of anxiety disorders and/or fibromyalgia; and they are prescribed off-label for obsessive-compulsive disorders, chronic fatigue syndrome and some menopausal symptoms. The DSM IV-TR defines dysthymia as the persistence of low mood for at least 2 years (or 1 year in the case of children and adolescents), with two or more of the following: poor appetite or overeating; insomnia or hypersomnia; fatigue; low self-esteem; poor concentration; hopelessness.

  3. Fantastic Voyage (Fleischer, 1966) narrates the journey of a manned nuclear submarine that has been shrunk to microscopic size in order to be injected into the bloodstream of a patient. The crew of the submarine have 1 hour to get to the patient's brain and destroy a blood clot.

  4. The FDA review of suicidality in paediatric populations (Hammad et al, 2006) asked the manufacturers of the major SSRI and SNRI antidepressants to provide ‘narrative summaries’ (p. 333) of each suicidal related adverse event in their trials. The summaries were classified into five types of suicidal event by ‘a group of 10 pediatric suicidology experts assembled by Columbia University’ (p. 333). These narratives may provide richer phenomenological data about suicidal ideation, but they are not publicly available.

  5. I am leaving the question of suicide to one side in this article. There doesn’t seem to be any indication in the reviews of paediatric use of SSRIs and SNRIs in RCTs that suicides have increased due to the pharmaceutical use (Whittington et al, 2004). The FDA review reports no suicides in 4582 paediatric patients. Moreover, autopsy studies have not found evidence of antidepressants in most adolescents who do kill themselves (Hammad et al, 2006). Hammad et al also note that the issue of suicidality early in pharmaceutical treatments is not new. In 1960 a psychiatry textbook observes that ‘with beginning convalescence, the risks of suicide once more becomes serious as retardation fades’ (quoted in Hammad et al, p. 337).

  6. The syndrome has been closely linked to SSRIs (and the increased profile of the syndrome in the last decade no doubt reflects the significant increase in the prescription of serotonergic antidepressants), but it has also been associated with TCAs, MAOIs, over-the-counter cough medicines, antibiotics, anticonvulsants, antimigraine medications, herbal products and recreational drugs (Boyer and Shannon, 2005).

  7. These particular sedimentations are not confined to humans: serotonin (5-hydroxytryptamine) is a neurotransmitter found in a wide variety of animals (for example, insect venom) and in plants (seeds and fruit). Even within the human body, serotonin is thought to be involved in the materialization of many different events: mood, appetite, sleep, pain, migraine and emesis (vomiting). Moreover, most of the human body's serotonin is not in the brain, but in the enteric and peripheral nervous systems (particularly around the gut). Serotonin is manufactured in the human body out of tryptophan, which has to be eaten as part of a regular diet; and for this reason it is a particularly important part of the traffic between world, gut, mood and brain (Wilson, 2004).

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  1. Department of Women's, Gender and Sexuality Studies, Emory University, 550 Asbury Circle, Candler Library 128, Atlanta, 30322, Georgia, USA

    Elizabeth A Wilson

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Wilson, E. Neurological entanglements: The case of paediatric depressions, SSRIs and suicidal ideation. Subjectivity 4, 277–297 (2011). https://doi.org/10.1057/sub.2011.12

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