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The young and old both need special attention for special side effects: Antidepressant suicidality, other side effects in the young, as well as risks in treating the elderly.
1-800-SUICIDE
maybe the Doctor Online could help you die
you need wings to fly, you need someone
to take your place, when you are gone...
--Zeromancer, "Doctor Online"
Yes, the risks are real. From birth up until young adulthood (ages 25 and below is now the US FDA guideline for this group), it's a well-known fact that the brains of these individuals are very changeable and indeed do change rapidly. There are umpteen studies that prove there are dangerous risks inherent in treating children and younger adults with psychiatric medications. And adults (especially the elderly) are not spared from their share of special considerations. Nonetheless, psychiatric medications do have benefits in these folks, so this is an area where we'll have to go through cautiously.
PATIENTS UNDER AGE 25: ANTIDEPRESSANTS AND SUICIDALITY
The recently well-noted risk of suicidality (i.e., the presence of suicidal thinking or attempt at suicide) seen with the initiation (starting) of antidepressant treatment is real. Very real. The The most comprehensive review description I could find was inside, no less, the prescribing information packet for the antidepressant EFFEXOR (venlafaxine). The manufacturer mentions the combination of many different suicidality studies, totalling in a population of 77,000 (!) treated patients. They note the risk of suicidal behavior increased (in absolute terms) by 1.4% when comparing antidepressant-treated pediatric (age <18) patients as compared to patients treated with a placebo. A figure of 0.5% increase was noted in the age group 18-24. Suicidality, the review found, actually decreased (by 0.1-0.6% in absolute terms compared to placebo) in those older than 24.
The real question, though, is "WHY?". Pre-existing depression sure doesn't help. Neither does being a teenager in general. As a 17 year old emeritus (my mind's been stuck at that age the past 7 years), I can personally testify to that factor. There must be something special about these brains that causes these antidepressants to act funny the first few weeks. I can't answer the question for sure, but I can definitely tell you what basic clinical and lab research is currently showing about the molecules involved.
BY THE WAY, CLINICAL NOTE: For those of you who are parents of kids and teenagers (or are yourselves younger adults making your own healthcare choices), please note that you will benefit from at least seeing a good psychiatrist and discussing the possibility of taking antidepressants if you are indeed depressed or have other psychological issues. Please don't let the risk of suicidality keep you away from meds -- It almost goes without saying that antidepressants do indeed help many in the younger crowd. 15 years ago, my family almost lost me, and I can promise you, I wasn't on antidepressants at that time!
THE OLD AND YOUNG: STIMULANTS AND CARDIAC (HEART) RISKS
I'm only mentioning this issue as younger adults are the most likely of any group to be on stimulants, such as RITALIN (methylphenidate) and DEXEDRINE (D-amphetamine). Namely for AD/HD. Therefore, it's important to note that most stimulants carry warnings stating that there is a very small, but existent, risk of heart arrhythmia (abnormal rhythm) in overdose as well as normal doses in sensitive individuals -- and that some instances of arrhythmias have been fatal. This is generally due to the fact that stimulants, are, well, stimulating. This goes for all stimulants, including those we consume every day, including our morning cup o'joe. It's all about managing your risks, you see.
Now that all said, RITALIN's manufacturer states that the risk of "serious cardiac events" (read: syncope/passing out, arrhythmia, sudden cardiac death, etc.) is actually increased as one gets older (they speculate it's due to age-related natural deterioration of the heart, which makes perfect sense to me at least), and that this risk is most pronounced, of course, in the elderly. Therefore, stimulant use also warrants some care as your body grows old and tired (and for me, that started around age 22, but your senescence will vary).
Now, going back to the molecules... in terms of stimulants dorking around with your body's chemistry, it has been considered that these drugs, in very high doses (or at usual doses in very sensitive individuals) may alter the heart's rhythm by changing the activity of the neurotransmitter norepinephrine and/or messing with the ion channels that help give the heart its rhythm.
MALES ON OLDER ANTIPSYCHOTICS: NMS (NEUROLEPTIC MALIGNANT SYNDROME)
Antipsychotic medications also have potentially fatal risks, as well. A group of symptoms known as the "neuroleptic malignant syndrome" (NMS) can (albeit very rarely) occur in patients taking antipsychotics (aka "neuroleptics"). Older antipsychotics (the so-called "typical antipsychotics") are associated with a much higher risk than the newer "atypical antipsychotics".
Focused studies and reviews find that men on antipsychotics seem to be more vulnerable to NMS than other treated groups of individuals (the most salient one I found stated that looking at many studies of NMS in terms of proper treatment, the authors had concluded that 66% of sufferers were male; however, this could be due to the fact that males are more likely to be on NMS-inducing drugs as opposed to females with similar conditions treated with more "benign" meds).
Some features of NMS include muscle rigidity (stiffness), hyperhidrosis (excessive sweating), nausea/vomiting, and worst of all, hyperpyrexia (i.e., one Hell of a fever!), which has been seen in NMS to exceed 110F/43C. NMS, untreated, has a decent possibility of becoming fatal.
As far as causes are concerned, it is possible that dopamine blockage by these antipsychotic drugs can lead to the muscle stiffness seen in NMS. I would speculate this wouldn't be too much of a surprise, given that Parkinson disease (and related syndromes) show a drop in dopamine function, and that this drop is correlated with dystonia (painful, stiff, and chronic muscle spasms).
FEMALES ON CERTAIN SPECIFIC DRUGS AND THOSE WITH "LONG-QT SYNDROME": TORSADE DE POINTES
Torsade de pointes, often known simply as "torsade" or TdP, is a syndrome whereby the heart's electrical rhythm becomes abnormal (the term literally means "twisting of points" in French, and describes what the issue physically looks like on the EKG). A few drugs (many in the typical antipychotic class, and also a few non-neuro/psych meds) are known to cause torsade, and a major aggravating factor in getting TdP whilst on drugs is being of the female sex (though, of course, males can get it too!). TdP is also seen in individuals with the disorder known as "long QT syndrome" (LQTS), a heart-related issue that makes one very prone to episodes of torsade (regardless of drugs; TdP-inducing drugs just could make the situation worse!). The torsade de pointes rhythm (or rather, arrhythmia!) can lead to syncope (fainting), or worse yet, completely up-end the heart's natural rhythm, resulting in ventricular fibrillation, which is universally fatal if not treated. (And treatment often consists of those electrical paddles, just in case you weren't familiar with the treatment of ventricular fibrillation!)
(Oh yeah, and also note - I did discuss above that stimulant overdose or sensitivity can cause arrythmia, but these arrhythmias are generally not TdP.)
All this is no reason to panic: Note that extremely few drugs are known to induce TdP. Also, torsade-inducing drugs are generally given only as a last resort, and your physician would generally order regular EKGs for you to make sure that your heart's beating normally.
As for how and why TdP occurs, it is possible that TdP-causing meds mess directly with a specific kind of ion channel (namely the potassium ion channel in your heart). Interference there can cause abnormal electrical currents in the heart (it's made up mostly of nerve/muscle cells anyways), leading to arrhythmias.
Now hear me out, I know what I said above about all those side effects sounds just plain scary -- But don't take it as reason to go running away from these medications (and don't take that as a reason to blindly accept them, either!). All throughout life, every second of the day, you have to weigh the consequences of any decision you might make. Sometimes, driving 80MPH in a 70MPH zone can get you hurt. Driving 60 in a 70 zone might cause a crash too. And even doing exactly 70 in a 70 could get you outright killed, for that matter. It just depends on the road conditions, traffic, and that idiot doing 40 in the left lane... who by the way, just cut you off by merging right without signaling. (He's from Georgia, in case any of y'all couldn't tell by his tags... or the way he's driving... Hey, I said he was from Georgia, not Atlanta!)
So get your attention back out on the road. You and your doctor know a lot more about yourself than I do. Please do speak with your physician if you are concerned about any of these risks.
*SPLASH*. And careful with where you put that cup of coffee -- Never between the legs, not even for a second -- that's what cupholders are for. I never said that burns to the groin had any part to play in serious stimulant-induced injuries, and I can't seem to find any research that supports that idea.
Sample antidepressant LEXAPRO's black box warnings: [Consumer Version] :: [Clinician Version]
EFFEXOR's PI sheet analysis of suicidality: [LINK]
Sample stimulant RITALIN's warnings, with information regarding cardiac (heart) events: [LINK]
Reulbach U. et al, "Managing an Effective Treatment for Neuroleptic Malignant Syndrome". Journal of Critical Care 2007;11(1). Full text courtesy of MedScape.
The above was just a summary of serious side effects seen in various populations. Although I did manage to cite and verify most of what's up there, I do intend to go into a lot more detail about the biochemistry and molecular biology of these serious side effects when I finally get to writing up the whole section here.
Page last updated 9 July 2008.
