Lethal Impulse

HUMPHREY, Neb. -- Studies suggest that antidepressants, such as Paxil, and strong acne medications, such as Accutane, can heighten a teenager's chance of attempting suicide.

So imagine the questions nagging Leslie and Nancy Vosteen of Humphrey, Neb., whose son shot himself early Monday evening, Aug. 27, 2001.

Lance Vosteen, 16, had been taking Paxil for sleeping problems, a generic acne prescription to clear up his skin and a third medication for a poison ivy rash. While the teen had other pressures, his father now wonders whether the drugs played a role.

"You wouldn't point your finger at him and ever think he would commit suicide, " Leslie said. "I mean, he had it made."

The role of prescription medications, especially antidepressants, in teen suicide is controversial. The U.S. Food and Drug Administration last fall slapped a "black box" warning on antidepressants with even slight links to increased suicide risk. It's the agency's strongest safety alert.

The move upset some psychiatrists. They fear it will discourage the use of antidepressants -- even though research also suggests the medications can lower suicide risks among teens. The teen suicide rate nationally has dropped by onethird since 1988, shortly after doctors began dispensing the medications for the treatment of child depression.

The Vosteens have consulted with an attorney. Meanwhile, an Omaha family that lost a child to suicide is suing two drug makers in federal court. The parents of 11-year-old Jacob Jackson believe the antidepressants Zoloft and Effexor may have contributed to his death in 2002.

The legal and medical quandary is that depressed children by definition have a heightened risk for suicide. One theory is that the medications take depressed children from utterly listless to hyperactive or agitated. Child psychiatrist Chris Kratochvil called it an "inner restlessness."

"When people start getting better with their depression, they can have an increased risk of harming themselves, " said Kratochvil, of the University of Nebraska Medical Center. "Maybe they finally have the energy to implement a plan that they had."

Kratochvil believes in using antidepressants. He was part of a national study published last summer that evaluated suicide risks in 439 severely depressed teens. They received prescription antidepressants, or therapy, or both, or neither

The study found the least suicidal feelings and most improvement among teens receiving both drugs and therapy. Teens taking drugs without therapy also experienced fewer depressive symptoms, but they also were more likely than teens receiving therapy or nonmedical placebos to consider or attempt suicide.

Kratochvil said the key is frequent monitoring of children on antidepressants by their psychiatrists, especially in the early months. This is one of the ways depressed Nebraska teens may be at a disadvantage if they live outside the Omaha or Lincoln metropolitan areas. The rest of the state has a shortage of psychiatrists, child psychiatrists and even pediatricians.

Leslie Vosteen advises parents to ask tough questions about prescriptions for their children and to seek second opinions when dissatisfied with the answers.

Drugs or no drugs, Lance Vosteen was under stress. Insomnia left him with only minutes of sleep every night -- to the point that he missed school and football practices for a week. He had also been accosted by a female classmate's father for making an insult that, Leslie Vosteen said, turned out to have been made by someone else.

Lance's death stunned Humphrey, a town of 800 located 23 miles north of Columbus. His football team dedicated its first game of the season to Lance and broke the school's five-year losing streak. The game was on a Friday, four days after Lance's death. His funeral was Saturday.

Of 37 teen suicides

Extensive interviews with their Nebraska parents showed:
28 used a gun
25 found gun unsecured
21 had a diagnosed mental illness or symptoms
19 came from divorced or single-parent homes
19 had family history of mental illness or suicide
18 used alcohol frequently
17 just had romance trouble
16 had talked of suicide
16 were on antidepressants or acne drugs with suicide risk
15 used illegal drugs frequently
9 had been teased or bullied
7 attempted suicide before
4 had been abused physically or sexually

Youth suicide in U.S.

Sparsely populated states have higher rates
Average annual rates per 100, 000 youths, ages 10-19, 1994-2002

Rates:
U.S.: 5.1
Neb.: 6.8
Iowa: 6.9

SOURCE: Study of mortality data from the National Centers for Diseaase Control and Prevention

Stress of divorce

Teens are particularly at risk for suicide when they feel detached from their families. Comparing a sample of teens who killed themselves with ordinary teens:

Family split apart
Suicdie teens: 48.3%
Ordinary teens: 33.3%

Poor communication with mom
Suicide teens: 16.1%
Ordinary teens: 7.5%

Poor communication with dad
Suicide teens: 31.2%
Ordinary teens: 12.8%

SOURCE: Psychosocial Risk Factors of Child and Adolescent Completed Suicide, 1996, Archives of General Psychiatry

Nebraska divorce rates

Like suicide rates, divorce rates are highest in midsize areas.

2000-2003 (Annual, per 1, 000 people)

Metro areas: 3.6
Midsize areas: 3.9
Small town/rural areas: 3.1

SOURCES: Vital statistics reports from Nebraska Health and Human Services System.