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ARTICLES: Shuu-Jiun Wang, Jong-Ling Fuh, Kai-Dih Juang, and Shiang-Ru Lu Migraine and suicidal ideation in adolescents aged 13 to 15 years Neurology 2009; 72: 1146-1152 [Abstract] [Full text] [PDF]

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Migraine and suicidal ideation in adolescents aged 13 to 15 years

Pasquale Parisi   (26 May 2009)

Reply from the authors

Shuu-Jiun Wang, Jong-Ling Fuh, Kai-Dih Juang, Shiang-Ru Lu   (26 May 2009)

Migraine and suicidal ideation in adolescents aged 13 to 15 years 26 May 2009
Pasquale Parisi, Child Neurology, Chair of Pediatrics, Sapienza University, Rome Italy Via di Grottarossa, 1035-1039, 00189, Rome, Italy Send Correspondence to journal: Re: Migraine and suicidal ideation in adolescents aged 13 to 15 years pasquale.parisi{at}uniroma1.it Pasquale Parisi	I read the article by Wang et al. with great interest. [1] The authors did not record antiepiletic and antidepressant usage but they noted that the bias would be minimal because usage was low in this adolescent sample. Furthermore, the authors maintained that antidepressants and antiepileptic usage in adolescents was potentially associated with an increasing suicide risk and that these two medications are frequently used in adolescents with migraine. It would be interesting to know if the authors excluded the diagnosis of early onset juvenile bipolar disorders (JBD). The onset of JBD before the age of 10 is rare and the first manifestation occurs most frequently between the ages of 13-15. The diagnosis of JBD is more difficult in children and adolescent populations versus the adult population due to varying symptoms. For example, in children and adolescents, dysphoria is more likely than a euphoric or depressive mood. Asymptomatic intervals rarely exist, yet rapid cycling prevails. In addition, it has been shown that antidepressants in JBD affected children can have severe adverse effects, particularly the amplification of suicidal ideation. [2,3] The self-administered questionnaires commonly used to assess and make a differential diagnosis between JBD and other psychiatric disorders, such as depressive conditions, show a relatively poor diagnostic efficiency. Parent reporting seems to be the best predictor in diagnosing JBD. Unfortunately, Wang et al. did not administer parental questionnaires. [1] It would have been interesting if the authors excluded amplification of suicidal ideation associated with inappropriately prescribed antidepressants in non recognized children affected by JBD. References 1.Wang SJ, Fuh JL, Juang KD, Lu SR. Migraine and suicidal ideation in adolescents aged 13 to 15 Years. Neurology 2009;72:1146-1152. 2. Benazzi F. Bipolar Disorder-Focus on Bipolar II Disorder and Mixed Depression. Lancet 2007;369:935-945. 3. Hamrin V, Pachler M. Pediatric Bipolar Disorder. Evidence Based Psychopharmacological Treatments. JCAPN 2007;20:40-58. Disclosure: The author reports no disclosures.
Reply from the authors 26 May 2009
Shuu-Jiun Wang, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital #201, Shi-Pai Road, Section 2, Taipei, Taiwan, Jong-Ling Fuh, Kai-Dih Juang, Shiang-Ru Lu Send Correspondence to journal: Re: Reply from the authors sjwang{at}vghtpe.gov.tw Shuu-Jiun Wang, et al.	Dr. Parisi reminded us that antidepressants may cause manic switching in pediatric bipolar patients. He suggested that we should have considered amplification of suicidal ideation in previously undiagnosed bipolar children who may be taking inappropriately prescribed antidepressants. Pediatric bipolar disorder has been increasingly recognized as a valid diagnosis in recent years. [2] In the pediatric population, complex cycling with frequent alternating episodes of depression and mania are noted more often. Some experts disagree with cycling and refer to this as “affective lability” or “mood dysregulation.” For the adult population, a meta-analysis suggested that selective serotonin reuptake inhibitors do not cause manic switching in adults with bipolar depression when patients are on concomitant mood stabilizers. [3] However, data of manic switching is not as clear for tricyclics, other classes of antidepressants, or for pediatric bipolar patients. In our study, we did not assess bipolarity or record our patients’ daily medications. In addition, parental questionnaires were not administered so we cannot evaluate or exclude the diagnosis of pediatric bipolar disorder in any of our subjects. However, the prevalence of juvenile bipolar disorder is not common within this age group sample and according to our observations, the use of antidepressants in this age group should be even less. Therefore, this possible confounder may not significantly change our findings. We agree with Dr. Parisi that the possibilities of manic switching and occurrence of suicidal ideation have to be closely monitored when clinicians prescribe antidepressants for treatment of either migraine or depression in adolescents. References 2. Pavuluri MN, Birmaher B, Naylor MW. Pediatric bipolar disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2005;44:846-871. 3. Gijsman HJ, Geddes JR, Rendell JM, et al. Antidepressants for bipolar depression: A systematic review of randomized, controlled trials. Am J Psychiatry 2004;161:1537-1547. Dr. Wang has served on the advisory boards of Pfizer, Allergan, and MSD Taiwan. He has received speaking honoraria from local companies (Taiwan branches) of Pfizer, Elli Lilly, Wyeth, Jensen-Cilag, Boehringer Ingelheim and GSK. He has received research grants from the Taiwan National Science Council, Taipei-Veterans General Hospital and MSD Taiwan. Dr. Fuh is a member of a scientific advisory board of Pfizer, and has as well received research support from the Taiwan National Science Council and Taipei-Veterans General Hospital. Dr. Juang reports no disclosures. Dr. Lu has received research support from the Taiwan National Science Council and Kaohsiung Medical University, Taiwan.