The recent tragic events of the teenage boy who took his own life flying a plane into a Tampa high rise has refocused attention upon the prescription drug Accutane. Most of us have heard there was a prescription for the drug found in the home. Late today it was announced that toxicology studies showed no Accutane in his system. But the questions remain. Does Accutane cause depression? And if so, can the depression lead to a spontaneous suicide simply from the use of the drug?

With the reports that surfaced in October of 2000 when the son of Senator Bart Stupak of Michigan committed suicide while on Accutane, there was a definite raised awareness of the use of this drug and closer supervision. Unfortunately the media circus did not convey to the public a well thought out examination of the drug and what information was available in the medical literature either pro or con. I personally think the public came away with fear without hard evidence.

An estimated 500,000 new patients will take Accutane this year. Accutane, whose recommended use is for severe scarring cystic acne, is typically going to be given to teens who are the natural group most commonly affected by this condition. This becomes highly complicated. A list of factors needs to be examined to try to get a grasp of what's really going on. So let's look at the facts in the literature.

Teenage suicide rates have skyrocketed.

Is it a fact that teens have a high rate of suicide, listed #3 as cause of death behind accidents and homicide. In 1997, there were 4186 reported suicides amongst young people age 15-24. The American Academy of Pediatrics Committee on Adolescence released a policy statement regarding Suicide and Suicide Attempts in Adolescents in April of 2000. In it they claim that from 1950-1990, the suicide rate for 15-19 year olds increased 300% with males more commonly affected at a 6:1 ration with girls. The ratio of suicide attempts to completed suicides is currently running anywhere from 50:1 to 100:1.

Depression is typically well hidden and suicide is a "spontaneous" act by its very nature. Sudden or unexpected suicide including associated violence is far more the norm. Just look at school shootings that after intense post event scrutiny are felt to be incongruous with the happy, quiet, good student who committed the act.

The National Youth Risk Behavior Survey of students in grade 9-12 found almost a quarter of students had seriously considered attempting suicide within a 12 month time span. How many of those families knew this was going on?

Depression in adolescents is on the rise.

Is the problem that teens have a high rate of depression, which naturally increases risk of suicide? An estimated 1 million teenagers experience depression annually, most of whom are not on Accutane.

Severe acne causes low self-esteem and poor self-image

Several factors contribute to depression. Low self-esteem and poor self-image are important causes leading to teen depression. Skin diseases in general are often accompanied by these concerns. And severe scarring cystic acne, visible on one's face is begging to cause poor self-image. I've been there as a teen and young adult, going through unsuccessful acne treatment after acne treatment and know what it feels like to have significant facial acne.

Unrealistic social expectations upon Accutane completion.

I was one of the earliest users of Accutane taking it while in medical school in the mid '80s. While the drug cured my acne, it wasn't the clear skin that made me more outgoing and popular, it was me. Feeling better about my skin gave me more self-confidence and I chose to use it to my advantage. Someone expecting a social miracle in the tough environment of high school simply by taking some medication won't find it. If this is not understood and dealt with, unmet expectations can compound the depression.

Is it the drug?

If something happens to someone while taking any medication, should you instantly jump to the conclusion it's the drug's fault? There's an old saying; "life happens." And life continues to go on whatever else is factored into your lifestyle including medication use.

At this time, there is absolutely no solid evidence linking Accutane as a definitive cause of either depression or spontaneous suicide. The FDA maintains there is still no medical evidence that Accutane causes depression. The American Academy of Dermatology came out with a statement in the fall of 2000 stating this as well. The president at the time, Richard Scherer, M.D. (whose comments are posted on www.aad.org) said "Depression is a common problem in adolescents with or without acne. The links between suicide or depression and Accutane are unclear," said Dr. Scher. "To our knowledge, studies addressing this issue are yet to be completed and/or made available in medical literature."

The numbers don't work out. Harvard Medical School's Department of Psychiatry just published an article in the Journal of the American Academy of Dermatology in November 2001's issue that worked the numbers. Statistics show that the number of suicides of those while on Accutane are actually lower than what you would expect compared to the rate of suicide in the normal adolescent population. The authors concluded that the MedWatch reports of suicides by youths using Accutane (and taken as gospel) does not meet the requirements for proving any causality link between the use of Accutane and major depression and suicide.

I have always asked my patients on any oral vitamin A medication if they were experiencing any symptoms of depression (and rechecked with parents if appropriate) at every check-up. The scattered reports of occasional Accutane patients who experience depression raised suspicion since the 1980's when Accutane went on the market, so it's nothing new. What is new are the special forms the dermatologist is expected to complete with all patients related to education about depression and possible suicide provided by the manufacturer Roche since the last Accutane/suicide media frenzy took place in 2000.

Are clinically depressed acne patients out of luck?

I have been highly successful treating patients known to be seriously clinically depressed who had severe scarring cystic acne and were being followed by their psychiatrist and on antidepressant medication. Simply by chance those who came to me were adults. Does that mean that adults are unaffected by Accutane and depression? It really shouldn't. Common sense tells us that these types of effects should be similar whether you're 17 or 37, but again we have no research to determine this. Careful control of the medication and close following of the patient by both the psychiatrist and me were mandatory to trying the treatments. None of the patients experienced any worsening of their symptoms and all felt well about themselves after treatment was completed.

So while I am most definitely sticking my neck out in support of what has to be one of the "wonder drugs" of modern dermatology, does that mean I don't have suspicions regarding the drug or its use? I have concerns and think patients should be appropriately monitored until we have an absolute answer in all of this. But that's simply the right thing to do when it comes to all "big gun" therapies.

Thank you for taking the time to read through this important information. I hope you have found this article informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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