Miller, Keith A.

ABSTRACT Background Multiple meta‐analyzes suggest that acne improvement with isotretinoin leads to improved mental health outcomes in adults, though isotretinoin‐related psychiatric data, including for suicidality, are limited for adolescents. Methods PubMed, MEDLINE, EmBase, PsychINFO, and the Cochrane Library databases were searched for papers published between 1982 and September 2024 that reported suicidality following isotretinoin treatment for acne vulgaris in adolescents aged 18 or younger. Results A total of 24 full text articles were reviewed. Despite numerous case reports describing suicidal ideation, suicide attempts, and completed suicides were rare. Databases suggest that adolescents taking isotretinoin are the group with the most suicide attempts, but epidemiological studies including matched controls suggest this could be a function of the number of prescriptions in this population. Observational, cohort, and case‐time‐control studies did not consistently report an increased risk of suicidality with isotretinoin. When compared with those prescribed antibiotics, isotretinoin‐prescribed adolescents had no increase in suicidality during treatment but had a higher prevalence of suicidal behavior in the year after treatment. If patients prescribed isotretinoin developed suicidal ideation, it was more likely to develop early in or following completion of treatment. Conclusion There exists a conventionally held belief in the association between isotretinoin use and suicidal ideation for adolescent patients, but this narrative review does not indicate a consistent relationship.

AbstractBackgroundIsotretinoin treatment for acne can reduce adverse psychiatric outcomes in adults, but there has been little investigation of the incidence of psychiatric outcomes in treated adolescents.MethodsThis retrospective cohort study using the Rochester Epidemiology Project identified 606 patients aged 12–18 prescribed isotretinoin over a 10‐year period between January 1, 2008 and December 31, 2017. Medical records were reviewed to identify psychiatric diagnoses before and during isotretinoin therapy, as well as psychiatric symptoms not captured by formal diagnoses and changes to isotretinoin dosing because of psychiatric diagnoses or symptoms.ResultsOne hundred seventy‐seven (29.2%) had a psychiatric diagnosis prior to isotretinoin initiation, but 98 (16.2%) had a new psychiatric diagnosis or psychiatric symptom while taking isotretinoin. Patients with a psychiatric history were no more likely than those without to receive a new psychiatric diagnosis during treatment (4.5% vs. 3.7%; p = .650), but did experience more psychiatric symptoms, primarily low mood and mood swings (23.7% vs. 7.7%; p < .001). Only 25.5% of the 98 with a new psychiatric diagnosis or psychiatric symptom had a subsequent dose change. A dose change was more likely if patients received a new psychiatric diagnosis (41.7% vs. 20.3%; p = .037) or patients did not have a psychosocial explanation for psychiatric symptoms (34.4% vs. 10.8%; p = .009).ConclusionsA substantial proportion of adolescent patients prescribed isotretinoin had a prior psychiatric diagnosis. This predicts more psychiatric symptoms during isotretinoin treatment. Adolescents with a psychiatric history who have worsening symptoms and those with new‐onset psychiatric symptoms would benefit from close monitoring while taking isotretinoin.

Superheroes and doctors don’t have the best history. In fact, it was psychiatrist Dr. Frederick Wertham, and not supervillain Dr. Doom, who raised significant concern that comic books were negatively impacting children in his provocative book, Seduction of the Innocent. Although Dr. Wertham nearly destroyed the comic book industry, it thankfully has recovered—as has the relationship between superheroes and the field of medicine. There has been a recent explosion of interest in graphic medicine, the intersection between comics, medical education, and patient care. Comics are now used to deliver public health education, 1-3 to communicate diagnostic criteria and informed consent to patients,4,5 and to help patients process their own illnesses.6,7