As a psychiatrist who treats young people, I've grown increasingly concerned as I read article after article warning against antidepressant use in children. The articles I've seen rarely quote any preeminent child and adolescent psychiatrists, and these accounts consistently gloss over key points. The drumbeat of negative publicity is so loud that I worry it will discourage many physicians, in this age of multiplying malpractice suits, from prescribing these lifesaving drugs. Worse yet, I'm concerned that, despite an alarming increase in depression among children, fearful parents and family members won't even bring their loved ones in for evaluation.
Psychiatrists' clinical experience and training makes us well aware that antidepressants, especially the group referred to as the SSRIs (selective serotonin reuptake inhibitors), can cause agitation and that they increase the risk of suicide in all age groups, particularly in the first month after a patient has started on one of them. Nonetheless, most of us are convinced, by what we see day in and day out in our practices, that these medications, when prescribed properly, save lives. It's also well-known that untreated depression is itself a major risk factor for suicide. Ultimately, a physician must weigh the risks of treatment against the risks of no treatment. (For the record, I have given talks on three occasions at industry-sponsored events, and received a small honorarium. But I have no vested interest in any pharmaceutical company. I'm writing because I believe strongly in the value of these drugs in treating depressed kids.)
At the heart of the controversy is the paucity of research studies on the use of medications in treating pediatric depression. Only Prozac has been shown to be effective in 7- to 17-year-olds as compared with placebos (sugar pills). But there are good reasons why so few studies are available. First, conducting trials involving psychiatric patients is fraught with complications, not least of which is their very high response to placebos. Some depressed people may be apt to feel better just by virtue of doing something about their plight, like taking a pill. Second, getting parents to enroll their children in experimental trials is very difficult. Lastly, until recently, there haven't been sufficient financial or other incentives for pharmaceutical companies to study the use of medications in kids.
One might ask whether talk therapy would be more effective than medication in treating most children. Wouldn't that be less risky? But it's not that simple. Research on the effectiveness of talk therapy has produced only two studies that has shown its benefits in treating kids. Ineffective therapy can be the same -- or worse -- than not treating at all.
Approximately 20 years ago, Prozac was the first of the SSRIs to be marketed in the United States. This new class of drugs dramatically changed the treatment of depression by providing an alternative that had fewer, safer and more tolerable side effects than the older antidepressants, such as tricyclics (TCAs) or monoamine oxidase inhibitors (MAOIs). This prompted a wider awareness and treatment of depression. Many individuals with mild to moderate cases, who wouldn't have pursued medication in the past out of concern over negative side effects, now sought treatment.
TCAs had been the mainstay treatment of childhood depression, but around the time that Prozac was introduced, their use dropped dramatically after reports of some half-dozen cases of sudden death (thought to be due to cardiac complication related to the drugs). Moreover, the question of whether children even suffered from depression was then still a matter of hot debate. In recent years, however, it has become apparent to many psychiatrists in clinical practice that childhood depression is even more virulent than depression that strikes adults for the first time. It disrupts the entire developmental process, sometimes irreparably. It can lead to a decline in school performance and an increased risk of suicide, and is also associated with substance abuse.
In my own experience of more than a decade, I've met with countless parents in despair over their kids, whose grades had deteriorated from A's and B's to C's and D's, who started to shut themselves up in their rooms, neglect their personal hygiene, and argue with their parents and siblings. Many had begun abusing drugs and, even more frighteningly, writing about death -- specifically their own.
Depression is a risk factor for suicide at any age. Each year a half-million adolescents reportedly attempt to kill themselves. But recently, studies have shown that suicide rates have declined as the use of SSRIs has increased. Although no clear causal effect has been identified, as a physician I have to wonder if there might be some correlation. Additionally, studies have reported that autopsies of individuals who had been prescribed medication and committed suicide often reveal the lack of any SSRIs in the blood, suggesting that they hadn't been taking their medication.
In this quagmire of concern over how to treat depression in children and adolescents, one of the often overlooked but significant issues is whether the patient is actually suffering from bipolar disorder (also called manic depressive disorder) instead of simple depression. Clinical experience shows that antidepressant use in the bipolar individual who isn't already taking a mood stabilizing drug is much more likely to set off a highly agitated manic state, where suicidal thinking or behavior can become more of a reality. It can be extremely difficult, even for a trained psychiatrist, to diagnose a bipolar child, so I wonder how many bipolar children seen by non-psychiatrists are misdiagnosed and given antidepressants. I also wonder whether some of the suicides might fall into this category.
Physicians who aren't psychiatrists, as well as psychiatrists who don't specialize in children, aren't trained to evaluate or differentiate among varying psychiatric disease states in young people. And yet much of this medication is prescribed by family physicians or other non-psychiatric doctors. (In the future, psychologists -- who are not medical doctors -- may also have the right to prescribe medication. At least two states passed laws allowing this.) Moreover, these physicians don't monitor the treatment closely, and changes in mood or behavior often go unnoticed.
I am hopeful that one byproduct of recent Food and Drug Administration hearings on SSRIs will be a more educated public awareness and acceptance of the seriousness of psychiatric illness and its treatment, especially in children and adolescents. But as a frontline physician, I also worry about the take-home message to lawyers. I can already envision the TV ads they could run: "Have any of your children ever been on Paxil? Have they ever thought about hurting themselves? If so, please contact. . . ."
In Pennsylvania, where tort reform is limited, lawyers have run amok and malpractice premiums are at an all-time high, residents are already hard-pressed to find a physician to deliver their babies or a brain surgeon to treat head trauma. What's next? Escalating suicide rates because of a lack of psychiatrists? From where I sit, it's not too outrageous to imagine that it could happen. And in that case, the newly required warnings on SSRIs, instead of helping to protect individuals, will only have further hindered their ability to get proper care.
The scourge of depression is a serious one among our young people today. And while no one would dismiss or downplay the suicide risk that could be tied to antidepressant use, let's not toss aside these valuable aids wholesale. If they are properly prescribed and their use is closely monitored by a psychiatrist who has a real relationship with a patient, they can and do save lives. I know. I've seen it happen.
Ruth Rosenberg is a board-certified child, adolescent and adult psychiatrist in private practice in Bucks County, Pa.