Research Questions Use of Antidepressants for Children
Provided by Albuquerque Journal on 3/15/2005
by Jackie Jadrnak

Antidepressants, once the smiley face among medications, have been sporting a black eye lately. Recent studies and statements have warned about a possible increased risk for suicide among people taking one category of the drugs, and even have questioned whether the pills work at all among children and adolescents.

That leaves parents with a dilemma. If they fill a prescription for antidepressants, are they increasing the risk that their depressed children will try to kill themselves? And is there a chance they would be spending good money on a useless drug?

Unfortunately, there's no simple answer.

In a written statement (www.nimh.nih. gov/press/StmntAntidepmeds.cfm), here's the bottom line of how the National Institute of Mental Health answers the question, "What should you do for a child with depression?":

"A careful weighing of risks and benefits, with appropriate follow-up to help reduce risks, is the best that can be currently recommended."

Talk to physicians and, while they may express some reservations in light of the latest findings, they tend to support the idea of continuing to prescribe at least some of the medications to children.

"The psychiatric community tends to be biased in one direction ... We feel the medications can be very helpful in kids who are properly diagnosed," said Dr. Steven Adelsheim, associate professor in psychiatry at the University of New Mexico.

Proper diagnosis is key, though.

Delfy Roach, executive director of Parents for Behaviorally Different Children, an advocacy group for children with mental illnesses and behavioral problems, said children with bipolar disorder could react with mania if they take an antidepressant.

Yet, on first glance, bipolar children may appear to be simply depressed. With 80 percent of psychotropic medications being prescribed by primary care physicians these days, it's a good bet a lot of children's mental disorders are being diagnosed by pediatricians.

"I personally do have an issue with that," Roach said. "Unless they are working closely with a child psychiatrist, they might prescribe the wrong medication based on what they are seeing or hearing."

That could be a problem at times, said Dr. Terence McAllister, a pediatrician at Kirtland Air Force Base's clinic. "If I am not clear on a certain diagnosis, I will not start treating," he said. "But sometimes it's pretty straightforward."

Dr. Lance Chilton, a pediatrician with Lovelace Sandia Health System, said he certainly is prescribing more antidepressants than he used to. One reason is that the newer class of drugs the selective seratonin reuptake inhibitors (SSRIs) are safer, he said.

But another reason points to a fact of life in New Mexico. "I just don't have much luck finding a mental health professional to deal with these kids," he said.

Like many places, New Mexico has a shortage of child psychiatrists.

"People have to wait two months to see me," said Dr. Bill Johnson, an adolescent and family psychiatrist with St. Vincent Hospital in Santa Fe. "Sometimes I encourage a family physician to start (drug treatment) so (the patient) can get some relief before he can get in to see me."

Johnson said he hasn't noticed children any more likely to commit suicide after starting on antidepressants. In any case, a person started on antidepressants should be followed closely for any side effects or increase in suicidal thoughts, he and others said.

Johnson added he is somewhat concerned about advertising that has "pushed" the drugs on the public.

"Perhaps we should be a little more cautious," he said. "We've been oversold even as physicians on how useful they are by (manufacturers) not publishing negative results."

Often, when drug companies fund clinical trials, they submit the positive results to be published in medical journals, but keep the negative studies under wraps.

When the U.S. Food and Drug Administration did a review of data on the SSRIs Prozac, Zoloft, Paxil, Celexa, Effexor, Serzone and Remeron in response to concerns about possible suicide risks, it asked for unpublished studies conducted by the drug companies. Some of those showed the drugs as no more effective than a placebo a dummy pill.

That review also showed some increase in suicidal thoughts or statements after a person started taking SSRIs, but it didn't show more people actually killing themselves.

To date, Prozac is the only SSRI the FDA has approved as being safe and effective in children. Yet, once drugs are on the market, many doctors prescribe them for "off-label" use giving them to categories of people or for medical conditions not included in initial studies leading to the drug's approval.

Part of the problem with testing drugs in children is that they have a high response rate to placebos, Adelsheim said. Depending on the drug and the study, up to half the kids may get better just taking the dummy pill.

All the physicians interviewed by the Journal said they have seen kids get better while taking antidepressants.

"I've seen a reduction in successful teen suicides because of use of antidepressants," Johnson said.

With each 1 percent increase in the use of antidepressants among adolescents, there has been a 0.23 per 100,000 decline in teen suicides. However, authors of an article in the April 8 edition of the New England Journal of Medicine note that association doesn't prove cause and effect.

"I've definitely had kids who seem to be helped (by SSRIs), as long as they get (talk) therapy at the same time," McAllister said.

Psychological therapy or counseling always should be used along with drug therapy, Adelsheim said.

Laura Smith, author of "Depression for Dummies" and a clinical psychologist with Presbyterian Medical Group, said too many people see depression only as a chemical imbalance and ignore the need for therapy.

"Wouldn't it be wonderful if we could give someone a drug and they would get better?" she said. "What is really disturbing is that a lot of research that was not published is pretty clear that at the least it (treatment with SSRIs) doesn't work very well, if it's not downright dangerous."

Looking at depression as something that can be cured with only a drug is simplistic, Smith said. "In 25 years I haven't seen children depressed without some other cause," she said.

Kids might be subjected to bullying at school; they might have problems with their parents; they might have a learning disability, she said. "There are a host of issues that giving a child an antidepressant doesn't address," she said.

Whatever the choice of therapies, depressed children should not be left untreated, the experts warned. After all, while it's not clear if antidepressants make kids more likely to commit suicide, it is clear that depressed children are more likely to kill themselves.

They also seek other ways to ease their emotional pain, said McAllister, who noted children's stress and depression seem to have increased as their parents in the military have been deployed to foreign lands.

"What happens when kids are not treated ... is they try to treat themselves through illegal drug use. They try to medicate their own depression," he said.

"Depression is treatable," Smith said. "Any child with symptoms of depression should have an evaluation."

Those symptoms don't just include the classic "blues," she added. Kids can express depression by being irritable, overreacting to criticism, engaging in risky behavior, or letting their grades slide, she said.

If you do have questions about whether your child should begin antidepressants, continue current medication or switch drugs, talk them over with a health professional, the experts recommend.

And, whatever you do, don't suddenly stop the drugs. "There are risks to discontinuing antidepressants suddenly," Adelsheim said.

People coming off the drugs need to reduce their dosage over time before stopping completely.