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Distributed September 10, 2004
Contact Mark Nickel

About 745 Words

Timothy Rivinus, M.D.
Antidepressants and kids: Safety starts with sound health services

The debate about prescribing antidepressants for children and adolescents has raised many good questions about how research is funded and how results are reported. It has also exposed a misplaced preference for a pharmacological “magic bullet” over a more comprehensive approach that includes “talk therapy.” The real problem is not the pills but a system of mental health care that does not deliver the careful treatment and follow-up young patients need.

Whether antidepressants are safe for children and teenagers is a matter of front-page debate. And it should be. The health of thousands of children – perhaps their very lives – hinges on the outcome of the dispute.

But the controversy over whether these drugs increase the risk of suicide in children and teens, and whether the Food and Drug Administration should ban pediatric antidepressant use, is missing an important point. The drugs themselves are being blamed when the real trouble may rest with the medical climate in which the drugs are being prescribed.

Improper diagnosis, dosing and monitoring are the most likely culprits behind suicidal tendencies in children taking antidepressants. Improve the care that comes with the pills and many of the dangerous, even deadly, side effects will disappear.

The drugs under fire are members of a class of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs, as well as another class, serotonin and norepinephrine reuptake inhibitors, or SNRIs. Although some studies have shown that these drugs are safe and effective for children, recent reviews of several clinical trials have cast this into doubt. Some research shows that these antidepressants are no better than placebo. Other research shows that the drugs can cause some children and teens to think about suicide – and act on those thoughts.

Initially, drug makers did not publish much of this unfavorable data, raising an international ruckus about bias in clinical trials. Earlier this year, the FDA forced several drug makers to change their labels. This month, the agency is considering additional regulation.

But the pills may be less the problem than the mental health delivery system. Many prescribing doctors simply do not have the training or the time to treat children with complex psychiatric disorders.

Diagnosing depression can be difficult. For example, doctors finding classic symptoms – loss of energy, feelings of sadness and negativity, crying spells – may reflexively prescribe an antidepressant. But these symptoms may simply reflect the “lows” that come with bipolar disorder. This condition calls for lithium or other mood-stabilizing drugs, sometimes in combination with an antidepressant. If doctors don’t have the time to get a full family history and conduct a rigorous evaluation, the diagnosis of bipolar or other disorders (e.g., substance abuse, family violence) may be missed and the drug may be wrong.

Dosing and response monitoring are also critical. If a child – or an adult, for that matter – gets a sudden energy surge from an antidepressant, they may be more likely to act on suicidal thoughts usually held long before treatment began. Drugs should be introduced slowly and followed by careful and consistent monitoring. A change in dose, and frequent follow-up visits, might prevent injury or death.

Much of the debate over antidepressants oversimplifies the complexities surrounding psychiatric care.

In the current culture, many consumers – and even some doctors – yield to the simplistic idea that prescription drugs alone are the answer to complex problems. If children are tormented at school, sexually abused, or devastated by divorce, antidepressants alone cannot cure them. The root cause of depression must be addressed by changing the child’s environment. This is not easily done.

The myopic emphasis on medication alone sidelines therapy, a powerful tool in the battle against depression. A new study on teens and depression shows that, when compared with drugs and therapy alone, patients showed the best improvement when treated with a combination of antidepressants and cognitive-behavior therapy.

This double-barreled approach has saved the lives of dozens of children and teens in my practice. But as a child and adolescent psychiatrist, I have the training and tools and I make the time to treat mental illness in young people. This is not true of many doctors prescribing to children and adolescents – pediatricians, adult psychiatrists, family practitioners – in the era of managed time and care.

So the job should be left to the specialist. Medical practice and reimbursement should honor this principle, so that children with mental illness are in the care of experts.

The current debate is justified. It has exposed flaws in how medical research is funded and publicized. It has cast a spotlight on major depression, a debilitating and sometimes deadly disorder whose symptoms appear in an estimated 10 to 15 percent of children and teens. But the debate, much like the published research, is deficient. Children’s safety starts with quality mental health services, not hastily written prescriptions uninformed by sound clinical practice.

Timothy Rivinus, M.D., practices child, adolescent and adult psychiatry in Providence, R.I. and is a clinical associate professor of psychiatry and human behavior at Brown University.

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