A depressing dilemma
Monday, July 19, 2004
by Anna Velasco, Birmingham News

Experts warn that depression in children needs treatment, yet questions remain about link between antidepressants, suicide

The new generation of antidepressants launched by the arrival of Prozac in 1987 ushered in an era of help for depression without many of the serious side effects of the older drugs.

But concerns have mounted in the last two years over whether the popular drugs are safe for children and adolescents.

U.S. and British health regulators warned last year that questions remain about whether the drugs increase suicidal thoughts in some younger patients. Mental health experts also agree that because of a lack of study, inadequate proof exists showing the new antidepressants, except Prozac, work in children and adolescents.

The situation has put parents in a quandary because many American psychiatrists believe the 4 percent of severely depressed adolescents won't get better without medication.

Severe depression is a known cause of suicide, while the risk from the drugs is theoretical, they have said.

"What a difficult spot to be in," said Dr. Tom Vaughan, a child and adolescent psychiatrist at Children's Hospital. "It's really unfair not to treat the depression because you know that's associated with suicide."

Prozac, the first to raise alarm bells over a possible link between teenage suicide and antidepressant use, has been largely cleared. After several studies in patients younger than 18 showed its safety and effectiveness, the U.S. Food and Drug Administration last year granted Prozac approval for use in children.

The other antidepressant drugs known as SSRIs - or selective serotonin reuptake inhibitors - do not have FDA approval for use in patients younger than 18, although many doctors prescribe them anyway. Other SSRIs include Paxil, Zoloft, Celexa, Lexapro and Fluvoxamine.

Paxil and suicide
The most recent concern was sparked last year over a study of Paxil showing a possible increase in suicidal thoughts among some children and adolescents, although no suicides were reported. British drug regulators in December urged doctors not to prescribe new patients SSRIs, except for Prozac. Data did not show that benefits of the drugs outweighed the risks, they said.

The FDA continues to review the situation and has recommended caution in prescribing the antidepressants to patients younger than 18. The National Institute of Mental Health is spearheading several studies of the issue, and drug makers recently warned doctors to watch patients closely for increased suicidal behavior, especially when they first start medication.

Dr. Jim Cullinan, a child and adolescent psychiatrist, said the British approach was extreme, especially since there is no evidence showing a link between the antidepressants and suicide.

On the other hand, Cullinan and Vaughan point to data showing both an increased use of SSRIs in patients younger than 18 and a corresponding decrease in teenage suicide. The data do not prove a cause-and-effect relationship between the two trends, although the doctors both say many of their patients get better with medication.

Combined treatment
Vaughan said research has shown that the best treatment for severe depression is a combination of therapy and medicine. "Combined interventions are most effective," he said.

Cullinan, medical director for inpatient child and adolescent psychiatry at Children's Hospital and UAB Hospital, said he doesn't want concern over a slight risk with antidepressants to keep parents from getting help for their children.

"Depression is a real disease that teenagers and children can get," Cullinan said. "Depression is a brain disorder. Children suspected of having depression need to be seen by a professional. ... We don't want people scared and trying to ride it out on their own."

Mary Ann Winfield knows from caring for her depressed granddaughter that the medicines don't always work as hoped. Her 18-year-old granddaughter, diagnosed at age 7, became worse on Prozac and several other SSRIs. But close monitoring and experimentation helped doctors find the right drug, Winfield said.

"I do know there are risks with the drugs," she said. "I think we all appreciate that, but I think the risks of untreated depression are far greater. The depression is pervasive. It affects every single thing they try to do."

Dr. Beth Jacobs, a clinical psychologist in Birmingham, said children and teens suffering from depression because of situational or adjustment problems can usually be treated with therapy alone.

But she agreed some patients must have medicine to get better.

"Kids who have a genuine, clinical depression often only benefit from counseling when given medication - judiciously," Jacobs said.

The Paxil study that electrified the debate is unpublished and its data inconclusive, Vaughan said. "You really hope there will be more data to clarify the issue and put parents' minds at ease," he said.

Cullinan said since the warnings, he's been extra cautious about prescribing antidepressants and has prescribed Paxil much less than before. The UAB associate professor said he hopes that all doctors who prescribe children antidepressants are closely monitoring their patients. Psychiatrists see their patients regularly but family doctors can go months without seeing theirs, he said.

"Depression is a disorder and cannot be treated simply by handing out medication," Cullinan said. "Doctors need to be meeting with them regularly."