Antidepressant scares sway few
September 25, 2004
Philadelphia Inquirer

Beth O'Connor and her 8-year-old son, Jarrett, listened carefully as his psychiatrist explained the bad news about antidepressants such as the one he takes for anxiety.

Studies have found an increased risk of suicidal behavior among a small percentage of children taking the drugs, Sarosh Khalid-Khan told them. The Food and Drug Administration is considering giving their parents an especially strong warning.

O'Connor, of South Philadelphia, already knew that. Jarrett's father had called in a panic after reading about the dangers of the drugs.

But she saw how Jarrett fell apart over the summer when he tried stopping his Paxil. And she sees no signs that he's thinking of suicide. "I don't see where it's doing him any harm," she said.

Khalid-Khan, like her colleagues at the University of Pennsylvania's mood and anxiety disorders section, is having such discussions with lots of parents. O'Connor's reaction is typical, she said.

Throughout the region, doctors and parents are considering months of negative publicity about newer antidepressants known as SSRIs - selective serotonin reuptake inhibitors. So far, doctors said, few parents are refusing the drugs for their children or stopping them.

Some doctors are more cautious about recommending them, however, and some psychiatrists say they're getting more referrals from skittish pediatricians. Everyone is doing a lot more talking about potential risks and how to spot problems.

"I tell [patients' parents] they've got to call me immediately," said Moira Rynn, a child and adolescent psychiatrist who works with Khalid-Khan at Penn. "They get my cell phone. They get my beeper number."

Doctors and parents agree that these are positive changes in protocol for those on antidepressants. But many worry that a shortage of child psychiatrists, combined with fear of the drugs, may prevent sick children from getting treatment they need. One psychologist said he had encountered a mother who was "scared to death" to give antidepressants to her daughter - a girl so depressed she had already tried to kill herself.

"The most dangerous thing we can do is to not treat these kids at all," said David Fassler, a Vermont child psychiatrist who testified for the American Psychiatric Association at FDA meetings on the drugs this month.

Doctors and parents have only recently learned of previously unpublished studies that reflected badly on the drugs. Taken together, they show a link with suicidal behavior, though there were no suicides among children in the studies.

More troubling to some doctors is that there is little proof most of the drugs work in children. The evidence of effectiveness is strongest for Prozac, the only medicine approved by the FDA for depression in children.

That leaves doctors in a quandary. The studies done so far do not tell them enough about the true risks and benefits of the drugs. There are no pharmacological alternatives: older antidepressants known as tricyclics don't work for children. Talk therapy can help some, but many remain depressed. Suicide rates have, in fact, been falling since the advent of SSRIs. And many psychiatrists say they have seen firsthand how much the drugs can help.

Because children with depression already are at higher risk for suicide, doctors worry about being sued if they prescribe antidepressants - or if they don't.

Ellen Sholevar, a child psychiatrist at Temple University Hospital, said that, over the last year, she had come to realize that "we don't have good science behind what we're doing... In terms of a young person in trouble, it's kind of scary and troubling."

Psychiatrists say perception of the drugs as "magic pills" had led to over-reliance on them. Doctors have felt pressured by parents and insurance companies to use them.

By requiring higher copayments for visits to psychiatrists than to pediatricians, some insurance companies encourage parents to seek psychiatric drugs from primary-care doctors, said Norman Fienman, a Broomall pediatrician. Many parents want him to refill prescriptions their children have gotten from psychiatrists.

"We are now refusing under any circumstances to fill prescriptions for these patients, and our patients are getting angry," he said. "We will not accept somebody else's responsibility."

Early reports conflict on whether prescribing patterns have changed as a result of bad publicity. IMS Health Inc., a pharmaceutical information company that tracks about 70 percent of the nation's prescriptions, found that prescriptions for SSRIs and a related category of antidepressants were 6 percent higher during the first half of 2004 than during the first half of last year. And in its own analysis of IMS data, the FDA concluded that the percentage of antidepressant prescriptions written for children - about 7 percent - had not changed.

Medco Health Solutions Inc., a pharmacy-benefits manager with access to fewer prescriptions than IMS, reported this week that the proportion of children on antidepressants in its programs fell 19 percent from the second quarter of 2003 to the second quarter of 2004. Less than 1 percent of the 10 million children in its plans were on antidepressants in either quarter.

Rynn, the Penn psychiatrist, who has been involved in several drug studies, said she was getting as many calls as ever from parents who wanted medications for their children.

Vince Bellwoar, a psychologist who runs Associates of Springfield (Delaware County) Psychological, said he had seen enough people who got better with antidepressants that he had no qualms about suggesting that patients talk to a psychiatrist about medication when therapy wasn't enough. "By the time they get to the psychiatrists, at least with us, they're clearly hurting and they're clearly looking for relief," he said.

A North Jersey woman said she had tried diet, exercise and therapy for her daughter's anxiety and depression. She turned to an antidepressant after she found the teenager crying in her bedroom, wedged between the bed and the wall. " 'I feel like I'm in a black box with no window and doors,' " the woman said her daughter told her.

Her daughter is doing much better after Rynn prescribed one of the newer antidepressants for her.

"Am I nervous about her taking something that could potentially hurt her? Yeah," the woman said. "But I had no choice. What was I to do?"