More threads by David Baxter PhD

David Baxter PhD

Late Founder
Parents Wary of Antidepressants for Kids
September 18, 2004
Associated Press

WASHINGTON (AP) - Alarmed at a recommendation that antidepressants for children carry a strict new warning label, some parents are not letting their kids take the drugs as part of a clinical trial for young people who have attempted suicide.

Government health advisers said last week the labels on these drugs should have bold warnings surrounded by a black box to draw attention and say that, in some cases, the medication increases suicidal thoughts and behavior.

A study financed by the National Institute of Mental Health is designed to determine whether treatment - medication or behavioral therapy, alone or combined - can prevent future suicide attempts.

Children enrolled in the small pilot study have attempted suicide previously, which normally would exclude them from such scientific trials.

Dr. Graham Emslie, principal investigator at one of the study's five sites, said only 15 percent of children diagnosed as depressed take medication.

"We're trying to increase the number who are treated,'' said Emslie, who works in Dallas, and the black box warning "is definitely not going to help.''

The Food and Drug Administration said it generally supports the recommendation from the advisory panel that labels on antidepressants have warnings about increased risk of suicidal thoughts and behavior.

For every 100 children taking antidepressants in controlled clinical trials, an additional two to three experienced increased suicidal tendencies.

In the trial, the parents of a child who had attempted suicide within the previous 45 days - a requirement to participate in the study - refused to let researchers use an antidepressant as planned.

In a second instance, divorced parents could not agree whether their suicidal child should take the medication.

Emslie said two refusals by parents in a single week, each citing the advisory panel's comments, mark the beginning of a worrisome trend. "I don't think it was isolated. I think it will continue,'' Emslie said.

On Capitol Hill, lawmakers are pushing for greater disclosure of the results from drug clinical trials.

The FDA said last week it has begun to adopt more strident warning labels for all antidepressants, not only those involved in pediatric clinical trials: Celexa, Effexor, Luvox, Paxil, Prozac, Remeron, Serzone, Wellbutrin and Zoloft.

The agency has not yet said whether that will be a black-box warning as the advisory panel recommended.

Last week's public hearings on the issue have led to changes already in how antidepressants are prescribed.

For psychiatrists like Dan Medeiros, the push to ensure that doctors first discuss the medication's risks and benefits simply reinforces what he has done for 14 years. Medeiros runs a day treatment program for New York teenagers who skip school or fail because of depression. Medeiros' warnings already include the risk that an antidepressant can boost energy.

"People can be so depressed they don't even have the energy to get out of bed. If the medication starts improving energy level ... you then have the means to commit suicide,'' he said.

John March, chief of child and adolescent psychiatry at Duke University Medical Center, said he's inclined to prescribe Prozac first among the new generation of antidepressants. The federal recommendations won't change that since three studies, including one led by March, point to Prozac's effectiveness.

Kathy Bruce's husband, Marty, killed himself in 1993, and her 10-year-old daughter, McLain, was diagnosed as bipolar in May.

For the past month, the girl has taken Zoloft, which is linked to increased suicidal thoughts among children. When prescribing the drug, McLain's doctor mentioned a "small risk'' associated with the antidepressant, Kathy Bruce said. "It was a risk I was willing to take,'' Bruce said from her home near Atlanta. "She's coming home every day happy and loving school.''

Dr. Phillip Kennedy said he limited antidepressant prescriptions after the FDA in March sent a warning letter to doctors. A black box warning would make prescribing physicians and drug companies "liability targets,'' Kennedy said. His strategy has been to tell slightly depressed adolescents and their parents that a drug could help, but that he would prefer that a psychiatrist prescribe it. "You get resistance from the mother and child. It's a weekly occurrence, if not more,'' Kennedy said.

Dr. Elissa Benedek, past president of the American Psychiatric Association, said referrals to mental health specialists are likely to increase. "If it makes some people more careful and more thoughtful about what they do, it's not a bad thing,'' said Benedek, a child psychiatrist in Ann Arbor, Mich.

In Augusta, Ga., where Kennedy runs a family practice, he said youths can face a three-month delay before seeing a psychiatrist.

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Food and Drug Administration


When this issue came up in the media, my first thought was that maybe the increased risk could be related to BP. From research and talking to MANY other parents of BP kids, I learned that putting a child on an ad without an ms is a bad, bad idea because it can throw them into mania or even worse, a mixed episode. In the BP community, it's a well-known fact. I have to wonder if the medical establishment has looked into it.

David Baxter PhD

Late Founder
That is certainly a known risk for bipolar patients -- indeed, sometimes the medication-induced hypomanic episode is the first clear evidence that the individual is bipolar rather than suffering from unipolar depression.

But the more recent general evidence seems to me to be quite clear for the majority of unipolar depressed individuals: Any increased risk may be a function of the already present suicide risk with any major depression combined with adolescent impulsivity and limited coping skills plus the enrgizing effect that antidepressant medications can have. The statistical increased risk disappears after a few weeks, which means that antidepressants can be appropriate for the under 18 age group but that close monitoring during the first few weeks should be a standard part of the treatment (and that parents, family members, and others in contact with the youth should be aware of the need for monitoring).

By the way, the same should hold true for depressed adult patients, in my opinion...
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