Treating kids with depression

[David Baxter PhD]

Treating Kids with Depression
September 21, 2004
NAMI Commentary

New FDA warnings about the use of anti-depressant medications for children leave parents, caregivers wondering about options.

The Boston Globe reports that parents and caregivers of depressed children, concerned by recent links of new anti-depressants to suicidal behavior, are in a quandary as they seek alternative therapies for their children. According to doctors, the best choice is to combine drugs with talk therapy. However, a scarcity of child psychiatrists and inadequate insurance coverage for mental illness prevent access to these services by most consumers and their families.

According to today's article, primary-care physicians see 75 percent of children with psychiatric disorders, but they are unprepared to provide adequate diagnoses and treatment for mental illness. Their reluctance to prescribe drugs or recommend alternative therapies will only serve to anger families of depressed children. Dr. Ken Duckworth, NAMI’s medical director, is quoted in the article: "What'll happen is the advocates and the family will say this is outrageous. You're telling me my kid can't get any treatment because you guys are afraid to prescribe it."

Read the Boston Globe article below...

 

[David Baxter PhD]

What's next for depressed kids?

What's next for depressed kids?
September 21, 2004
By Carolyn Y. Johnson, Boston Globe

Talk therapies work, but there aren't enough therapists to do the talking

Last week's finding by a government advisory panel that the newest generation of antidepressants is linked to suicidal behavior in a small percentage of children has left parents and care givers in a quandary as they weigh the drugs' risks against possible benefits and search for other options.

The nine medications, which the Food and Drug Administration panel said should be labeled with the agency's sternest "black box" warning, already presented doctors with a confusing array of treatment choices.

Only one, Prozac, has been shown effective in treating depression in children, but doctors prescribe the others in the belief that they work better for some children. Now doctors will have to balance this potential benefit against an even murkier level of risk -- since the extent of each drug's suicide risk remains unclear.

There are alternatives to the drugs -- mainly talk therapy -- but therapists are in short supply nationwide, and insurers often provide minimal or no coverage, said mental health professionals.

"I feel terrible for parents because depression is a totally debilitating problem for children and they are at risk of suicide if it's severe depression," said Dr. Michael Yogman, a Cambridge-based pediatrician.

Doctors all stress the importance of getting some kind of help for depressed youngsters. More than 1 million are now treated with the antidepressants linked to suicidal thoughts and attempts.

Increasingly, doctors say the most appealing treatment involves combining medications with talk therapy -- so-called cognitive-behavioral therapy and interpersonal therapy -- that have been proved successful in adolescents. School and family interventions by social workers and psychologists also can alleviate some of the social problems that may trigger depression.

But there is widespread agreement, among primary-care doctors and specialists themselves, that there is scant access to these services.

There are only 7,000 child psychiatrists nationwide, and the American Academy of Child and Adolescent Psychiatry projects a more serious deficit in the near future. Even in Massachusetts, which has the best ratio in the nation with 17.53 child psychiatrists per 100,000 children, the average wait for a specialist is six weeks, according to the Parent/Professional Advocacy League, a network for families dealing with children with mental illnesses.

Despite research showing psychotherapy helps depressed teens, insurance companies have made it "economically devastating to practice psychotherapy," said Michael Goldberg, director of child and family psychological services in Norwood.

President Bush's New Freedom Commission on Mental Health concluded in 2002 that the country's underfunded mental health system is "in shambles."

"There's a crisis for children in availability of mental health professionals," Yogman said. "Pediatricans have tried to fill in the gap in trying to get people services and care."

Primary-care doctors are often the first -- and sometimes only -- line of treatment for depressed youths. These physicians see 75 percent of children with psychiatric problems, while mental health specialists see just 2 percent, according to a study in this month's issue of the journal Pediatrics.

Many of those doctors lack the training, time, and resources to adequately monitor and diagnose children. They may have to assess a child, talk with the parent, choose a diagnosis and a treatment -- all within a 15-minute appointment. Many doctors were already reluctant to prescribe the drugs because of their own interpretation of the antidepressant data, but last week's ruling is likely to drastically drive down the number of prescriptions by pediatricians.

Then, "what'll happen is the advocates and the family will say this is outrageous. You're telling me my kid can't get any treatment because you guys are afraid to prescribe it," said Dr. Ken Duckworth, medical director of the National Alliance of the Mentally Ill.

Nobody thinks physicians will resort to using the older generation of depression therapies, including so-called Monoamine Oxidase Inhibitors. Those didn't promote suicide, but they had serious side effects, said Dr. Martin Teicher, chief of the lab of developmental psychopharmacology at McLean Hospital in Belmont.

Critics say the newer drugs have been irresponsibly prescribed in the past. Doctors have been known to hand out the drugs to young patients for headaches, insomnia, or infections that led to fatigue, according to Dr. David Healy, a longtime critic of the pharmaceutical companies and psychopharmacology expert. The FDA advisory panel's announcement will ideally stop doctors from prescribing the drugs in such a cavalier way, said Healy, author of Let Them Eat Prozac.

"There's been so much hype about these drugs, and they've been used so carelessly," he said.

That was the experience of Jessica Baycroft, 19, a Northeastern University student who first showed signs of depression as a freshman in high school. She ran away from home and felt increasingly isolated from her friends, but was able to "somehow get out of that," she said.

In her sophomore year in college, Baycroft complained to her family doctor about feeling down, and she prescribed Lexapro, with instructions to call after a month.

A month later, "[The doctor] asked me, 'How are you feeling?' I said I was feeling pretty good," and the doctor advised her to keep taking the pills.

Baycroft said she was never warned of any side effects -- not suicide, even though she had previously felt suicidal -- or more subtle problems, like not being able to eat without feeling nauseous. She also never was given an idea of how long she would need to take the pills.

"I guess I thought she just meant for me to be on it indefinitely," Baycroft said.

She stopped taking the drug eventually, but, depressed again, she saw two psychiatrists this summer, both of whom offered to prescribe her medications on the first visit. She has since decided to turn from drugs and instead draw on the support of her mother as she continues working to find a way to live with a disease she believes may never be cured.

"I still get depressed. I still don't know why I am the way that I am," she said, adding that exercise and diet have given her some relief. "But I don't need a pill for the rest of my life."

Baycroft said that the FDA warning is probably a positive thing, if it convinces doctors and parents that drugs alone aren't enough.