Healthy Skepticism Library item: 6023

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Publication type: news

Wasowicz L.
Ped Med: Anti-depressant questions rise
UPI ( United Press International) 2006 Aug 30
http://www.upi.com/ConsumerHealthDaily/view.php?StoryID=20060825-012004-3650r

Full text:

Ped Med: Anti-depressant questions rise
By LIDIA WASOWICZ
UPI Senior Science Writer

SAN FRANCISCO, Aug. 30 (UPI) — Despite a horde of studies looking into the drugs’ effects, as many questions as answers surround the use of anti-depressants in adolescents.

While some investigations suggest the pills may curb suicide rates, others implicate them in harmful behaviors.

A new study, reported in the August 2006 issue of Archives of General Psychiatry, for example, notes that, in contrast to adults, “in children and adolescents (aged 6-18 years), antidepressant drug treatment was significantly associated with suicide attempts … and suicide deaths.”

A review published in “Develop Mentor,” an American Academy of Child and Adolescent Psychiatry newsletter for residents and medical students, summarizes the quandary facing practitioners, parents and patients.

“What are we to make of all this data? Should children and adolescents be treated with antidepressants? Do they really cause an increased risk of suicidal behavior? Or do they cause a decrease in suicidal behavior? Is fluoxetine (Prozac, the only antidepressant approved for treating depression in minors) the only one that really works?” the authors wondered.

“The answer is we just don’t have enough research to know with any certainty,” they said.

The authors’ recommendation: “Until we see the data and can evaluate the risks more fully, it would be wise to use SSRIs (selective serotonin reuptake inhibitors, a newer class of antidepressants) in children and adolescents with caution, monitor for … possible problems … and pay special attention to suicide risk assessment when treating children and adolescents, especially early in their treatment, with these medications.”

Putting such preaching into practice would satisfy most critics, who contend too many physicians appear more cavalier than cautious in reaching for the prescription pad.

That’s a particularly perturbing state of medical affairs given the gaps in science behind the SSRIs and their risk of side effects, which can affect most young users and worsen if the medicines are abruptly withdrawn, the critics argue.

Adolescents can plunge into the abyss of severe depression and suicide, but skeptics suspect the drugs that can pull them from the brink of disaster also are doled out to those nowhere near the edge.

“(I)t is often possible to define boundaries for any drug’s use that represent best practices in terms of who will definitively benefit from the drug,” said Dr. Randall Stafford, associate professor of medicine at Stanford University.

His research has shown depressed youth are increasingly treated with tablets rather than talk.

“In children and adolescents, there is a particular need for caution when drugs are used on patients that fall outside of these ‘best-practice’ boundaries,” Stafford said. “Antidepressant use in children and adolescents is one example.”

“Current expert guidelines suggest that antidepressants should be reserved for children with more severe depression and should be used in conjunction with counseling/behavioral therapy approaches,” he noted.

“Despite this, children with more mild mood disorders are receiving antidepressants and often without concomitant counseling/psychotherapy,” he added. “In addition, there has been relatively little evidence accumulated for SSRI drugs other than fluoxetine … and yet the use of other SSRIs in children has become common.”

To Stafford, the situation is disturbingly reminiscent of the over-the-top use of the immensely popular drug Vioxx, which was pulled off pharmacy shelves in 2004 after clinical trials showed its long-term use could double the risk of heart attacks and stroke.

Developed solely for arthritis sufferers unable to tolerate the gastrointestinal side effects of ibuprofen, naproxen and other so-called non-selective non-steroidal anti-inflammatory drugs, the painkiller burst way beyond the boundary of that market niche.

Within four years of its introduction, what was meant to be medicine for a small, select minority of patients metamorphosed into a $2.5 billion blockbuster prescribed primarily to patients who didn’t need it.

Those unintended users — who faced little risk of adverse effects from the older, cheaper, safer meds — accounted for a phenomenal 63 percent of the boom in Vioxx and its fellow COX-2 inhibitors between 1999 and 2003, Stafford’s analysis of prescription practices showed.

Traditionally infatuated with the novel and newly influenced by direct-to-consumer advertising, Americans open themselves up to the “therapeutic creep” of drugs — including those for hypertension, diabetes and some infections — beyond their most effective use, Stafford said.

In the case of COX-2s, this expansion meant millions of people needlessly paid a double price: not only shelling out as much as six times the cost of the older equivalents, like ibuprofen, but also exposing themselves to raised risks of serious cardiovascular complications, he said.

The heart-wrenching complications of this drug class that have since come to light should serve as a painful lesson of the danger of turning custom-fit medications into one-size-fits-all remedies, the study authors cautioned.

“I believe that some of the same factors that underlie the expansion of COX-2 inhibitor use are also at play for antidepressant use in children: a combination of physician and patient/parent attraction to new medications and the promotion of these products in the marketplace,” Stafford said.

In contrast, as Stafford’s research shows, talk therapy is increasingly given the short shrift even though the child and adolescent psychiatrists’ own clinical guidelines favor it as a defense against all but the most severe cases of youthful depression, and even then recommend combining psychotherapy with the pharmaceutical approach.

A task force of the American College of Neuropsychopharmacology, which concluded the benefits of SSRI treatment in children and adolescents outweigh the risks, deemed cognitive-behavior therapy the only viable alternative to antidepressants.

The task force found it problematic that psychotherapy — shown to work for most adolescents — has not been tested in children and appears ineffective in some 40 percent of teens.

However, none of the antidepressants has been approved for this age group either, with the exception of Prozac — and it has about the same failure rate as the behavioral treatment.

Critics like Dr. Joanna Moncrieff, senior lecturer in social and community psychiatry at University College London, argue it is high time to re-evaluate the current approach to depression and push development of non-drug alternatives.

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Next: Problem of accessibility, availability and affordability.

(Editors’ Note: This series on depression is based on a review of hundreds of reports and a survey of more than 200 specialists.)

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UPI Consumer Health welcomes comments on this column. E-mail Lidia Wasowicz at lwasowicz@upi.com