Think About the Children

 You are worried about seeing him spend his early years in doing nothing.  What!  Is it nothing to be happy?  Nothing to skip, play, and run around all day long?  Never in his life will he be so busy again.  ~Jean-Jacques Rousseau, Emile, 1762

They don't work? Why do we prescribe them?

One special subgroup of the depressed population consists of depressed children. As mentioned in my previous post, children (which we can consider anyone up to the age of 18) are depressed in large numbers. However, on the other hand, according to Peter Breggin's book Medication Madness: A Psychiatrist Exposes the Dangers of Mood-Altering Medication, antidepressants are currently considered by the FDA as no more effective than placebos in depressed children. In fact, Breggin claims that due to the risks of side effects, including increased suicidal tendencies, antidepressants are not helpful to children but are actually consistently harmful to them if there is any effect. So how do the depressed children get help? Some families have opted out of medicating their kids with antidepressants, favoring instead child psychologists. However, despite what Breggin seems to consider a decisive verdict of ineffectiveness for antidepressants in children, they are still commonly prescribed. I have mentioned highly sought after child psychiatrists who charge between hundreds and thousands of dollars for an initial assessment. The rest of this blog post will be an attempt to understand why this medicine continues to be prescribed to a vulnerable social group if it is known to be useless or harmful.

In 2004, the FDA applied a black box warning to antidepressants that states that they can increase "the risk of suicidal thinking and behavior in pediatric patients." By doing this, the FDA drew attention to a serious side effect and directly mentioned the group they considered the most at risk. It is definite that harmful antidepressant side effects have been documented in children. However, these risks also exist to a lesser extent in adults but, unless lethal or intolerable side effects are certain or overwhelmingly likely, I do not think the prescription of antidepressants should stop due to those side effect risks. There's still a chance that an adult individual will find an antidepressant that can help them with manageable or negligible side effects. Does this possibility for improvement not exist for children?

After examining the FDA-sponsored study, it seems that Dr. Irving Kirsch concluded that, in children, as compared to placebo, the effects of tricyclic antidepressants were statistically insignificant and that while SSRIs were statistically significant, they were not "clinically significant." The FDA has spoken. Who disagrees? I am not sure. I can find a variety of studies concluding that tricyclics are worthless for children and while most studies say more information needs to be ascertained about SSRIs for children, they admit that SSRIs are minimally effective, if at all. Even the drug company GlaxoSmithKline sent out warnings about prescribing paroxetine to children due to the suicide risks in 2003, before the FDA put out the black box warning.

Overall, it seems that science does not support the effectiveness of antidepressants in children. The fact remains that there are children, even small children, taking these drugs. SSRIs are considered by many in the medical profession as the safest antidepressant to prescribe to children despite the apparent lack of therapeutic reward that accompanies the drugs serious side effects. Why are children taking these medications? Perhaps, there is evidence of effectiveness that I have not been able to find. Perhaps, their lack of effectiveness is not widely known or agreed upon among the doctors actually making prescriptions. Perhaps, science cannot yet give us a full evaluation of the positive effects these drugs can potentially have, effects that could be observed in practice. Perhaps, doctors suppose that some cases of depression in children are severe enough to risk side effects to attempt to achieve even a slight improvement. I fear I do not have the resources to decisively explain why children are still prescribed antidepressants. In the end, the FDA did not create a ban, it simply issued a warning. If doctors continue to prescribe these pills to children, they do so at their own risk. Unfortunately, they also do it at the risk of the patient and his loved ones, who often rely primarily on the advice of their doctor. Should we allow parents and their children to collaborate with their doctors and make up their own minds or should the prescription of antidepressants to children be limited by law? This important juncture between social responsibility and personal choice in psychiatry will be discussed further in my next blog post.  

"Efficacy and Safety of Antidepressants for Children and Adolescents." BMJ Group. Web. 18 Apr. 2012. <http://www.bmj.com/content/328/7444/879.full>.

"Dr. Irving Kirsch and Dr. David Antonuccio on the Efficacy of Antidepressants with Children." Web. 18 Apr. 2012. <http://www.ahrp.org/risks/SSRI0204/KirschAntonuccio.php>.

Papanikolaou, K., C. Richardson, A. Pehlivanidis, and Z. Daifoti-Papadopoulou. "Efficacy of Antidepressants in Child and Adolescent Depression: A Meta-analytic Study." National Center for Biotechnology Information. U.S. National Library of Medicine, 3 Aug. 2005. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/16075184>.

Tsapakis, EM, F. Soldani, L. Tondo, and RJ Baldessarini. "Efficacy of Antidepressants in Juvenile Depression: Meta-analysis." National Center for Biotechnology Information. U.S. National Library of Medicine, July 2008. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/18700212>.

Hazell, P., D. O'Connell, D. Heathcote, J. Robertson, and D. Henry. "Efficacy of Tricyclic Drugs in Treating Child and Adolescent Depression: A Meta-analysis." BMJ Group, 8 Apr. 1995. Web. 18 Apr. 2012. <http://www.bmj.com/content/310/6984/897.short>.

"A Black-Box Warning for Antidepressants in Children?" The New England Journal of Medicine. 14 Oct. 2004. Web. 18 Apr. 2012. <http://www.nejm.org/doi/full/10.1056/nejmp048279>.