Now there's a new reason to worry. The only drugs thought to be effective in treating youngsters with major depression are being investigated as a possible cause of suicidal behavior themselves.
Reviews of existing drug company research are under way in the U.S. and England. Hopefully they will shed more light on whether the drugs -- most of which are selective serotonin re-uptake inhibitors, or SSRIs -- cause suicidal behavior. But there is also the more fundamental question of whether these drugs work in children in the first place. Only one antidepressant, Prozac, has proven its effectiveness to the Food & Drug Administration and been approved for pediatric use, although many think Zoloft has also demonstrated efficacy. Other well-known drugs in this category include Paxil, Celexa, and Lexapro. In England, the heath-care regulatory agency has already decided the risks of SSRIs -- except Prozac -- outweigh the benefits for children.ON THE ALERT
Until the U.S. results are in, probably some time this summer, the FDA has advised doctors prescribing these drugs, as well as parents and patients, to be on the lookout for suicidal behavior or worsening depression. Doctors should be particularly vigilant with patients who may have bipolar disorder. Anxiety, agitation, panic attacks, mania, and akathisia (severe restlessness) are some of the symptoms associated with use of antidepressants.
Given the uncertainty, what should parents of a depressed youngster do?
First, children already taking an antidepressant should not stop suddenly or without first consulting a physician, since withdrawal can hold its own dangers. A 19-year-old Indiana college student hung herself in February after coming off a drug under review. Dr. David Healy, a British psychopharmacologist and leading critic of SSRIs, says patients are most at risk when they start the drugs, increase the dosage, or stop taking them.
Second, depressed children should be evaluated by a specialist in child and adolescent psychiatry, says Dr. David Shaffer, director of Child & Adolescent Psychiatry at Columbia University's College of Physicians & Surgeons. The American Academy of Child & Adolescent Psychiatry (aacap.org) can help you find one. The diagnosing psychiatrist should be able to explain the problem, specify a treatment, explain the reasons for psychotherapy or medication, and describe good and bad effects of any drugs used, he says.
While a nonphysician may be in charge of psychotherapy sessions, a psychiatrist should prescribe and monitor the drugs, says Dr. Shaffer. Antidepressants should not be prescribed by a family doctor or pediatrician unless that doctor has a great deal of experience dealing with childhood depression, says Dr. Robert King, a professor of child psychiatry at Yale University School of Medicine who, in 1991, published the first study suggesting a link between SSRIs and suicidal behavior in children.
For those who want to avoid antidepressants altogether until the evidence is in, two forms of psychotherapy have been shown to be effective in children, according to Dr. Shaffer. The first is cognitive-behavioral therapy. It teaches patients to monitor their moods and to challenge their negative thoughts. For example, a child who thinks no one likes him might be taught to question what evidence he has of that. The patient is also encouraged to participate in social activities as a way to limit negative introspection.
The second form of therapy is dialectical-behavioral therapy, which helps patients understand what causes them stress and avoid getting into those situations. The patient also learns how to cope with unavoidable stress without having a meltdown.
Both treatments are expensive, costing perhaps $100 to $300 a session. Dialectical-behavioral therapy is especially costly since patients meet with a therapist up to four times a week for a year, vs. perhaps one or two sessions a week for four months with other therapies. Just finding someone who practices these disciplines can be difficult for those not living in a major city.THE PRACTICAL OPTION
That leaves drugs as the most practical treatment option for many. Psychiatrists have strong opinions about whether a link exists between antidepressants and suicidal behavior. Some say much of the behavior described in drug company clinical trials was not really suicidal. Others, like Dr. Healy, argue that studies have pointed to problems with SSRIs since the early 1990s, but drug companies put the evidence aside, dismissing any suicides as an unfortunate but not surprising result of depression.
Dr. Shaffer, who has studied suicide rates among teens, says the rate has dropped as the use of SSRIs has increased. The suicide rate for 15- to 24-year-old males fell from 23 per 100,000 in 1994 to 17 per 100,000 in 2000, he says.
It may turn out that antidepressants reduce suicide risk for the general population of depressed children but increase it for a subset of patients who react adversely, says Dr. King. "I'm absolutely sure that sometimes when you give an SSRI, you get a psychological change for the worse," says Dr. Shaffer. The number of youngsters taking the drug that become more irritable, agitated, and likely to talk about killing themselves may be as high as 10% or 12%, he says.
For those who can't afford therapy or gain access to it, drugs may be a far better solution than not treating a depressed child. But parents need to monitor treatments to make sure the drugs are not producing a dangerous effect. By Carol Marie Cropper