Are antidepressants endangering our children?

A generation ago, parents worried about giving their children too much Baby Aspirin. Today, psychiatric drugs rank among the top five medicines prescribed to Canadian children and teens.

Prozac-like drugs are being prescribed to children in emergency rooms and even walk-in clinics, with virtually no follow-up, and children are increasingly being put on not just one mind-altering pill, but two or three, including potent anti-psychotics that may have contributed to nearly 75 reported deaths in Canada in people taking the pills. Doctors once doubted children could even get depressed. Earlier ideas about depression centred on complex psychological states that doctors felt children couldn’t experience — feelings such as guilt and worthlessness. In other words, says Toronto child psychiatrist Dr. Mark Sanford, little children had little problems. “It’s hard to know how it was missed for so long.”

Today, it’s widely accepted that children not only get depressed, they can suffer a wide range of mood disorders. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the “bible” doctors use to diagnose mental illness, contains an entire chapter devoted to disorders that typically first surface in childhood. They include conduct disorders (“often bullies, threatens or intimidates others”), oppositional defiant disorder (“often loses temper”) learning disorders such as mathematics disorder and “disorder of written expression” (writing skills that fall below those expected given the child’s age), and separation anxiety disorder. Preschoolers are being diagnosed with bipolar disorder, or manic-depressive illness — a diagnosis once reserved for adults. Some experts say the criteria have become so soft and slippery every normal childhood behaviour now runs the risk of being labelled a disorder that needs to be “cured” with a pill. But others say the growing list of sicknesses and symptoms is a positive sign doctors are finally paying attention to mental health problems in children. “In the past, a lot of those kids would have been in the gastro-intestinal clinic getting worked up for stomach aches,” says one doctor. Panic disorders in kids were frequently misdiagnosed as epilepsy or heart problems.

Today, the use of SSRI antidepressants in children is soaring. But just how many children truly need the drugs is murky. “The fact that 20 per cent of young people are being diagnosed with a major psychiatric illness (depression) that does not respond to conventional treatment (antidepressants) and the placebo response is so great begs the question, are we misdiagnosing this group of patients?” one doctor wrote in a recent electronic letter to the Canadian Medical Association Journal. Meanwhile, some parents of mentally ill children see a bitter irony. While healthy children may be getting drugs, parents of children so sick they think Walt Disney cartoon characters are real struggle for years to get doctors to take their concerns seriously so they can get the appropriate treatment.

“Doctors would say to me, ‘You don’t want to label him,”’ says Cynthia Clark of Ottawa, whose son Justin has schizophrenia. “Would they say that if he had cancer?”

Even when Justin had a full-blown panic attack at 15, the doctor in the emergency room thought it was an asthma attack, and sent Justin home with Benadryl. Justin was once so psychotic he thought h is mother was an alien and that people on television were speaking to him. More doctors wondered if he had a substance abuse problem. Justin finally got the help he needed when Cynthia refused to leave a children’s hospital emergency room until she saw a psychiatrist. Justin, now 20, is doing well on medication.

Kathryn Graham, whose 18-year-old daughter Kaitlin died by suicide two years ago, fought for five years to find her daughter help in a mostly adult mental health system. “I remember many times just begging the doctors for something — anything — just something to zombie her out so she would be safe and unable to harm herself.”

While as many as one in five children suffers from a mental illness, it can take six months or longer to see a child psychiatrist, leaving pediatricians and family doctors to care for them — doctor s who often have no special training in treating psychiatric disorders. In a 1999 survey of nearly 600 U.S. family doctors and pediatricians, 72 per cent reported prescribing an SSRI for a patient younger than 18 years of age. (None of the drugs has been licensed for u se in children in Canada.) Just eight per cent of the doctors surveyed said they had adequate training in the management of childhood depression, and 16 per cent “reported feeling uncomfortable” with the care of depressed children. Nearly three-quarters had written an SSRI prescription for children and teens with mild to moderate depression, while more than half had ordered an SSRI for another diagnosis, including attention deficit disorder, aggression disorder and even bed-wetting. Many doctors are finding it hard to come to grips with the evidence that whatever success they might have had treating children with SSRIs might have been entirely due to the placebo response. A recent editorial in the Journal of Adolescent Psychopharmacology maintains the medicines are “remarkably safe” and that while it makes “emotional sense and heart-wrenching sound bites” for parent s who have lost a child to suicide to blame the drug they were taking, “the best science we have does not back this up.”

Dr. Barbara Mintzes begs to differ. “The basic information we know about these drugs would suggest against using them in children,” say Mintzes, an epidemiologist at the University of B.C.’s Cent re for Health Sciences and Policy Research. She says the larger “scandal” in the SSRI controversy is that the negative studies only now coming to light were done 10 years ago.

GlaxoSmithKline, makers of Paxil, stresses that their drug has never been approved for use in children. The drug giant says pediatric studies it sponsored “were not conclusive” on the risk of suicidal thoughts and attempts and that an analysis of suicidality was completed in the fall of 2002. “Once we had investigated the data as fully as possible, we made it a priority to bring the data to the attention of regulatory bodies around the world in spring 2003,” the company said in a written response to a request for an interview. In July, the company warned Canadian doctors Paxil should not be given to children. A similar warning was later issued by Wyeth Canada, makers of Effexor. (When contacted this week, the company said a spokesperson was unavailable to comment.) However, an internal GlaxoSmithKline memo reveals a U.S. study conducted from 1993 to 1996 indicated Paxil was no better than placebo in treating teenagers.

But as the furor over the use of antidepressants in children and teens builds, some parents worry any move to ban their use in kids in Canada will only make a bad situation worse. “If a child needs help, and the only thing (doctors) have to offer is an SSRI, we don’t want them to be prevented from using them because it might be the only thing they have,” says Cynthia Clark. “Believe me, when you have a child who is mentally ill, you will grasp at anything that might help.”

Sharon Kirkey
June 11, 2004

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