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TALK THERAPIES WORK, BUT THERE AREN'T ENOUGH
THERAPISTS TO DO THE TALKING
What's next for depressed kids?
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.
Carolyn Y. Johnson
21 September 2004
http://www.boston.com/news/globe/health_science/articles/2004/09/21/whats_next_for_depressed_kids/
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