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Children of Prozac If your youngster has more than the blues, he may be depressed. But is the popular prescription drug the right treatment? Tuesday, March 03, 1998 By Christopher Snowbeck, Post-Gazette Staff Writer
Thirty years ago, most doctors believed children couldn't get depressed.
Now, not only are more children being treated for the disease, but many are receiving anti-depressant drugs such as Prozac to subdue the blues.
There's little research that shows whether Prozac and other drugs affecting serotonin levels in the brain are safe and effective in children. Yet, children as young as 3 are being given these drugs.
Moreover, the number of times doctors recommended, prescribed or refilled prescriptions for Prozac for children age 6 to 12 doubled between 1995 and 1996. Those results come from a survey of physicians by IMS America, a pharmaceutical research firm in Plymouth Meeting, Montgomery County.
The increased usage has caught the attention of the Food and Drug Administration, which has not approved any drugs for treatment of childhood depression. Doctors who prescribe children Prozac do so on an "off-label" basis, meaning the drug is used for a purpose other than that for which it was tested.
"It's only alarming in the sense that it's a practice that's ongoing in the absence of research data to support the use of anti-depressants in children," said Thomas Laughren, FDA team leader for psychiatric drug products.
Laughren is part of a group at the FDA working on rules that would make manufacturers conduct more studies looking at the effects of drugs like Prozac on children.
Although most doctors say they try therapy first before medication, they say they will continue to prescribe anti-depressants because the results are so impressive. In some suicidal children, the drugs have helped save lives, they say.
"The real question, I think, is what are the risks of putting a child or adolescent with a developing brain on an anti-depressant medication? What's the effect 30 years from now?" asked Dr. John V. Campo, a psychiatrist at Children's Hospital. "The answer is, obviously, we don't know. We don't have reason to believe there are negative consequences down the road, but that's certainly a risk.
"But there is probably some chance that these medications may turn out to be protective later on, as well," he said.
The National Institute of Mental Health estimates that as many as 2.5 percent of all Americans under the age 18 are seriously depressed. That comes to 1.5 million children and adolescents.
The American Academy of Child and Adolescent Psychiatry says the number of "significantly" depressed children and adolescents is 3.4 million, or 5 percent of all youngsters.
A change in thinking
There's no way to compare these figures with data 30 years ago because doctors at the time believed children couldn't get depressed.
Depression was seen as a problem of the "superego," the part of the mind that tells a person what she should or shouldn't do, said Dr. Boris Birmaher, a children's depression researcher at Western Psychiatric Institute and Clinic.
Depressed people were thought to have poor self-esteem, Birmaher said, because their superego was too strong and made them feel ashamed.
Children couldn't have depression like adults, according to psychoanalytic theory of the time, because their superego was not fully developed.
But Joachim Puig-Antich, a doctor at Western Psychiatric Institute and Clinic, helped change that idea.
His work in the 1970s and 1980s helped doctors realize that children experience depression like adults, but they express their symptoms in different ways, Birmaher said.
Puig-Antich encouraged doctors to ask children the same questions they ask adults when diagnosing depression, but to explain terms like "self-esteem" and "depression" in ways children could understand.
Like a depressed adult, a depressed child might be tearful, withdrawn and lack energy; but other depressed children might become hyperactive, get into fights, start using drugs and alcohol or engage in risky behavior.
"I don't think we really appreciated in the 1960s and 1970s that kids can present [their illness] with a wide variety of symptoms," said Dr. David G. Fassler, author of a highly regarded new book on childhood depression called "Help Me, I'm Sad."
"All depressed kids don't look like depressed adults," said Fassler, a professor of psychiatry at the University of Vermont.
Some doctors say it's hard to tell if more children are depressed today than in the past because of the definition change. And the increased number in diagnoses in recent years does not necessarily equal a higher rate, they say.
But Fassler believes more youngsters today are depressed.
"We know that depression is caused by a combination of biological and environmental factors - it's neither entirely biological or completely a result of your experience," Fassler said. "But many kids are growing up in more stressful environments characterized by disruption, increased exposure to violence, multiple moves.
"Basically, they have less stability in their lives and the research does indicate that these kinds of stressful life experiences do increase the child's risk for depression."
One major reason doctors feel comfortable giving children medications like Prozac is because they have been so successful in treating adults, Fassler said.
Prozac belongs to a family of drugs called selective serotonin reuptake inhibitors, or SSRIs. The drugs work by affecting the level of serotonin in the brain, which impacts mood.
While some poorly designed studies have suggested these anti-depressants are safe and effective for children, the results of the first study comparing an SSRI with a placebo were published only last November.
In the study of 96 children and teen-agers, researchers from the University of Texas Southwestern Medical Center at Dallas found that 56 percent of the patients felt better after taking Prozac for eight weeks. Only 33 percent of those who took a placebo saw improvement.
"I believe we will continue to see more studies that will hopefully help us determine which kids in advance are most likely to respond to drugs," Fassler said.
University of Pittsburgh researchers, for example, have preliminary results showing that anti-depressants that affect serotonin levels are more effective than a placebo in treating adolescents with major depression.
"We found that it was safe and well tolerated," Birmaher said of the study, which was conducted at five medical centers but has not yet been published.
Nonetheless, the FDA is calling for more research on the long-term effects of these drugs on children. The government proposed rules in August that would require drugs to include label descriptions for how the medicines can be used in children.
Laughren of the FDA said the government has no evidence to suggest that using drugs such as Prozac poses a "unique" risk to children; reports thus far suggest children and adults experience similar side-effects to the medication.
Anti-depressant use can cause headaches, nausea, diarrhea and sweating, Fassler said, and some adults have reported changes in their libido as a result of taking the drugs.
But these are not reasons to stay away from the drugs, he said, adding that children who have side effects with one anti-depressant usually do fine when they switch to a comparable drug.
"They are not side effects that interfere with [children's] ability to take the medication," Fassler said.
Treating the cause
Medicine isn't always part of the solution, Fassler said. If used to the exclusion of psychotherapy, medications don't solve the root problem.
Dr. J. Octavio Salazar, medical director of child and adolescent psychiatry at St. Francis Medical Center, agrees, saying he prescribes anti-depressants as a "last resort" in many cases.
"There are not as many little kids using medication," Salazar said. "We prefer that small children up to age 10 begin with psychotherapy, family therapy, some type of environmental changes."
Non-medication forms of treatment come in various formats.
Some therapists try to help children express thoughts, feelings and fantasies to uncover unconscious ideas that affect behavior. Other therapists try to help children break out of negative patterns of thinking about themselves. Another approach, called family therapy, involves parents and siblings in counseling sessions.
But in some cases doctors think it's appropriate to go right to the medicine cabinet, Fassler said. Medication can subdue suicidal tendencies more quickly than psychotherapy can, he said.
"If a child has a lot of biological problems associated with the depression such as problems with sleeping, appetite and energy, then clinicians may be more inclined to use medication," he said.
Quiz: Is your child depressed?
Pediatric depression: For more information
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