Kids and antidepressants

Out of this world

Pediatricians’ perspective on kids and antidepressants

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs

It’s the dawn of a new year and quite naturally we should be thinking about beginnings – about babies and children.

A few months back, in an article in Postmedia News, journalist Sharon Kirkey reported the most incredible nose-stretcher of a statement by the Canadian Paediatric Society: “The group representing the nation’s paediatricians says the potential benefits of Prozac-like antidepressants – drugs that have only ever been officially approved for use in adults in Canada – outweigh the potential harms when used in children.”

This means the medical specialty most interested in the health of our kids is telling parents, “Don’t worry your pretty little heads about feeding your child Prozac, Zoloft, Paxil, Cymbalta, Cipralex, Effexor or any other of the major antidepressants known as SSRIs because the ‘disease’ of depression is likely to be much worse than the drugs.”

Sound convincing?

Their recommendations are a bit more nuanced on paper, but at the risk of being overly bombastic, I have to ask, in the nicest of tones, “On which planet do these paediatricians live?”

The Canadian Paediatric Society arguably does some very good work, but when it comes to recommendations on children and antidepressants, my sense is they are many light-years away from rationality. (Read their position statements at www.cps.ca) In fact, when I looked at their advice about kids and antidepressants, I wondered if any voices in that organization are wondering if tossing more jet fuel on the flaming inferno known as childhood angst might make things worse?

According to their recommendations, “Within the context of a comprehensive management plan, SSRI medications may be effective in the treatment of child and adolescent depression and anxiety disorders.” They follow that up with: “Because depression in particular is associated with high rates of suicidal ideation, behaviour and completed suicide, untreated illness may be more harmful than appropriate use of SSRI medication.” Let’s translate: The drugs might work and the kids should take drugs because the harm of the drugs could be less than the risks of suicide. They add, “Following medication initiation, patients should be closely monitored for potential adverse effects, including suicidal ideation and behaviour.”

What does this mean in practise?

A “comprehensive management plan” complete with help from a psychiatrist or counsellor sounds good on paper, but in the real world that plan would include an adequate number of quality counsellors, relatively easy access to child psychiatrists and solid, dependable supports for families struggling with poverty, addictions and violence. Since the world doesn’t look like that, what do our physicians really do when worried about a child’s social and emotional well-being? Write a script for an SSRI antidepressant, that’s what.

A child who is sad, confused, upset and angry might have good reasons for feeling that way yet once inside the medical system, the child is likely to be told he has a brain disorder and out come the prescription pads. Like children, the paediatricians are innocent, hopeful and trusting when they say the meds “may be effective in the treatment of child and adolescent depression and anxiety disorders.” Yup, possibly true, but the reverse may also be true. SSRI medications may not be effective or they may actually make things worse.

We know about SSRIs’ short-term side effects including nausea, vomiting, diarrhea, sleep changes – such as insomnia or wild dreams – as well as restlessness and headaches, but in the long term? Those are more scary to contemplate because we’re talking about the drugs’ effects on developing brains and bodies.

Author Robert Whitaker, whose book Anatomy of an Epidemic (Crown, 2010) explores why the number of adults and children in the US disabled by mental illness has soared over the last 50 years (in line with the soaring prescribing of SSRIs), demonstrates quite convincingly that SSRI prescribing is essentially part of the problem. Compared to depressed people not medicated with SSRIs, those on the drugs seem to actually do worse in the long-term, have high relapse rates and are more chronically depressed. The debilitating withdrawal symptoms when trying to stop SSRIs mean they are a one-way street: easy to start, with almost no going back. And we want to inflict that on a child?

These facts should be flashing red lights of caution around these drugs yet the paediatricians maintain, “Untreated illness may be more harmful than appropriate use of SSRI medication.”

That could be true, but how many studies have looked at the long-term effects of these drugs in children? Both the USFDA and Health Canada have issued warnings saying these drugs in children increase the risks of suicide. What do the paediatricians know that the regulator doesn’t? Why are they ignoring a substantial body of research, published in major medical journals like the Lancet and the BMJ, demonstrating SSRIs are largely ineffective and harmful in children and that children on antidepressants have a high rate of converting to bipolar disorder?

An FDA review of 2,200 children found four percent of those taking SSRI medications experienced suicidal thinking or behaviour, including actual suicide attempts which was twice the rate of those on placebos. Also, SSRIs in adolescence can cause long-term sexual dysfunction, loss of libido and so on, dangers that can continue even after the drug is stopped. (Google PSSD which stands for Post-SSRI Sexual Dysfunction and you’ll find a whole online universe of kids self-reporting the disastrous effects of SSRIs on their lives.) An exhaustive review of the literature published in the BMJ concluded that, in children and adolescents “recommending (any antidepressant) as a treatment option, let alone as first-line treatment, would be inappropriate.”

I’m not saying mental illness isn’t a problem or that we shouldn’t help withdrawn, sad or anxious kids, but when Canada’s paediatricians say it’s OK to use SSRIs in children as long as we ‘monitor’ them closely, maybe they are forgetting the child mental health system in Canada is largely a joke – an uncoordinated, inadequate system unlikely to be helped by pouring even more drugs of dubious value into the mouths of children.

Some might write off the Canadian Paediatric Society as somehow being in the pockets of the manufacturers of SSRIs, but I can’t buy that explanation. Paediatricians as a group are incredibly caring, intelligent and compassionate people, but is their Society really that naïve, unaware that the ‘real world’ of childhood mental healthcare in Canada largely features general practitioners facing anxious or confused kids in a standard 15-minute office visit with nothing but a prescription pad. A pad, I might add, that could well condemn these kids to a more miserable future than it should be.

So in contrast to the official voice of Canada’s paediatricians, let me issue a “position statement” on behalf of Common Ground magazine and my many loyal readers who are asking, “What do you really think, Alan?” Here’s my opinion: The Canadian Paediatric Society is in Lulu-land or at least orbiting another planet that looks nothing like Earth. That planet is inhabited by those making careless recommendations around powerful and potentially dangerous pharmaceuticals, threatening to turn many young people into long-term pill-takers. But we earthlings think differently.

Let me try to lure them back to Earth with one thought: It’s called the “Precautionary Principle” and it’s as important as gravity is here on Earth. It’s a useful concept and one worth considering the next time they make recommendations around the prescribing of powerful pharmaceuticals to our children.

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Alan Cassels is a pharmaceutical policy researcher and author in Victoria. He acknowledges the work of Mary Ellen Turpel-Lafond, BC’s Representative for Children and Youth whose office is doing much to improve the health of BC’s children. www.alancassels.com