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Antidepressants in depressed adolescents: to prescribe or not to prescribe?
- Krishna Menon (21 August 2008)
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Re: Antidepressants in depressed adolescents: to prescribe or not to prescribe?
- Evangelia M Tsapakis, Federico Soldani, Leonardo Tondo, and Ross J. Baldessarini (19 October 2008)
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Krishna Menon, Specialty Doctor Mole Valley CAMHS
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kmenon{at}nhs.net Krishna Menon
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I read with great interest the results of the meta analysis on the efficacy of antidepressants in juvenile depression published in the July,2008 of the British Journal of Psychiatry. Despite the possible heterogeneity among some of the studies included in the study, the results, if accepted by the psychiatric fraternity, could lead to further reduction in the use of antidepressants in the child & adolescent population. The use of antidepressants in this group has already decreased by 33% since the CSM warning against the use of most antidepressants in children & adolescents (1). Although the NICE guidelines on the treatment of depression among children and adolescents states that medication should only be used in conjunction with psychological interventions, the provision of psychological therapies remain thin on the ground in most parts of the country, which means that medication is often the only option available to clinicians for treatment of severe depression. Although purely pharmacological treatment would be the least desirable option in depression and research evidence on the efficacy for antidepressants for depressants in all age groups is either mixed or at best shaky, depending on which side of the debate one is on (2), most clinicians would agree that many patients with significant depression do improve on antidepressants. Although it is too early to judge whether reduction in antidepressant prescribing resulting from the CSM warning has resulted in an increase in depressive morbidity among children & adolescents in the UK, disturbing evidence is already emerging from the United States, Canada and the Netherlands (3) on an increase in completed suicide among children and adolescents, which seems to coincide with the reduction in antidepressant prescribing following warnings by regulatory agencies. In a retrospective study done in Canada, a significant reduction in antidepressant prescribing, accompanied by a statistically significant increase in suicide among children and adolescents (RR 1.25, 95% CI 1.08–1.44; annual rate per 1000 = 0.04 before and 0.15 after the warning) was noted in the 2 years following issuance of the warning(4) Given the well established link between depression and suicide, one can only conclude that clinicians may be under treating depression in children and adolescents since the emergence of concerns in relation to antidepressants. I feel clinicians should use their own clinical judgement and take into account local resources before making decisions on the course of treatment in juvenile depression. This would help one maintain the right balance between evidence based practice and what's best for individual patients, especially in an area of practice were research evidence is often ambiguous and contradictory. References: 1)Benji T Kurian, Wayne A Ray, Patrick D Arbogast et al Effect of regulatory warnings on antidepressant prescribing in children & adolescents. Arch Pedia Adolsec Medicine Vol 161 (No 7) July 2007 2)Joanna Moncrieff,Irving Kirsch Efficacy of antidepressants in adults. BMJ 2005;331:155-157 (16 July), doi:10.1136/bmj.331.7509.155 3)http://pn.psychiatryonline.org/cgi/content/full/43/10/14 4)Laurence Y. Katz, Anita L. Kozyrskyj, Heather J. Prior et al Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults. Can Med Assc Journal April 8, 2008; 178 (8). doi:10.1503/cmaj.071265 |
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Evangelia M Tsapakis, Clinical Research Fellow and Honorary Specialist Registrar in General Adult Psychiatry Institute of Psychiatry, King's College London, UK and Harvard Medical School, MA, USA, Federico Soldani, Leonardo Tondo, and Ross J. Baldessarini
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e.tsapakis{at}iop.kcl.ac.uk Evangelia M Tsapakis, et al.
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We agree with Menon (1) that, in clinical practice, many depressed juvenile patients almost certainly are under-diagnosed, reluctant to accept treatment, under-treated or leave treatment prematurely, and that competent clinical help, especially other than use of antidepressants, for such patients and their families is hard to find. However, the proposition (1) that antidepressants may have similar effects at all ages is inconsistent with our findings of quite limited, and perhaps inversely age-dependent, efficacy of antidepressants, as a class, as well as a lack of statistically significant differences between older and modern agents (especially of TCAs vs. SRIs), and the powerful influence of study-size on conclusions about “significance” of separation of antidepressants from placebos (2). A timely and pressing question is whether antidepressant treatment alters suicidal risks. Depression and suicide are strongly associated, but prediction of suicidal behavior, even in depressed individuals, is very difficult, and evidence concerning relationships of antidepressant treatment to suicidal behavior, although consistent in randomised clinical trials, remains controversial (3,4). Whether or not youth suicide rates will consistently increase or decrease, remains to be seen, and to be sorted out from high international variation in yearly suicide rates and poor documentation of attempts (3). For now, it seems an inescapable conclusion that clinicians are left to their own clinical judgment about using antidepressants for young individuals diagnosed with major depressive disorder. Furthermore, disbelief that modern antidepressants show relatively modest effects compared to placebos, and failed to separate statistically from older agents (2), paired with the repeated, and the poorly documented assertion that some modern antidepressants work well in clinical practice seems to avoid the issues. We considered various ways in which even randomized, controlled trials may be misleading, including selection of atypical or mildly ill outpatients or use of inadequate doses of antidepressants (2), as well as current controversy about how to diagnose and quantify changes in affective disorders in children and adolescents (5). Nevertheless, it is difficult to simply dismiss and ignore the findings of the research that has been done to test the efficacy of antidepressants in juvenile depression (2). References 1 Menon, K. Antidepressants in depressed adolescents: to prescribe or not to prescribe? Br J Psychiatry 2008 [e-publ 21 August]. 2 Tsapakis EM, Soldani F, Tondo L, Baldessarini RJ. Efficacy of antidepressants in juvenile depression: meta-analysis. Br J Psychiatry 2008; 193: 10–7. 3 Baldessarini RJ, Tondo L, Strombom I, Dominguez S, Fawcett J, Oquendo M, Licinio J, Valuck R, Tollefson G, Tohen M: Analysis of ecological studies of relationships between antidepressant utilization and suicidal risk. Harv Rev Psychiatry 2007: 15: 133–45. 4 Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006; 63: 332–3. 5 Henry C, Demotes-Mainard J. SSRIs, suicide and violent behavior: is there a need for a better definition of the depressive state? Curr Drug Saf 2006; 1: 59–62. |
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