“Drug companies have deliberately suppressed evidence that many antidepressants are unsuitable or even dangerous for children, according to psychiatrists and child health experts.
Researchers uncovered unpublished data about clinical trials of the most popular antidepressants on the market, known as selective serotonin re-uptake inhibitors (SSRIs), which raise serious doubts about prescribing them to children.
Published studies have so far indicated that the benefits have outweighed risks for all five drugs studied – Prozac, the brand name for the drug fluoxetine, paroxetine, sertraline, citalopram, and venlafaxine.
But the review published today in medical journal the Lancet showed this was true of only one, the leading brand, Prozac. The others at best were not proven to help children and at worst linked to an increased risk of suicide or suicidal thoughts.” —Guardian.UK
Readers of FmH will know that I have been preoccupied with developments in this area in the weblog. The Lancet article (only an abstract of which is online) makes it clear that evidence of antidepressant efficacy in children only exists for fluoxetine. But reportage lumping the ineffectiveness of the other antidepressants so blithely with the imputation of their dangerousness is unwarranted and irresponsible. Adverse outcomes to antidepressant therapy in both children and adults are a function of the way they are marketed and prescribed rather than their physiological effects on the patients who take them. ‘It’s a poor workman who blames his tools’, the saying goes, which seems to be one of our society’s pervasive pathologies of thought as exemplified in jumping so uncritically on this particular bandwagon. I do find it plausible that, in the wake of various difficulties in extending their customer base to the fertile untapped area of treating children, the pharmaceutical giants probably suppress evidence that these medications are ineffective in children, but several factors come into play in a complicated way in assessing their efficacy:
- childhood depression is difficult to diagnose
- it is dicey to do medication trials on minors, so the data is quite limited compared to that we have with adult subjects
- while physicians are not duty-bound to use medications for only FDA-approved indications, extrapolation of adult efficacy data to children may not be warranted, since children are (neurologically, physiologically, developmentally), it goes without saying, not just ‘small adults’
- in general, negative studies are more difficult to publish in scientific journals than those which demonstrate a beneficial effect
Furthermore, it pays to be reminded that even a positive result, a ‘statistically significant’ beneficial effect of a drug on a target symptom, may not represent a clinically significant benefit. A couple of points’ worth of improvement on some clinical rating scale may not mean the patient feels or functions appreciably better. There are certainly good arguments not to consign “depressed” children to medication right off the bat, but they have very little to do with the dangerousness of the drugs.
There is, however, one sense in which I think these drugs are sometimes indubitably ‘dangerous’. In the rush to pharmacological treatment, we do not spend enough time thinking about the negative impact on one’s self-image of being offered a medication. Psychiatrists are usually preoccupied with the flip side of this coin, exploring the reluctance of patients to accept the medical model for their mental health problems and the potential benefits of medication therapy. For example, I hear myself asking patients fairly often something along the lines of, “If you were told you had diabetes, would there be any moral failing in taking medication to do the job your body’s own insulin was not doing well at?” But persuading someone that they need medication can also unintentionally convey messages such as they are defective, have no responsibility for their behaviors, do not have to participate in thinking about the origins of their problems or how to cope differently. The impact these messages can have is especially formative when the patient is a child. It is quite tricky, and not at all trivial, to be at the interface of treating with medication and working on self-conception, as a psychotherapeutically-informed psychopharmacologist should be…
