Childhood Depression Tricky to Treat

Lack of evidence on whether antidepressants up suicide risk clouds picture, review finds

THURSDAY, Sept. 8, 2005 (HealthDayNews) -- Although depression is common among children and adolescents, treating it can be problematic, with little in the way of scientific evidence to guide the use of antidepressants, a new report finds.

Recent data about the increased risk of suicidal behavior among children taking antidepressants such as Paxil, Prozac and Zoloft have called their use in children into question. However, experts say the benefits of these drugs outweigh the risks when patients are properly monitored.

The latest research, reported in the Sept. 10 issue of The Lancet, notes that major depressive disorders strike about 1 percent to 2 percent of children aged 6 to 12, and 2 percent to 5 percent of teens. In addition, 14 percent to 25 percent of children and adolescents have at least one episode of major depression before adulthood.

"Depression in children is relativity common, with a lot of impairment that lasts quite awhile," said study author Dr. Neal D. Ryan, a professor of psychiatry at the University of Pittsburgh School of Medicine. "It really deserves treatment. It's not a short or transient phenomena."

In his review article, Ryan looked at the current state of what is known about treating depression in children and teens. "There is a large gap in what is known about treating childhood depression compared with what is known about treating depression in adults," he said.

This knowledge gap exists because there are far fewer studies about depression in children. "It looks like there are a couple of psychotherapeutic approaches that probably work," Ryan said. "But we don't really have the studies to pin down how well they work, compared with medications, to give you a rational basis of what to do first."

In addition, Ryan found that the studies that dealt with using antidepressants showed mixed results. Part of the problem is that there are not enough studies to really tell how well these medications work in children, he said.

Ryan noted that whether these drugs make children suicidal is also an unanswered question. Whether the problem is due to the use of older medications, and is relieved by newer ones, is not clear from the last analysis done by the U.S. Food and Drug Administration, Ryan said. "It's a really mixed picture about the suicidality thing."

"The real question is, 'Is there an increased risk of something related to suicide when you first start taking the medication?' " he said. "Certainly, there is data pointing that way. There is also data that people are better off on medications."

Given the potential problem with antidepressants and the lack of complete knowledge, it is an open question whether to use psychotherapy or medications first with children, Ryan noted. "It's not a straightforward picture," he said.

Ryan believes children with severe depression can benefit from antidepressants, but children using these powerful drugs need careful monitoring. "Anything you can do to monitor for suicidality makes a whole lot of sense," he said.

One expert agreed that both medication and psychotherapy are valuable in treating depressed children.

"When we talk about treating depression, we shouldn't be limited to medication," said Dr. Robert N. Golden, a professor and chairman of psychiatry at the University of North Carolina. "Psychotherapy is also very effective."

But Golden also believes antidepressants are a valuable tool to use with depressed children. "Despite all the public attention that was focused on this finding of increased suicidal ideation in children on antidepressants, we shouldn't lose sight of the fact that there is an overwhelming body of evidence that these medications decrease completed suicide," he said. "That's what it's all about -- saving lives."

Medications have their risks, Ryan said. "But the risk of not giving them is much greater than the risk of giving them under controlled conditions," he added. "You can't give anybody, whether it's a child or adult, a pill and send them on their way. There has to be close supervision, and there has to be a public policy that allows for follow-up services."

More information

To learn more about depression, visit the National Institute of Mental Health.

SOURCES: Neal D. Ryan, M.D., professor, psychiatry, University of Pittsburgh School of Medicine, Pittsburgh; Robert N. Golden, M.D., professor and chairman, psychiatry, University of North Carolina, Chapel Hill; Sept. 10, 2005, The Lancet
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