Child Psychiatry is not adult psychiatry: children are not adults: what works for adults may not work for kids, and when kids are involved the problem is often affecting the family, the school or the wider society. So, let us start with the latest press problems: the number of prescriptions in Scotland in going up. But is this a problem? Moreover, what do we use antidepressants for — in adults they are as or more effective for anxiety disorders than depression.
Well, here you go.
BBC Scotland reports that last year four times as many children under the age of 13 were prescribed antidepressants as seven years ago.
Last year 252 children in Scotland below the age of 13 were given antidepressants, versus just 57 in 2009/10.
Now, this could indicate not that more children are struggling, but that more are actually seeking professional help. But it’s still alarming to think that a significant portion of young people are suffering enough to require drugs – and that there are likely even more experiencing depression but feeling they can’t ask for support.
Young people are most commonly prescribed Fluoxetine, also known as Prozac, which is the only drug recommended for under 18s.
41% of the children who were given antidepressants were prescribed sertraline, and 13% were given citalopram, which are recommended only if fluoxetine doesn’t work.
Ten teenagers (between the ages of 13 to 17) were prescribed paroxetine, despite warnings that this particular antidepressant should not be given to children and young people.
While the National Institute for Health and Care Excellence recommends that antidepressants should be given to teenagers and children in conjunction with talking therapies, there’s currently no data on how many children given medication go on to receive therapy. It’s also not clear how many therapy sessions they’ll be given, or how long they’ll have to wait between prescription and talking things through.
The Scottish government stated that it believes doctors are prescribing mental health medication correctly, and are only being given to children if talking therapies alone have not worked, in the cases of severe depressive symptoms.
There’s nothing wrong with needing antidepressants – and if they help someone to live a happy, comfortable life, antidepressants should be prescribed.
But it’s worrying that so many young people are being given medication when there hasn’t been significant research into the longterm effects of giving people antidepressants at a young age.
There also hasn’t been an increase in funding for mental health services to match the rise in the number of young people being prescribed meds
The short answer in that there are less studies in children and adolescents, but antidepressants as a class tend to be effective. Since I don’t live in the UK and can quietly ignore the NICE guidelines (which are driven by the needs of the UK health service, which is uniquely dysfunctional) I would add that in adults I don’t use fluoxetine, that I recommend internet based or face to face cognitive therapy routinely, but the data is that antidepressants have more side effects than placebo, but untreated depression is worse than the side effects.
Severe depression is crippling and at times lethal. The press tend to forget that: they don’t see the sharp end of mental health care.
But to the paper, from JAMA psychiatry. DD is depressive disorder, AD is anxiety disorder, OCD is obsessive compulsive disorder and PTSD is post traumatic stress disorder.
Our meta-analysis addresses the response and safety profile of SNRIs, SSRIs, and placebo in pediatric DD, AD, OCD, and PTSD. Results indicate that SSRIs and SNRIs are more beneficial than placebo in treating these commonly diagnosed conditions in children and adolescents. However, the overall drug-placebo difference is small and varies significantly by disorder, with a larger response in AD than DD, especially for SSRIs (g?=?0.71; 95% CI, 0.45-0.97; P?< ?.001). This difference in drug-placebo difference response is mainly due to a higher placebo response in pediatric DD. Furthermore, patients with OCD exhibit a significantly smaller response to both drug treatment and placebo treatment compared with AD and DD. The small effect size between SSRIs and SNRIs vs placebo in paediatric DD might be owing to the lack of a clear depression phenotype. This was apparent in DSM-5 field trials on major depressive disorder (MDD), which found a low test-retest reliability (??=?0.28) for children, adolescents, and adults.68 Furthermore, there is high comorbidity between paediatric DD and other disorders, especially AD. A recent review on the use of SSRIs and SNRIs in paediatric populations reported that approximately 25% of patients with MDD had a co-morbid AD. In our meta-analysis, although not all included studies reported comorbidity rates, those doing so reported comorbidity rates in AD ranging between 6% and 56% in patients with DD. Yet, attempts by the DSM-5 work group to create a “mixed anxiety and depression disorder” resulted in an unacceptable rate of test-retest reliability (??=??0.004) when tested in the DSM-5 field trials. Although it appears that the response to placebo is robust in paediatric DD, children and adolescents with ADs, who respond to pharmacologic treatment to the same degree as those with DD, do not appear to exhibit such a robust placebo response. While in line with older reviews in children, this finding is in contrast to adult studies that found no significant differences in placebo effect size between depression and anxiety. This contrast is not unique: placebo responses between children and adults differ significantly for binary outcomes across a wide variety of diseases. One explanation might be that children and adolescents with major DD may be more demoralised than patients with AD and are therefore more sensitive to changes in hope and favourable meanings.69 However, because no paediatric trial included a no-treatment arm that could serve as a control for the natural course of the disorders, the difference in placebo response may also reflect differences in the probability of spontaneous improvement between the 2 paediatric disorders rather than differences in the placebo effect.
So, yes, medications can work in children. With caveats: diagnosis in children remains a challenge and the current classification system does not capture well the differences in mood or anxiety disorders that occur as a child develops.
In many places, the alternatives are internet based treatments such as SPARX — note that this is only available for Kiwis — or medications. There are no child mental health psychologists available. Good enough is good enough. Our guidelines should not argue for perfection if it means that children continue to suffer.
The press can signal their virtue and damn doctors for prescribing. We are doing what we can, when the alternatives will mean considerable delay.