Depression – A Children’s Health Scandal
Children as young as two are being prescribed powerful mood-changing drugs such as Prozac and other antidepressants. Although usage usually begins at the age of six and then carries on until the age of 19, the number of two- to four-year-olds taking stimulants (such as Ritalin), antidepressants (such as Prozac), antipsychotics and clonidine (used to treat adult high blood pressure and insomnia in hyperactive children) has skyrocketed.
Data from America show that, from 1988 to 1994, antidepressant use in children increased 400 per cent (Pediatrics, 2002; 109: 721-7). Today, around 2 per cent of all youths are taking antidepressants.
In one review carried out in France, 12 per cent of the children beginning school were receiving psychotropic medications, mostly phenothiazines; 76 per cent of these had started treatment by age four (Rev Epidemiol Sant’e Publ, 1992; 40: 467-71).
Last year, UK doctors wrote 170,000 prescriptions of antidepressants for children.
Of all the antidepressants, the increased use of selective serotonin reuptake inhibitors (SSRIs) among children has been the most dramatic, with a 10-fold increase from 1993 to 1997 (Can J Psychiatry, 1998; 43: 571-5).
Only eight per cent of GPs and paediatricians have received adequate training in the management of childhood depression. Yet, that has not stopped 72 per cent of them from prescribing SSRIs (such as Prozac) to children under 18 (Pediatrics, 2000; 105: e82).
In addition, 57 per cent of these physicians acknowledged having prescribed an SSRI for a diagnosis other than depression in an under-18-year-old patient. These included children diagnosed with attention-deficit and hyperactivity disorder (ADHD), obsessive-compulsive disorder, aggression/conduct disorder and even enuresis (bed-wetting).
Off the label
Once a drug is approved and on the market, further studies to determine its safety and efficacy in infants and children are rarely conducted (Curr Opin Pediatr, 1995; 7: 195-8). So, many medicines used for children are not licensed (have marketing authorisation) or are used ‘off-label’ (outside the terms of the product licence) (Arch Dis Child, 1999; 80: F142-5). Such prescriptions depend on little more than ‘educated guesswork’ and ‘experiences of peers’; they are not supported by scientific evaluation.
Concerns over the use of unlicensed and off-label drugs in children were first raised in the late 1960s (J Pediatr, 1968: 72; 119-20). The alarm went unheeded, however, and the practice of off-label prescribing for children is now a worldwide phenomenon (JAMA, 2000; 283: 1059-60).
A recent survey of five European hospitals analysed 2262 prescriptions given to 624 children and found that nearly half were either unlicensed or off-label. On the whole, 67 per cent of children received an unlicensed or off-label prescription (BMJ, 2000; 320: 79-82).
Drug safety in children cannot be inferred from widespread use. Nor can safety in adults be used to infer safety in children, as they are not ‘little adults’. Indeed, off-label use in children on paediatric wards has been shown to produce many more adverse effects than drugs properly licensed for use by children (Acta Paediatr, 1999; 88: 965-8).
Suicide and self-harm
With children, the picture of adverse drug reactions is complicated, as they often react to drugs in a completely different way from adults. Consider the paradoxical responses to phenobarbital in children vs adults. Phenobarbital acts like a sedative in adults, yet produces hyperactivity in children.
Conversely, Ritalin (methylphenidate), a cocaine-like drug, is used as an antihyperactive drug in children, but produces a stimulant effect in adults.
Without adequate studies, it is left to postmarketing surveillance, when it exists, to turn up adverse effects. The results are often distressing.
Recent reports have raised concerns that SSRIs may be associated with an increased risk of suicide in children. Two of these – venlafaxine (Efexor) and paroxetine (Seroxat/Paxil) – have recently been banned for children because the risk is so great. Last September, the UK Committee on Medicines announced a ban on Efexor. Only months earlier, Seroxat was similarly banned for children in the UK, Canada and Ireland.
In both cases, previously concealed evidence from controlled clinical trials conducted by the drugs’ manufacturers, Wyeth and GlaxoSmithKline, respectively, had shown that children taking SSRIs were driven to acute emotional distress, leading some to become suicidal or homicidal.
Only when this concealed information had been uncovered did healthcare providers receive letters from the manufacturers confirming that the drugs caused an increase in problems such as aggression, suicidal thoughts and attempts, and self-harm rates by up to 3 per cent.
Newspaper reports suggested that both drug companies knew for several years that their products could be causing children to feel murderous and suicidal (see www.guardian.co.uk/uk_news/story/0,3604,1045902,00.html).
The manufacturers were able to conceal these effects in their own studies by describing the intense emotional distress and violent behaviour of the children taking the drugs as ’emotional lability’, a euphemism not uncommon in clinical research that should have, but didn’t, raise alarm bells for drugs regulators.
The increased risk of suicide among young children is not new. In one study carried out by Yale University, 14 per cent of young people aged 10 to 17 developed tendencies towards, and thoughts of, self-injury while taking fluoxetine (J Am Acad Child Adolesc Psychiatry, 1991; 30: 179-86). This effect has been noted in adults as well (Am J Psychiatry, 1990; 147: 207-10).
While Efexor and Seroxat are no longer recommended for children, the suicide risk has not gone away. A review by the US Food and Drug Administration (FDA) of 20 placebo-controlled trials, involving over 4100 children and adolescents prescribed one of eight antidepressants – citalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline and venlafaxine – conceded that these were all more likely than a placebo to cause suicidal thoughts.
Adding insult to injury, the FDA also concluded that there was no evidence that the drugs were effective in treating childhood depression.
Pfizer, the manufacturer of sertraline (Lustral/Zoloft), was quick to distance itself from the review by recently funding a study of 376 depressed children (aged 6-17) that found that sertraline was ‘effective and well-tolerated’ – despite the fact that 17 of the children withdrew from treatment because of an adverse effect, and that two attempted suicide (JAMA, 2003; 290: 1033-41).
In the face of overwhelming evidence, the UK’s Medicines and Healthcare Products Regulatory Agency finally banned the prescription of SSRIs to under-18s in December 2003, although the practice continues elsewhere in the world.
Developmental damage
Whether the use of antidepressants and stimulants leads to addiction later in life is also poorly studied. Although recent evidence suggests childhood use of stimulants like Ritalin does not lead to stimulant addiction in later life (J Clin Psychiatry, 2003; 64 [Suppl 11]: 9-13), there’s a catch. These studies generally look for physical, not psychological, addiction.
Proponents believe that children clear medications from their bodies quicker, thus leading to less physical addiction. This may or may not be true. Nevertheless, there is still the unresolved matter of potential psychological and spiritual damage from taking psychotropic medicines.
Giving children medicine at the first sign of a problem, whether paracetamol for a headache or Prozac for a bad mood, sends a powerful message to the youthful mind – pills will cure your ills. It’s a message that drug companies would like to see embedded in all of our minds.
In fact, it is the hidden damage of early drug use that is most difficult to spot and remedy. Early childhood is a time of tremendous changes in the human brain. Cerebral metabolic rate peaks between ages three and four (Ann Neurol, 1987; 22: 487-97), and visual processing, language and motor skills are acquired at this time. The influence of mind-altering medications on the timing and direction of physical and mental development is simply not known (J Am Acad Child Adolesc Psychiatry, 2003; 42: 651-5).
For this reason, a recent review (JAMA, 2000; 283: 1025-30) concluded that the ‘possibility of adverse effects on the developing brain cannot be ruled out’. The report’s authors then went on to recommend that now is the time for parents to start actively looking for signs of subtle changes in the developing personalities of their children, which could be the direct result of mood-altering drugs on the neurotransmitters of the brain.
Barriers to change
Many things stand in the way of effective medical treatment for children. One is the ethical issue of testing drugs in children. What parents, after all, would consent to such participation and potential harm of their child?
Yet, the extensive off-label use of medications in children suggests that many are already participating in such research (J Law Med Ethics, 2000; 28: 362-78).
Also, paediatric drug use traditionally represents only a small portion of the market, so there is little incentive for paediatric drug testing. To comply with current regulations, drug companies need only insert a disclaimer, cautioning against paediatric use.
Even so, a review by Australian authorities found that 70 per cent of the products surveyed had either no information, or only a partial or general disclaimer regarding use in children (Report of the Working Party on the Registration of Drugs for Use in Children, Canberra: Therapeutic Goods Administration, 1997). This finding is similar to that of the US Physicians’ Desk Reference (Pediatrics, 1999; 104: 598-602).
Clearly, whatever the official line, children do not have equal access to ‘safe’ regulated drugs. But other socially based problems have promoted the acceptance of the use of mood-altering drugs by children.
Chief among these is how parents are continually being encouraged to abdicate their parental responsibilities to doctors, schools, social services officials and, ultimately, drug companies.
There is also the growing belief, unique to the post-baby-boomer generation of parents, that all children must fit into an idealised behavioural picture – well behaved, uncomplaining, never bored or fussy and never an inconvenience to the parents. The more widespread this expectation, the more children will be diagnosed with ‘behavioural problems’ and ‘depression’.
The backlash against Ritalin and overdiagnosis of ADHD may also be a factor. Parents unhappy with the ‘diagnosis’ of ADHD have successfully argued that the symptoms of ADHD can be easily confused with other problems.
For practitioners who still don’t know how to help children who don’t fit society’s mould, depression – the ‘common cold’ of mental illness – is perhaps the easiest dumping-ground diagnosis. The terrible cost of such an oversimplified verdict on our children is only just beginning to surface.
Sidebar: Approved for Use in Children?
Prozac is not the only mood-altering drug approved for use in children. In fact, a number of drugs have been cleared for use in the under-18s even though few have been safety-tested in this age group and many produce distressing adverse effects. According to the 2003 edition of the Physicians’ Desk Reference and the US National Institutes of Mental Health, the following can all be used to treat emotional disorders in children and adolescents.
Antidepressants
Children/adolescents
- Faverin/Luvox (fluvoxamine)
- Prozac (fluoxetine)
- Tofranil (imipramine)
- Lustral/Zoloft (sertraline)
Adolescents
- Anafranil (clomipramine)
- Elavil (amitriptyline)
- Sinequan (doxepin)
- Surmontil (trimipramine)
Antipsychotics
Children/adolescents
- Haldol (haloperidol)
- Melleril/Mellaril (thioridazine)
- Stelazine (trifluoperazine)
- Largactil/Thorazine (chlorpromazine)
Adolescents
- Moban* (molindone
- Navane (thiothixene
- Orap-TS (pimozide)
Mood stabilisers
Children/adolescents
- Depakote (divalproex sodium)
- Tegretol (carbamazepine)
Adolescents
- Cibalith-S*/Eskalith*/Lithobid* (lithium)
ADHD
Children/adolescents (stimulants/others)
- Adderall* (dextroamphetamine plus levoamphetamine)
- Attenade* (D-methylphenidate)
- Concerta (methylphenidate)
- Cylert* (pemoline)
- Desoxyn* (methamphetamine)
- Dexedrine (dextroamphetamine)
- Dextrostat* (dextroamphetamine)
- Focalin* (dexmethylphenidate)
- Metadate* (methylphenidate)
- Ritalin (methylphenidate)
- Strattera* (tomoxetine)
* US-only formulations
Sidebar: Recognising Childhood Depression
How do we know when it is emotionally abnormal for a two-year-old to cry, or a four-year-old to be fussy and argumentative? What exactly is childhood depression?
The signs and symptoms of depression in children are notoriously difficult to detect accurately (and to study) and are dependant on a multitude of other, usually external, factors. In a patient-information sheet produced by the Mayo Foundation for Medical Education and Research, the authors note that: ‘Depression is more difficult to diagnose in children because many behaviours associated with depression can be normal behaviours in children. In evaluating a child for depression, a therapist considers the number, duration and severity of signs and symptoms.’
Fair enough, but the factsheet then goes on to list symptoms such as listlessness, irritability, crying easily, complaints of boredom, arguing with parents, a lack of interest in schoolwork and even ‘looking sad’ as signs of childhood depression.
What parents can put their hands on their heart and say their child has never experienced any of these states?
What emerges in the evidence is that a child’s mental stability is highly dependent on that of its parents and surroundings. A recent study by researchers at Columbia University in New York City, for instance, reports that poor parenting may put children at a higher risk for anxiety and depression. The investigators interviewed nearly 600 parents and their children, and concluded that poor parental behaviours, such as verbal abuse, inconsistent rules, parental arguments in front of children and a lack of supervision can all increase the chances of childhood anxiety or depression (Arch Gen Psychiatry, 2001; 58: 231-6).
Many studies show that, if the mother is depressed, the child will be too (J Am Acad Child Adolesc Psychiatry, 2001; 40: 1367-74; Matern Child Health J, 2000; 4: 215-21). In one study, if the mother was depressed and smoked, the likelihood of her child having ‘low social functioning’ was nearly doubled (Ambul Pediatr, 2003; 3: 288-94).
There is, likewise, evidence that we are using drugs to make bigger problems, such as social inequality, go away. Data suggest that poor and black children are those most likely to be given mind-altering drugs (Arch Pediatr Adolesc Med, 1999; 153: 1039-45) rather than receive counselling.
Sidebar: How Diet Can Lead to Depression
Drug treatment for depression usually focuses on ‘normalising’ serotonin. Manipulation of neurotransmitters, however, is poorly understood, difficult to regulate and unlikely to have long-lasting effects.
Recently, nutritionists have turned their attention to morphine-like substances derived from the incomplete digestion of proteins in cereal grains and dairy products as a possible cause of depression. These substances, called ‘exorphins’, were first recognised in the late 1970s (J Biol Chem, 1979; 254: 2446-9). Further research has identified five distinct exorphins in the pepsin digests of gluten (Life Sci, 1995; 57: 729-34) and eight other exorphins in the pepsin digests of milk (N Engl J Med, 1982; 307: 895).
Exorphins act as depressants and are believed to be responsible for the reported psychiatric symptoms, including ‘brain fog’, that often accompany immune reactions to these foods.
Depression is a common symptom of coeliac disease, a disorder where the inner lining of the small intestine (the mucosa) is damaged after eating wheat, rye, oats or barley (Am J Gastroenterol, 1999; 94: 839-43) as well as allergies. Investigations into the abnormal electrical brain activity seen in more than two-thirds of untreated children with coeliac disease has shown that, in most cases, such activity returned to normal when dairy and grain were removed from the diet (Psychiatr Pol, 1991; 25: 30-4; Z Klin Med, 1985; 40: 707-9). Abnormal brain activity may be an indication of neurological dysfunction associated with depression.
Clearly, not every child who is depressed will have coeliac disease but, for some, cutting out wheat and other grains, or avoiding dairy, may mean the difference between a normal life and a life on drugs.
Sidebar: Other Options When Your Child is Sad
One of the most common responses on hearing that a child has depression is, ‘But what does he/she have to be depressed about?’ While it is possible that ‘depression’ is overdiagnosed in young children, some children do suffer from depression. Recognising and tackling the problem early may be more important than whether or not you use drugs. Indeed, brain scans of children with mood disorders have shown that electrical activity in the brain can return to normal whether or not drugs are used. The key appears to be finding the right treatment for the given child (Arch Gen Psychiatry, 1992; 49: 681-9) and supporting the recovery.
Talking works better than drugs. Unlike treatment with medication, psychotherapy requires a significant commitment by both parents and children. Nevertheless, studies show it is more effective and produces longer-lasting improvement than drugs. Give your chosen therapy (or therapist) at least three months before assessing effectiveness.
Low self-esteem is a major contributor to childhood depression. Parents can improve self-esteem in their children by improving communication, setting clear expectations and limits, and nurturing a sense of responsibility.
Physical activity can help relieve or manage depression. Exercise also has the benefit of improving body image in adolescents. Non-competitive activities such as swimming are more appropriate than those with ‘winners’ and ‘losers’ (Am Fitness, 1993; 11: 24-6).
Teach your kids to cope with stress. This may mean going on a course yourself and sharing what you have learned with your child. Similarly, speak to your child’s teachers and ask them to consider initiating a school programme that teaches coping and social skills. Reports suggest that school-based programmes are often effective for students at risk for depression (J Sch Health, 1995; 65: 390-4).
Companion illnesses. Depression often goes hand-in-hand with other mental illnesses or disorders, including attention-deficit and hyperactivity disorder (ADHD) and, especially in teenage girls, eating disorders and self-injury. Thyroid imbalances, parasites and Candida overgrowth can also cause depression. If any of these conditions are present, they need to be treated along with the depression for a long-lasting or permanent cure.
Ask questions about proposed drugs. Ask your physician and pharmacist about potential interactions and adverse effects. Learn as much as you can about any medications the child is currently taking and, if possible, seek independent information to confirm what your doctor has told you. Remember: drugs that are not medically appropriate can make depression worse.
Reactions to medications such as antibiotics, asthma medicines, heart drugs, anticancer drugs, pain relievers, immunosuppressants and cough medicines can all cause depression. If your child is taking any of these, it could be the root of the problem.
Maintain a regular and nutritious diet. Don’t let your child skip meals, and do avoid foods that are high in sugar or caffeine as well as preservatives, flavourings and colourants. A good diet is a critical source of energy and nutrition while your child is recovering from depression. In addition, you may wish to consult a qualified nutritionist as deficiencies in certain nutrients, such as B vitamins, essential fatty acids and some minerals, can also be associated with depression.
A regular sleep cycle maintains energy, whereas an irregular sleep pattern prolongs or worsens symptoms of depression. Avoid letting the child sleep or nap during the day even when it is difficult for him/her to sleep at night.
Consult a qualified homoeopath. Case studies suggest that several remedies, such as Aurum, Natrum muriaticum, Aurum muriaticum natronatum and Stramonium, in very high, single doses (200 C to 1 M) can help ease the symptoms of depression.
Toxic exposures to metals, dioxins, polychlorinated biphenyls (PCBs) and organochlorine/organophosphate pesticides/solvents are very common, and can cause the sort of hormonal and neurotransmitter imbalances associated with depression (Townsend Lett Docs, 2001; 210: 64-72). Mercury exposure, usually through vaccines and amalgam fillings, may be particularly influential. Consider having your child tested for toxic overload.
- This article appeared in the January 2004 (volume 14 number 10) edition of What Doctor’s Don’t Tell You
