When Mary Poppins taught her
young wards that, "a spoonful of sugar makes the medicine
go down," she probably wasn't referring to sertraline,
paroxetine or any other antidepressant for that matter.
But that was then. Nowadays, the growing trend to prescribe
antidepressants to kids could spell the end of the carefree
days of childhood as we know it. A 2000-2002 survey of
physicians' prescribing habits in nine countries pointed
to the rapidly increasing use of antidepressants in children.
Canada is one of the few countries bucking this global
trend — but don't celebrate yet. This may only be
because its prescription rates of antidepressants to kids
are already among the highest in the world, surpassed
only by the US.
The research, published in the
December issue of the Archives of Disease in Childhood,
is based on records kept by 13,223 physicians in Canada,
the UK, France, Germany, Spain, the US, Argentina, Brazil
and Mexico. The study was based on an international
database called IMS MIDAS Prescribing Insights, to which
a representative sample of physicians from each country
reported their prescribing habits for a few days each
year.
HIGHS
AND LOWS
The use of antidepressants and other psychotropic meds
such as stimulants and calmants rose in all nine countries
over the two-year period. The fastest increase was seen
in Britain, where antidepressant use climbed 68%. The
smallest increase was seen in Germany, where use rose
by a statistically non-significant 13%. After Germany,
Canada saw the most modest rise, at just under 15%.
In fact, Canadian prescriptions
in this sample rose dramatically last year but this
was counterbalanced by a fall in 2000-2001 — the
only annual decline seen in any of the nine countries.
Another study in the same journal
tracked the prescription of various antidepressant types
in Britain between 1992 and 2001. Unsurprisingly, the
figures showed a steady decline in the use of tricyclics
(TCAs) and the irresistible rise of the selective serotonin
reuptake inhibitors (SSRIs). However, TCAs were more
likely to be used in the youngest children, though most
prescriptions in the under-10 age group were for bedwetting.
SSRIs, on the other hand, were mostly given to children
with diagnosed depression.
Boys were more likely to take antidepressants
young. Use soared in both sexes from age 15 on, and
girls led the way there. The largest single increase
was in SSRI use in girls aged 11 to 14, who were receiving
23 times as many prescriptions in 2001 as in 1992.
GROWING
PAINS
Perhaps the most interesting finding was the poor compliance,
suggestive of limited benefit, in this age group. A
quarter of these patients switched drugs and most of
these switched from one class to another. Among those
diagnosed with depression, more than half discontinued
treatment within two months. Those taking TCAs were
particularly likely to stop treatment.
With the recently discovered link
between SSRIs and child suicide, these figures may be
frightening to some. However, Dr John Strauss, a mood
disorder specialist at the University of Toronto's Centre
for Addiction and Mental Health, cautioned against overreacting
to the new SSRI warnings. "The black box warning is
not a contraindication. Naturally, physicians will be
concerned by reports of suicidality, but the overall
risk is fairly small. To me, the most interesting aspect
of the recent review of research, and the new data that
has come out, is that these drugs are less effective
in under-18s than previously thought."
Tricyclics are definitely not the
answer, according to Dr Strauss. "It's pretty clear
from the existing research that TCAs are not very useful
in young patients." Physicians should remember that
non-pharmaceutical approaches like cognitive behavioural
therapy can be either an adjunct or an alternative to
SSRIs, he added.
Physicians who do prescribe SSRIs
to young patients should monitor them closely at the
outset for signs of suicidality, hostility or manic
behaviour, advised Dr Strauss. "It's generally accepted
today that these drugs can bring to the surface previously
undiagnosed symptoms of bipolar disorders."
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