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Are We Overmedicating Our Kids?
The credibility of drug companies and psychiatry has taken a recent beating. What does this mean for our kids?
It took us nearly an entire century to recognize the obvious - that depression and bipolar disorder do occur in teens and children, these days in epidemic numbers.
But it has taken only a very short time for a public backlash to develop over whether we are doing the right thing by treating our kids with powerful drugs.
In 2002, two million pediatric prescriptions were written for Paxil alone, many to toddlers. According to a Medico Health Solutions analysis of customer data, the use of behavioral medications for children topped all other areas of drugs in 2003 at 17 percent of total spending. This compared to 16 percent for antibiotics and asthma drugs, 11 percent for skin conditions, and six percent for allergy meds. Antidepressants spending grew by 21 percent over a three-year period and ADHD by 369 (no typo) percent compared to 4.3 percent in the use of antibiotics.
A 1999 University of North Carolina study found that only eight percent of a surveyed group of 600 family physicians and pediatricians reported having received adequate training in the management of childhood depression. Yet that did not stop 72 percent of the same group from prescribing SSRIs to patients under age 18.
FDA Investigates Antidepressants in Kids
A 2003 FDA analysis of 15 pediatric antidepressant trials found only three established efficacy, with only Prozac reaching the threshold of two successful trials generally required for approval. Moreover, the analysis uncovered worrying data that the kids on antidepressants engaged in more suicidal behavior than the kids on placebos (see article). Agitation and emotional lability are acknowledged side effects of these meds, usually short term. For kids with undiagnosed bipolar disorder, an antidepressant can result in manic and hypomanic episodes. Although the FDA did not connect these effects to suicidal behavior, in October 2004 it instructed manufacturers to warn on the product labeling that kids on antidepressants need to be carefully monitored as "there is concern that such symptoms may represent precursors to emerging suicidality."
The FDA also instructed manufacturers to put black box warnings on their product labeling, stating in part: "Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders."
The warning urges that doctors and patients closely monitor kids on antidepressants. Black box warnings are the strongest warnings that can be placed on a drug, but do not ban its use in children and adolescents. The FDA's UK counterpart, the MHRA, went further by contraindicating the use of all antidepressants in kids save Prozac.
Backlash Against Treating Kids with Antidepressants and Other Meds
A lot of the credit for lighting a fire under the FDA goes to the much-maligned antipsychiatry movement (for want of a better term). It's most prominent spokesperson is Peter Breggin MD, author of "Toxic Psychiatry" and numerous other books. The home page of his website seems designed to frighten parents, with tabloid style headlines such as, "New Review of SSRI Induced Violence, Suicide, and Abnormal Behavior." The article in question, however, is a closely reasoned document with convincing citations.
For years, Dr Breggin and others have been lone voices pointing out how drug companies have essentially bought off the psychiatric establishment, including leading academic researchers who have been paid to lend credibility to very questionable industry research. This research - most of it done on adults - has been used to justify coercing unsuspecting kids into submission (Dr Breggin's terminology).
As a result of the highly publicized FDA investigation into antidepressants in children in 2004, a wider public learned for the first time how drug companies routinely suppress negative findings and manipulate statistics to suit their own purposes. Academic researchers linked to these studies came across looking like industry publicists, while the FDA came under heavy fire for apparently sleeping on the job all these years.
In many ways, Dr Breggin has been vindicated. But Dr Breggin is also on record as saying there is no biological basis to ADHD, depression, and schizophrenia. In 2000, he testified to a House subcommittee that:
"By diagnosing the child with ADHD, blame for the conflict is placed on the child. Instead of examining the context of the child's life - why the child is restless or disobedient in the classroom or home - the problem is attributed to the child's faulty brain. Both the classroom and the family are exempt from criticism or from the need to improve, and instead the child is made the source of the problem.
"The medicating of the child then becomes a coercive response to conflict in which the weakest member of the conflict, the child, is drugged into a more compliant or submissive state. The production of drug-induced obsessive-compulsive disorder in the child especially fits the needs for compliance in regard to otherwise boring or distressing schoolwork."
Psychiatry could certainly benefit by following some of Dr Breggin's counsel, but ADHD researcher, Russell Barkley PhD of the University of Massachusetts has this to say: "His assessment of ADHD children ... ignores more than 30 years of longitudinal research on ADHD."
The Case for Treating Kids with Antidepressants
Yes, our kids need humane psychiatry, but they may also require medications, even if the drug companies thus far have failed to make a case for them. In a study published in the Oct 2003 Archives of General Psychiatry, researchers from Columbia University reviewed 588 case files of kids aged 10 to 19 and found that a one percent increase in antidepressant use was associated with a decrease of 0.23 suicides per 100,000 adolescents per year.
This is not the same as saying a direct link has been found, but the study does advance a strong case that your depressed child may be at far greater risk of suicide by not taking antidepressants than by taking them.
In 2007, diagnosing and treating bipolar in kids came under media attack following the tragic death of Rebecca Riley, aged 4, on what was apparently an overdose of an antipsychotic and a heart med. The New York Times and Boston Globe and other publications treated the issue as a matter of bad parenting and bad medicine.Their point was that we are over-eager to attach psychiatric labels to ordinary behavior in kids and then over-react with meds not FDA-approved for kids. A 60 Minutes piece on the topic came across as a Church of Scientology recruitment video.
The media uniformly ignored four vital facts, namely:
- You don't have to be voting age to have bipolar or any psychiartic illness.
- The behaviors bipolar kids display (such as trying to jump out of moving vehicles) are not ordinary child behavior.
- The compassionate response is to seek treatment for these kids, even if that involves medications, rather than ignore their suffering.
- The FDA regulates the sale of medicine, not the practice of medicine. Off-label use is often best practice in many situations.
Caution for Parents
Still, when it comes to antidepressants and mood stabilizers and antipsychotics, the best that psychiatrists can do for now is cite their own clinical experiences with these meds. Parents are entitled to take a skeptical approach and hold the doctor or psychiatrist to account for any medication he or she may recommend. This includes asking if the drug has worked well for other kids treated in his or her practice, as well as evidence of any research (such as a pilot study) to show at least some evidence of efficacy and safety.
Parents should also be fully satisfied what the drug is being used for - what symptoms or side effects it is supposed to manage, how it works with other drugs in the cocktail, and how long the child is expected to remain on the drug. Since side effects can have a more pronounced effect on kids than adults, parents should not leave the office until the physician has recited the full litany of things that can go wrong and how they apply to your child's individual needs.
Since these side effects may affect your child's development more than the underlying illness, the parent needs to establish from the beginning that there is no such thing as a fair trade-off between improving mood symptoms and worsening health and deteriorating quality of life.
The top side effect priority is the agitation and emotional lability that may occur from taking antidepressants (plus mania and hypomania in kids with bipolar disorder). As mentioned earlier, these may be transient features, but new product warnings on these drugs urge close monitoring by both physicians and parents. The warnings also advise these effects could be precursors to suicidal behavior.
Some of the drugs also cause extreme weight gain, especially Zyprexa and Depakote. In addition, Zyprexa and other antipsychotics carry warnings of increased risk for diabetes. In 2003, a joint panel of the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity issued a consensus statement recommending that doctors screen and monitor their patients on atypical antipsychotics for: 1) personal and family history of obesity diabetes, high cholesterol, hypertension, or cardiovascular disease; 2) weight and height; 3) waist circumference; 4) blood pressure; 5) fasting blood glucose; 6) fasting blood cholesterol.
Psychiatric meds may also result in sedation and cognitive dulling. At a conference on alternative approaches to meds, a mother of a bipolar child reported that after her son was put on meds, he became a vegetable, sleeping all the time and not engaging in the outdoor activities he once loved. Whereas the boy had once tested four to six years above grade level, he was now testing two years below. As the mother explained: "They felt they had solved my problem. I felt I lost my child."
But parents also swear by the positive benefits. Said Sheila McDonald, vice president of the Child and Adolescent Bipolar Foundation, testifying at an FDA public hearing in September 2004: “Just two days ago there was a posting on our website, and I quote a woman about her 10-year-old son where she says, 'I thank God for each and every pill, each and every day that I don't have to listen to my son, my little boy say that he wishes he was dead.'”
Any decision involving your child's treatment should be the result of an equal partnership between you and the child's physician. Hopefully this means a psychiatrist and ideally a psychiatrist specializing in treating child and adolescents. If a primary care physician is your only option, make sure he or she has at least a working competence in treating kids with psychiatric meds. One of the main lessons from the FDA public hearings in 2004 came from bereaved parents who testified that primary care physicians were a contributing factor to what happened to their children while on antidepressants. These doctors uniformly failed to advise parents on any possible adverse effects and did not provide adequate follow-up care.
Accordingly - and this cannot be emphasized enough - close monitoring of your child's condition is paramount, whether for weight gain or potentially harmful behavior or any other effects. This applies to both parents and physicians. Keep an eagle eye on your kids, and do not just attribute any strange behavior to their acting like a teen. Regular follow up visits need to be par for the course, and your child's physician should be a phone call away.
Dr Breggin and others are undoubtedly right in saying that we are dispensing meds to too many kids with no concern for their real needs or for the permanent damage these meds may causing. But they are wrong to leave the impression that mental illness is not real and that there is not a time and place for these meds.
But who are the real sinners? As the FDA hearings most unequivocally brought to light, psychiatry was complicit with the pharmaceutical industry in overselling the benefits of at least one type of psychiatric medication while downplaying the harmful effects. For years, the FDA allowed this to happen. Heaven help that we need the likes of Peter Breggin to keep these guys honest. But the reality is we do.
In the meantime, do hold out hope for your child. Thoughtful meds treatment in the hands of a skilled clinician - often as part of a program involving talking therapy and other interventions - can work wonders. But that clinician is only effective as the partnership you establish. Be advised: You have your work cut out for you.
Updated Feb 15, 2008
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