Youth and depression treatment
Depression is disabling a growing proportion of children, but evidence on treatment is disputed. In this week’s BMJ, two experts debate whether young people should be given antidepressants.
To deny these vulnerable groups the possibility of receiving antidepressants would be to withhold one of the few evidence based treatments available to them, argues Andrew Cotgrove, Clinical Director and Consultant in Adolescent Psychiatry at Pine Lodge Young People’s Centre in Chester.
It is the use of selective serotonin reuptake inhibitors (SSRIs) in children that has been most controversial. However, objective analysis of the studies shows a significant benefit over placebo for some SSRIs and guidelines recommend that they can be used for the treatment of depression and obsessive-compulsive disorder in young people.
Research shows that there is an increase in suicide related events, but the risk is small and can be reduced further by careful monitoring, he says. There is also some evidence that psychological treatments (cognitive behavioural therapy, interpersonal therapy, and family therapy) are effective for depression in young people, but the effects are small.
Worrying methodological errors, publication bias, and omissions of evidence in the conduct and reporting of some SSRI trials have rightly alarmed the medical profession and the public, he writes. However, careful and objective review of the evidence shows that antidepressants have a place in treating young people with depression or obsessive-compulsive disorder.
Parents and young people need to be told the risks and benefits, given advice, and be supported in choosing an evidence based treatment.
Removing antidepressants from this choice would take away one of the few potentially effective interventions for these disabling conditions, he concludes.
Continuing to use SSRIs in young people is not good value for money, dangerous, and ethically unsound, argues Sami Timimi, Consultant Child and Adolescent Psychiatrist in Lincolnshire.
None of the studies on SSRIs for childhood depression have showed significant advantage over placebo. Despite this, national guidelines have concluded that fluoxetine has a favourable balance of benefit over risk.
But the profile for fluoxetine is similar to that of all other SSRIs, says Timimi – it has little efficacy and is potentially dangerous. However, he acknowledges that the high placebo response can make it difficult for doctors faced with a distressed young person to accept that SSRIs may be ineffective.
Distorted reporting hasn’t helped this situation, he adds, and marketing spin has taken precedence over scientific accuracy. One reason for doing the studies in the first place was to justify well established prescribing patterns. It created a trend which has been difficult to reverse despite the evidence. But reverse it we must, as it is neither value for money nor clinically useful, may have resulted in a small but tragic number of avoidable suicides, and contributed to a trend of inappropriately medicalising common emotional states and experiences.
Most states of childhood distress are self limiting and do not require extensive intervention but, when intervention is necessary, psychotherapy has a well established record of effectiveness, he concludes.