SAN FRANCISCO, May 31 (UPI) -- The use of anti-depressants in adolescents has kicked up a psychotropic dust-storm of controversy.
In what many consider a vindication of their minority viewpoint, a team from the Stanford University School of Medicine in California has dug up evidence of potential misuse of the medicines in young patients in the years preceding the 2004 federal warning of a doubled risk -- from 2 percent to 4 percent -- of suicidal thinking and behaviors in some medicated adolescents.
Surprised at how little data existed about depression treatments in this age group, the Stanford sleuths began their own investigation.
The probe uncovered a troubling trend of physicians taking liberties with their own clinical guidelines, often bypassing psychotherapy as a component of first-line treatment. Instead, the study shows, in the years 1995 to 2002 they increasingly relied solely on the drugs that were supposed to support, not supplant, counseling.
The Stanford team, led by Dr. Randall Stafford, also found although federal regulators have deemed only one anti-depressant, Prozac, to be sufficiently studied for safety and effectiveness in minors to warrant their seal of approval for such use, doctors were prescribing a variety of other, unsanctioned mood-altering medications.
It should be pointed out some 30 percent to 40 percent of children fail to fully respond to Prozac, so other options may be needed.
Also, the "off-label" doling out of drugs is routine in the underage population so, in that respect at least, anti-depressants are not that different from many other medicines prescribed to minors without benefit of federal authorization.
However, the guidelines of the American Academy of Child and Adolescent Psychiatry call for trying talk treatments first in depressed children and, in the most severe cases, combining pharmaceuticals with psychotherapy. Part of the reason for this recommendation is to increase the odds the physician will monitor the medicines' effects and ensure patients' compliance.
But what the Stanford team found was that while office visits by depressed teens more than doubled over the seven years studied -- soaring from 1.4 million in 1995 to 3.2 million in 2002 -- the use of psychotherapy in that period sank from 83 percent of the visits to 68 percent. At the same time, reliance on drugs increased from 47 percent to 52 percent of the cases.
That may not seem like such a big change -- until you consider the dramatic increases in the diagnosis of depression in children and realize the actual number of youngsters on anti-depressants more than doubled during the period studied, the scientists said.
What's more, as the drugs took center stage, they shoved talk therapy to the back burner, they said. So much so that it was forsaken altogether in between 42 percent and 52 percent of doctor's visits by anti-depressant-using children, the Stanford team reported.
Among other issues, the cutback raises the question of adequacy in patient monitoring, which serves as a crucial safeguard -- especially during the first critical months after drug treatment begins, when suicidal behaviors and other serious side effects are most likely to appear, researchers said.
Some of the figures in the report, published in December 2005, may be dated because anti-depressant use in adolescents appears to have started to decline in the wake of the Food and Drug Administration suicidal-risk alert, issued March 22, 2004.
Nevertheless, no long-term trends have been established yet, and the basic findings still apply.
The reports add fuel to the debate over the medicating of young minds.
If some 84 percent of teens are erroneously judged in screening tests to be suicidal, as some studies suggest, if they then have to undergo a second potentially embarrassing or stressful evaluation, if any are needlessly referred for treatment, as can happen in an imperfect system, if that treatment tends to rely exclusively on drugs carrying FDA warnings of raised risk of suicidal behavior, the calls for caution begin to look like words of wisdom, critics contend.
In "setting the record straight," a Web site for a popular mental-health screening program for adolescents, called TeenScreen, emphasizes fewer than 10 percent of the teens referred for further services end up receiving psychotropic treatment. To the critics, however, even one unnecessarily medicated child is too many.
There is no foolproof way to determine in advance who will opt to opt out early. All healthcare providers can do is use their expertise and experience in estimating the odds a teen will decide to take his or her own life.
That they don't have the art down to a science is reflected in some estimates, including from studies conducted in Denmark and Sweden, that suggest as many as one in five of those who commit suicide were getting professional help at or around the time of their death.
"We're still trying to get basic information to tell us how many of those who die by suicide are in treatment currently or ever were in treatment because, depending on the answer, there will be different implications," said Richard McKeon, special expert on suicide prevention at the Substance Abuse and Mental Health Services Administration in Rockville, Md., an arm of the federal Department of Health and Human Services.
"The information we have currently, which is not as good as it could be, would suggest probably somewhere between 15 percent and 20 percent of those who die by suicide are in treatment at the time or had been in treatment sometime within the last year," he said.
Such research is scarce, so no one really knows the actual numbers, but some clues are trickling in.
A Utah study found anti-depressants in none of the 49 teens who had committed suicide, a New York survey detected the drugs in 10 percent of the 66 adolescents who died by their own hand, and most post-mortems on adults indicate nearly 20 percent are on medication when they cut their life short, according to a task force report by the American College of Neuropsychopharmacology, which concluded in favor of anti-depressant use.
"It is not possible to prevent all suicide," McKeon noted. "Patients can get good treatment but still die of suicide, just like there can be death during surgery."
And that is something every parent and patient should be fully aware of before treatment begins, the critics emphasize.
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Next: the tricky business of diagnosing depression in the young
(Editors' Note: This series on depression is based on a review of hundreds of reports and a survey of more than 200 specialists.)
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