Suicides Rise As Antidepressant Use Falls?
This is certain to cause a ruckus. Two years after Health Canada warned about prescribing antidepressants to children, a new study reports that the number of children and teens who died by suicide increased 25 per cent after years of steady decline, The Vancouver Sun writes. At the same time, the increased suicide rate coincided with a 10 percent drop in the rate of visits to docs for treating depression in children.
The researchers tracked health records of more than 265,000 Manitoba children per year between 1995 and March 2006. Health Canada warned in 2004 that antidepressants may be associated with an increased risk of suicide-related events in patients under 18. They found the warning was followed by a 14 percent drop in antidepressant use among children and teens, fewer visits to docs for depression, and - among 8 to 17-year-olds - increased suicide rates. And more than 90 percent of those who killed themselves weren’t taking antidepressants when they died. The suicide rate was also relatively small, from 0.04 for every 1,000 children and teens before the warning, to 0.15 per 1,000 after.
The study, which appears in the Canadian Medical Association Journal, is the first to chronicle “such a wide range of unintended health consequences” from a major drug warning, the authors write. Laurence Katz, a child and adolescent psychiatrist in Winnipeg and the lead author, tells the Sun the increased risk of suicide could be a “random fluctuation.” But “we can’t say the warning, or the change in antidepressant use or the physician office visits caused changes in suicide rates,” says Katz.
Katz worries the widely publicized warnings have led to more cases of untreated depression, and an impact “beyond what was intended.” The drop in doctor visits for depression suggests that some vulnerable children are getting no treatment, including psychotherapy, at all. He says his hunch is that families were afraid to go to the doctor for fear their child would be put on medication. “Understandably, parents who kept bringing their children, their teenagers in for troubles with depression were already struggling, and fearful (and) often appropriately cautious about whether their child or teenager should be put on a medication,” he tells the paper.
This is likely to renew a heated debate that erupted last September…
…after the American Journal of Psychiatry published a study blaming a 14 percent rise in teenage suicides - from 2003 to 2004 - on the widespread publicity given links between antidepressants and suicide. (Here is the abstract). The study also predicted further suicides if scrips continue to decline. Although the Black Box warnings didn’t appear on product labeling until early 2005, the conclusion prompted federal officials to say the warnings may be reviewed, depending upon future suicide data.
The AJP study drew criticism because the conclusion was reached after the warnings were circulating only a year. In a letter to the American Journal of Psychiatry, David Shaffer, who created Columbia University’s Teen Screen program, and a colleague, Mark Olfson, wrote that it is “risky to draw conclusions from limited ecologic analyses of isolated year-to-year fluctuations in antidepressant prescriptions and suicide.” So perhaps the CMAJ study will be subject to the same skepticism, given that the researchers examined data through early 2006, which means the warnings were circulating for about a year or so in Canada.
The CMAJ study looked at the number of children and teens who received newer antidepressants, whether they went to see their doctors as often, whether they were hospitalized as often, whether they attempted suicide as often that led to them being hospitalized, and how many died by suicide, the Sun writes. The rate of attempted suicide didn’t change among children and adolescents.
Between 1995 and 2005, there were 99 completed suicides among children and adolescents, and 136 among young adults. The percentage of suicides who were Aboriginal remained relatively unchanged (74 per cent to 85 per cent). The most common method of suicide was hanging. Among children and teens who completed suicide, the average age was between 14 and 15. The youngest was eight. For young adults, there was no significant change in the rate of completed suicide
Dan
Clearly, this issue needs to be studied further that should include many more variables for more answers, since the results are conflicting with SSRI intake and suicide risk of some studies that have been conducted.
Jack2
Let me get in on the ground floor on this one.
Correlation dose not equal causation - whether we see an increase or a decrease in suicide rates with an increase or decrease in antidepresant use. It’s entirely possible (I would say even likely) that other factors influence the suicide rate more - cultural phenomena, global politics, the economy etc.
As a believer in scientific medicine, I would encourage anyone who feels the need for treatment for a mental health problem to talk it over with their doctor to decide on the best option for him/her (which may or may not include drug treatment), and ignore what everyone else says.
truthman30
It would be interesting to find the money trail on this one..
It seems to me that there are always two conflicting studies relating to this issue..
An independent one usually comes out saying the suicide rate has not gone up and then a pharma funded one saying it has ..
I know which one i would trust…
Time to find the money trail?..
truthman30
http://www.canada.com/vancouversun/news/story.html?id=dff6cd63-5780-48bc-b086-33f8936bf429&k=44661
Same article in the vancouver sun..
Interesting information at the end of the article..
“Muhammad Mamdani, director of the applied health research centre at the Li Ka Shing Knowledge Institute at Toronto’s St. Michael’s Hospital, says more balanced health advisories are needed.
“I’m supportive of due diligence and a healthy dose of skepticism when it comes to drug safety,” says Mamdani, author of a related commentary in Tuesday’s journal. But he worries society has become hypersensitive - to the point “we deny ourselves beneficial therapies.”
Mamdani was employed by Pfizer Inc., makers of Zoloft, from January 2006 to April 2007, after which he was a paid consultant to Pfizer until last October.
“With these therapies, from what I’ve seen in terms of the data, the risks do not outweigh the benefits”
How many vested interests are pushing for the black boxes to be removed?..
And are these interests for the good of depressed children?
Or better for pharmas depressed bank balances?..
truthman30
http://www.mts.net/~wolven/madrg/katz.htm
Some info on Laurence Katz , Lead author of this study..
Steve
truthman30: you raise interesting points. Yep, there’s the appearance of a conflict of interest here — but everyone has a conflict of interest. You think the folks at NIH who were behind the CATIE study didn’t have a motive in mind? And the folks pushing for less meds for kids - I suppose you think they’re not in bed with some other interest?
The drug companies are just one of the conflicts ever present in medicine - and there’s not much that can be done about it.
truthman30
The folks pushing to keep the black box warnings are ordinary people, concerned citizens, parents etc … (no agenda apart from saving lives)
The folks pushing to remove the black box warnings are usually psychiatrists with drug company affiliations .. (thats a fact)
Child/adolescent psychiatrists seem particularly keen to remove the black box warnings because they know that child psychiatry and the profession of psychiatry itself is not based on “therapy” but based on drugs and dispensing prescriptions..
So, you could effectively say that it us “child psychiatry” which has suffered since the black box warnings were removed..
And the profession itself has declined..
The study proves no nothing..
It is a random study which concludes that suicides rose in a certain area of Canada within a certain demographic ..
Suicides may have increased anyway, with or without the black box warnings..
Hypothetically, if there were no black box warnings and suicide rates rose, would this study be publicized? And if it was you could assume that psychiatry would be calling it a suicide epidemic and they would call more more drug intevention and more screenings..
Data and studies and be used in a subjective way to suit any agenda..
this study will be widely publicized and it will be backed by pharma funded psychiatrists and used as a propaganda campaign to further the pharmaceutical agenda..
Which is to get more kids on psychiatric drugs..
I’ve seen this type of thing countless times before..
truthman30
Laurence Katz, a child and adolescent psychiatrist in Winnipeg and the lead author, tells the Sun the increased risk of suicide could be a “random fluctuation.” But “we can’t say the warning, or the change in antidepressant use or the physician office visits caused changes in suicide rates,” says Katz.
… But i bet that won’t stop the militant psychiatrists with industry associations pouncing on this study …
HorusCat
The SSRIs are off-patent. No drug company stands to benefit from their use, except the generic makers.
truthman30
HorusCat
The SSRIs are off-patent. No drug company stands to benefit from their use, except the generic makers.
Pharma still reaps massive profits from SSRI’s HC..
And as I pointed out in my last comment..
It is the psychiatric industry which stands to gain most from a removal of the black box warnings..
NO DRUGS TO PRESCRIBE = NO PSYCHIATRY
Jack2
I thought the same thing, HC, when I saw the dates in TM30’s own post (2006-2007).
Nathan
This is only marginally related, but I thought I would let Truthman, Lisa Van S, Matthew, and pg know that there is some really exciting non-SSRI antidepressants coming through the pipeline. I hope you guys will rationally consider the effectiveness of these new medications and not simply write them off. I’m at a conference in New Orleans covering a lot of recent medicinal chemistry research. Here’s some new targets for depression coming through the pipeline:
Glucocordicoid receptor (GR) antagonist: It’s been reported that RU486 has activity against depression due to its GR antagonism. It’s now in phase III trials for women of non-childbearing age as a treatment for depression. (called “Corlux”, not RU486). Other non-abortive versions are approaching phase I trials.
TREK1 inhibitors: This is a potassium channel believed that has shown exciting activity in animal models of depression.
Seratonin receptor antagonist — 5HT1B. This is an alternative (non SSRI) way to increase seratonin levels in the synaptic cleft. In phase II clinical trials is has a much more rapid onset (1 week) than Fluoxitine and much fewer sexual side effects.
NMDA channel blockers: new drugs are targeting this channel, but an old drug called Katamine shows essentially the same responce after 1 week as SSRI treatment does after 8 weeks. (much more rapid onset of activity)
Lots of exciting stuff. Hopefully SSRIs will disappear from chemical treatment of depression within the next 10 years, being replaced by more effective and safer drug treatments.
Lisa Van S
This Study isnt worth the paper its written on!! I have reviewed his CV,.. he has not conducted placebo controlled clinical trials of antidepressants in children and adolescents. This is one Physician’s perception of a patient file!!!
As one of the FDA advisory committee members who voted for the Black Box Warnings(Dr. Thomas Newman, an epidemiologist and pediatrician from the University of San Francisco)stated:
We have I think very strong evidence of harm and really not very good evidence of efficacy… You bring people in, you start a medication, and you see an improvement, you are very likely to believe that the drug is effective, and the reason why we do randomized, double-blind trials is because personal experience, however compelling, is not a reliable way to tell whether drugs work.
Dr. Newman later articulated his point when he wrote:
It is easy to see why the personal experience of clinicians and patients would lead them to believe the drug to be effective, since they would have no way of knowin that more than 85 percent of the benefit they observed would alsoo have occurred with placebo.
Lisa Van S
Nathan,
The study of RU486 in the treatment of depression is not knew to me, and I have been aware of this for a few years now. This is not exciting news, I forsee damage to the maturing adolescent female,.. who would ultimately be prescribed this drug at an alarming rate.
And you dont want me to get started on adolescents abusing this drug!!!!!
Anita
Industry and psychiatry both stand to gain with the removal of black box warnings.
As stated previously, most SSRI’s are no longer on patent. Industry is trying to make the case now that the blackbox warnings were harmful on SSRI’s so that they can hender and to try and evade the warnings on the new drugs of choice, anti-psychotic.
Jack2
Or, the BBW gives the industry the opportunity to develop a safer new med that doesn’t carry the same BBW, which will differentiate it from existing products.
truthman30
Nathan says
“This is only marginally related, but I thought I would let Truthman, Lisa Van S, Matthew, and pg know that there is some really exciting non-SSRI antidepressants coming through the pipeline. I hope you guys will rationally consider the effectiveness of these new medications and not simply write them off”
“Lots of exciting stuff. Hopefully SSRIs will disappear from chemical treatment of depression within the next 10 years, being replaced by more effective and safer drug treatments” ..
Nathan ..
While I can see that you are genuinely trying to come up with new treatments for depression and I honestly think you believe you are doing depressed people a service, you must consider this..
You claim these new compounds and chemicals will be more effective and safer than the SSRI’s ..
And granted , I believe your intention..
But..
We heard exactly the same hype about the SSRI’s being safer than Tricylics and we know now that is far from being the case..
The SSRI drugs are one of the most complained about drugs of our times..
They have worse publicity than the Tricylics..
They are hugely controversial and hundreds of thousands of people claim terrible damage , injury and death from these drugs.. (not to mention the behavior of pharma and its treatment of patients has been deplorable throughout)
While I would like to believe that pharma is searching for safer and alternative drugs to the SSRI class..
I honestly dont believe it..
(that’s not to say i don’t believe your passion and intention Nathan, i do. I just don’t trust the industry you work for)
I don’t believe the risk:benefit ratio is a priority for pharma.
And I don’t think that pharma genuinely cares what the effects of the “real world study” will have on consumers of these drugs..
As long as they can suppress the side effects profile for long enough to make their profits , thats all that matters..
It will take a long time for pharma to be trusted by the public, it is scandal after scandal..
Until that gulf of mistrust is built with a bridge of ethics and morality , the public will continue to be cynical of the pharmaceautical agenda..
That is not the publics fault..
It is pharma who has failed and not the public ..
And it’s up to pharma to repair its image..
On the subject of chemical treatments for depression… I understand that as a scientist you look at people as just biological entities and their brains as complex chemical machines which regulate their moods and thoughts..
And you think that by tinkering with these chemicals and neurons , someday you will come up with the holy grail of neuroscience.. the perfect drug which will cure the human condition.. goodbye melancholy and worry.. Hello Brave new world..
But , you fail to see that we are much more than plasma , blood and neurons …
Even if you did create your “perfect” , “side effect free” , ’soma-type’ medication and everyone in the world was on it.. would you feel successful in the knowledge that you have disconnected the human race from their own thoughts and emotions? …
If the same amount of money which is currently spent on searching for the “chemical cure” was spent on proper care for depressed people, it would revolutionize the understanding of this ‘condition’
Depressed people need compassion, understanding and above all vaidation.
To tell a depressed person, that its not ok to be depressed, that its somehow their fault or that they have a faulty brain is completely invalidating, unjustified and wrong…
You will never find the holy grail Nathan..
And even if you did..
It would still be missing the point..
The world is imperfect , people are imperfect and making a drug which makes them feel that everything is perfect is a creating a grand illusion…
Jack2
I think the belief that depression stems from neurotransmitter imbalances validates depression stronger than anything else, and it validates depressed people. In a non-pharma, non-chemical view of depression, depression could become synonomous with weakness. Neurotransmitters are precisely what reduces the stigma of depression.
And while you could take all the money currently spent on research, and spend it on therapy and help a lot of people now, it would also mean that therapy tomorrow would not be much better than therapy today. Drugs, more than any other development in healthcare or biomedical science, provide an innovation that promises better healthcare in the future than today.
M Helm, MD
I’m compelled to weigh in on this too…
TADS (Treatment of Adolescent Depression Study) NIH funded. Combination of CBT (Cognitive Behavioral Therapy/counseling) and fluoxetine appears to be the fastest to yeild improvement and safest from a suicide prevention perspective.
TORDIA (Treatment of Resistant Depression in Adolescents) also NIH funded, and very recent. Addition of CBT and medication switch for patients failing fluoxetine alone resulted in improvment. Venlafaxine ER appears to have more CV risks than either parocetine or citalopram as an alternative treatment. Just swithcing the meds around without adding CBT - not helpful. This report is new in JAMA.
The dramatic percent increases in suicide rates are typically a phenomenon of small changes in low rates if the rate is 3 per 10,000 and increases to 4 per 10,000, this is a 33% increase. Alarming, and in the case of suicide tragic! But when you look at the actual underlying rates they are not that different.
In the US adolescent suicide rates increased ~22% from the rates increased from 2003 to 2004 The real causes for this growth were changes in the rates from 56 to 94 per 100,000 10-14 yo females, from 265 to 365 per 100,000 15 to 19 yo females, and from 1,222 to 1,345 per 100,000 for 15 to 19 yo males.
There was an alarmist report in 2007 by Gibbons in Am. J. Psychiatry which actually fails to show a drop in prescribing in the time frame he claims has an increase in suicide rates. Despite the lack of a drop in the relevant time period, he claimed that decreased prescribing of SSRIs led to increased suicide.
Another perpective is Olfson in Arch. Gen. Psych. this year. He reports a decrease in the use of paroxetine after the specific warnings, but relative stable use afterward. Olfson’s dataset is far more reliable than Gibbons (who use IMS data).
It is true that most of the SSRI agents are generic, and certainly, fluoxetine is the only FDA approved SSRI/SNRI agent. Citalopram has some supporting data, at best paroxetines data in adolescents is mixed. Paroxetine might be a safe med if used with CBT, but then again, CBT appears to be protective against “suicidality.”
Horus Cat, you may be appalled to learn that although there are not data to suggest that the few brand name medications in the category are safe or effective in adolescents. They are much more widely used in this population than are the agents which are well-studied and supported. The Olfson article outlines this, and my group is presenting a poster with data on this at the International Society for Pharmaceutical Outcomes Research next month. Basically in children and adolescents, the remaining branded meds - Lexapro, Cymbalta, Effexor XR and Wellbutrin XL are about 45% of the “market.”
Child and Adolescent Psychiatry is not always all about prescribing a med. The problems in this area are that Adult/General psychiatry is typically about the medicine - whether or not that is what it should be, that is where we seem to find ourselves. There are not nearly enough Child and Adolescent Psychiatrists to go around. When a general psychiatrist treats a child in the same way as an adult this leads to problems, and worse outcomes than we should tolerate.
Based on what I’ve read, and on my studies, the rate of medication prescribing is not nearly so important as the connection to support services for children and families and most of all a capable psychologist or other therapist.
The study we still lack is the one that correlates suicide rates and treatment of all kinds. The true cause of the increased rates of suicides in our children may be the trend towards reliance on medication as the only treatment needed. It would seem that Dr. Katz and company could mine the same data to find the answer. Who will fund that?
Suicide among Canadian children seem different than in the US. Strangulation is by far the method most used up North. I will not speculate on the possibility that some of these may be accidental suicides related to a bizarre dangerous and ineffective attempt to “get high.” This is a phenomenon that is reported elsewhere.
truthman30
Jack2
I think the belief that depression stems from neurotransmitter imbalances validates depression stronger than anything else, and it validates depressed people. In a non-pharma, non-chemical view of depression, depression could become synonomous with weakness. Neurotransmitters are precisely what reduces the stigma of depression.
The Audacity of your ignorance is astounding ..
As a former sufferer of depression, a former user of SSRI drugs , I have an insight into the reality of what us going on which you do not Jack2..
How dare you condescend and patronize people who suffer from depression with your pharma propaganda.. You should be ashamed of yourself ..
DEPRESSION IS A SYMPTOM OF THE CAUSE
TREATING A SYmPTOM IS NOT TREATING THE ROOT OF THE PROBLEM
THE ROOT PROBLEMS ARE USUALLY EMOTIONAL IN NATURE
HAVE ANY OF YOU PHARMA FOLKS GOT A BRAIN BETWEEN YOU?
HAVE YOU NO INSIGHT WHATSOEVER????
Lisa Van S
Dr. Helm,
The TADS Study was of great debate in 2004. On Sept 23, 2004,.. before Congress,.. and under oathe!,.. Dr. Andrew Moseholder, a Pediatric Psychiatrist; FDA Medical reviewer testified that the TADS Study did not meet FDA standards for approval for treating pediatric depression
M Helm, MD
Lisa Van S.
Maybe he said that because there was not a placebo comparison arm? That seems to be the standard. Not is this treatment better than other (medication or not) treatments, but is it better than the idea of a medication/no real treatment? This is a stupid standard, but that’s what the FDA requires. (Imagine Tevye from “Fiddler on the Roof” singing “Tradition” in the background.)
That was kind of a moot statement/silly question at the time anyway. In Jan 2003, Lilly secured FDA approval for fluoxetine in children and adolescents for depression and OCD.
The most recently published TADS update has more useful long-term follow-up information and specific information and tables on “suicidality.”
Ironically, the only way to become an FDA advisor is to do a lot of work, be widely published and recognized as “an authority.” That usually involves having received a lot of PhRMA funding. That rules out anyone who, like me, lives under stringent Conflict of Interest disclosures. This is not to say that PhRMA funding is universally corrupting, but truly you can make more $ as a friend to the industry than as a neutral party (or as a Sidney Wolfe - though I think he does ok for himself too).
Lisa Van S
Dr. H
May I respectfully ask you to review the whole TADS Study, and not just its summary. There were six suicide attempts in the fluoxetine group, verses 1 suicide attempt in placebo, Efficacy also came into question. It would have been beneficial to all Physians had they taken the time to attend the FDA & Congressional hearings on the Safety of Antidepressants in the pediatric population. Im just a Mom,.. and I did. Its a shame that Physicians arent as concerned as parents when it comes to the safety of medications for children!!
HorusCat
Dr. Helm,
Horus Cat, you may be appalled to learn that although there are not data to suggest that the few brand name medications in the category are safe or effective in adolescents…
Actually, Dr. Helm, I have never argued that anti-depressants should be used to treat depressed children. In fact, quite the opposite. I believe that children are less inclined to be depressed than adults, so that when a child appears to be depressed, it is cause for not just concern, but some deep digging into what is going on in that child’s life. I have stated before that this warrants a hard look from the standpoint of a provider–and it may be uncomfortable because it means looking at the caregivers’ behavior, as well.
I have said multiple times that we did not market Zoloft for childhood depression. We had safety data, but no efficacy data. And the indication we did have, OCD, I believe was best treated with a combination of medication and CBT or a variant thereof.
I have also noted that I think the best model for care is a child psychiatrist in combination with some sort of counseling and other support services–as a requirement. Ironically, I noted, the community mental health centers may offer superior care because they require that a child or adolescent receive counseling, group therapy and other support services; whereas, a child whose parent has private insurance may indeed go to a psychiatrist (who may or may not specialize in children) and never receive any other support services.
So, Dr. Helm, it would appear that you made an erroneous assumption about where I stand on the use of medication in children.
HorusCat
truthman,
I think you were a little harsh with Jack. You are very solid in your belief that depression has all emotional causes…AND Jack, Nathan and I are equally solid that THIS IS TRUE–and gets expressed in the brain chemically.
All of our experiences, memories, beliefs, thoughts and emotions are chemically and electrically propagated. The brain is plastic, in a sense, and can be molded by our experience. It seems to me that in depression, the signal experience or experiences that we have that trigger the depression cause a permanent change in the way our brains function. Over time, the repeated experiencing of the feelings associated with depression: despair, sadness, grief, emptiness, loneliness, suffering, physical pain, thoughts of death…all of that becomes molded into our brain. That becomes our “default” setting.
I think all that Jack2 is saying is that telling a depressed person that their brain chemistry has been set in this default position is less stigmatizing than telling them it is … what? Just in their head? That does seem to me to be telling them that if they were just strong enough or smart enough they could will their way out of their feelings. That is what my dad used to tell me–”it’s all in your head. Quit thinking about it. Do something else.” In essence, he was telling me that I was somehow defective for feeling so profoundly…bad.
Like I said before, this is where you and I disagree, and where I agree with Jack2. Sometimes, in order to get out of the default setting that our brain has been molded into, we need some chemical tweaking, to sort of jump the train off the old track and into a new track. Then comes the really hard work that I have noted before–you have to start re-molding your synapses into healthier patterns, using whatever means works for you (prayer, meditation, talking with supportive, caring people, good nutrition, etc.). For some of us, like me, depression was a way of life for decades. There is good reason for my brain to be solidified into that pattern–it had lots of practice. Zoloft didn’t “cure” me, nor does it take away all my feelings–it just gave me enough of a boost so that I had the energy to do what I needed to do to get better.
You don’t see things this way, truthman, but surely you can acknowledge that with all that we don’t know about the brain, there is room for reasonable people to have different theories.
M Helm, MD
Sorry if my comments weren’t as clear as they could have been.
Lisa Van S. I agree that the entire TADS experience argues against fluoxetine alone in children because their is an increase in “suicidality.” I read the whole study as saying that CBT provides as much benefit as any other approach, but takes longer to provide relief of symptoms. CBT carries no undisclosed risks. The combination gives a benefit of more rapid relief of symptoms. This does come with a risk, and frequent monitoring of “suicidality” should always be a part of the treatment. I’m sure that you also noted how differently the last long-term follow-up read versus the first report especially in regard to CBT alone.
I did mistate the abscence of a placebo arm - this was a part of the initial 12 weeks of the study. The design had more to do with comparing between the three treatment arms - and still wouldn’t likely have been an acceptable study for approval despite the pretty rigorous design. As I recall it, the placebo arm was effectively discontinued after no more than 12 weeks for any patient, and everyone continued on some active treatment. Correct me if I’m mistaken on that.
HorusCat, I actually wasn’t trying to be ironic/snarky. Your comment about the SSRIs being generic and therefore, of no benefit to branded manufacturers should have been correct since the only product with safety/efficacy or approval in children are - in fact - the older generic agents. However, that is not borne out in the marketplace. This may be because there are samples available for the newer agents, but not the older agents. As a physician, I can say that, sometimes, physicians are lazier about these issues than we should be. I know that in your work, you know physicians from whom you would never seek treatment, but who frankly can be good for a bump in NRXs or share.
It is also fairly appalling that about one in 20 children/adolescents are still being treated with paroxetine. I know there is some supportive data for anxiety in children, but why ever go there? And why ever use medicine alone. CBT/counseling/behavior modification are almost always first line approaches for emotional/behavioral issues in children, and virtually always useful as adjuncts (maybe not in Tourettes). You are right, sometimes the psychopathology is in the parent/caregiver not the child.
I agree with your other comments to me, and I think there is a lot of evidence supporting your position on depression and anxiety in children… I’ve tried to agree with you these point on a prior comment weeks ago, but for some reason it didn’t post.
I suspect probably that all here would agree that relying on medication treatment alone for a child with significant mental health issues is too simplistic. (Even if Nathan is still hopefully engaged in the never-ending search for the panacea, I don’t think he said biochemistry was the only way.) However, by examining ONLY the possibility of a link between rates of SSRI/SNRI use and suicide rates, this study from Canada leaves us a little cold, eh?
truthman30
You don’t see things this way, truthman, but surely you can acknowledge that with all that we don’t know about the brain, there is room for reasonable people to have different theories.
I do see your point as i do see Nathan and Jacks ..
It is just so frustrating trying to voce my view against the biological depression argument ..
I understand that there may be changes in the chemical make up of the brain after the onset of a depressive episode, and I also understand that SSRI’s were designed to boost the brain chemically, therefore in theory to alleviate the “symptoms” of the condition..
But to say that it is more validating to tell a depressed person that it is their “faulty” brian chemistry which is making them depressed is untrue …
When in fact, it is there depression which is affecting their brain ..
And because the causes of depression can be so deeply rooted in the mind , emotions and psyche of an individual , it is patronizing to tell someone its all down to their brain chemistry..
Depression can have many triggers..
From grief, sadness, loss, low self esteem, reaction to trauma, disappointment etc..
So it would be more validating and truthful to tell the individual they are depressed because of something they have experienced because of their perception of something which has happened to them..
This is most often the case..
And in the majority of SSRI cases, people are not taught how to deal with the original trigger, so it is like putting a chemical band aid over a septic emotional wound… The wound festers and gets worse , yet the SSRI masks the symptom (sadness-depression) , so when the person comes off the SSRI, not only are they hit with withdrawal and a shock to their brain and body they are also hit with the original psychological and emotional issues which they did not deal with..
That’s why you have so many people who crack up when they come off these drugs, because the orginal trigger has not been addressed..
It is similar to how junkies and alcoholics react when they come off their chemical crutches.. They might be able to give up the crutch but then they have to deal with way they were “self medicating” in the first place.. They have to face their demons eventually…
Lisa Van S
Dr. H,
Canadian Report: Again, this study isnt worth the paper its written on, a Physician’s perception of a patient file is evidence of nothing, as we see more tragedy in children and adolescents who are abruptly withdrawn from a medication. Physicians, patients and family are poorly educated on how to safely taper, Ive been there,..I know.
As far as the TADS Study: Id like to see the raw data, because,..believe me,.. that paints a much different picture than whats submitted by Industry in patient summmaries,.. have personally seen how things are drastically changed
M Helm, MD
Lisa Van S.
Agreed that the Canadian paper does not contribute to knowledge.
Also agreed that MDs typically (though not always) know how to write a prescription, but not how to advise on discontinuation. A Child and Adolescent Psychiatry colleague of mine says his (academic/referral) practice now consists mostly of removing the polypharmacy started by others (usually psychiatric hospital-based, and general psychiatry specialists), and arranging appropriate out-paitent therapy.
Just noted last PM that Archives of General Psychiatry just published another TADS follow up report on sustained responses in the three arms. Haven’t read the report yet. Maybe Ed will pick that story up too?
Finally, agreed that knowing the findings that didn’t survive the edit for publication is always revealing. I hope there’s a better chance of getting the straight skinny on the TADS data since it is NIH funded, but you never really know how that will go.
I may be too trusting still. I know that certain journals and reviewers are very conscious about the kinds of studies and conclusions they will publish for fear of affecting advertising revenues…
We are a long way from a comprehensive picture in children’s mental health, and there will always be a lot of individual variation.
HorusCat
Dr. Helm,
You wrote: As a physician, I can say that, sometimes, physicians are lazier about these issues than we should be. I know that in your work, you know physicians from whom you would never seek treatment, but who frankly can be good for a bump in NRXs or share.
Dr Helm, you are so right!!! I have often said the bad thing about being a drug rep is you develop a long list of physicians to whom you would not send your dog, let alone family or friends. The main reason for this is docs who don’t keep up and/or those who are just billing machines.
I have one psychiatrist (I don’t talk to him, because he doesn’t see reps–it would interfere with his revolving door) who sees comm mental hlth ctr patients. He sees them every 6-8 minutes!! These are the chronically mentally ill–schizophrenics for the most part. All he is doing is checking the box and billing Medicaid. Another I know ONLY prescribes Zyprexa and Clozarel. He doesn’t talk to reps (except to tell me my drug “uses big numbers for dosing” and his patients don’t like big numbers), he doesn’t go to dinner programs, he doesn’t read clinicals…I happen to believe that if he listened to a little pharma marketing, he might be inclined to try something besides Zyprexa, but who knows?
I was talking to several of my child psych residents about atypicals in kids…not SSRIs…and they said medication is the last step in a set of guidelines that emphasizes behavioral intervention, psychosocial investigation, parental and family counseling…yet it seems that medication is the first place many doctors go. My youngest complains he can’t focus in school; he gets distracted all the time; noises and lights take his attention off of his work…I am having his evaluated for ADD, but with an eye to finding behavioral modifications and study tips that will help him focus better without medication.
All of that is kind of tangential…sorry.
truthman,
You and I agree. The problem with using medication is that it is too easy to ONLY use medication, and ignore the underlying WHATEVER that is the source of the depression or anxiety. First of all, medication shouldn’t be used for most situational depressions. Grief and sorrow should be experienced and in a way, embraced. But for long-standing endogenous depression like I have, one has to dive into the pit and face the demons. Otherwise, the problem comes back. And for me, medication alone doesn’t even bandage me enough to function–I have to work on the underlying cause.
truthman, you and I are not so far apart. I think you would argue better not to use medication so that you don’t fall into the trap of relying only on the meds…I would say better to have a physician who pushes you to find the means to face the causes of your depression while also being willing to use meds if needed.
I was thinking about you as I got dressed this morning, truthman (NO! Not that way!!) I am visiting my parents with my kids (hubby not here bec of new job) and so my self-maintenance is minimal. No make-up, no jewelry (I think I am on the autistic spectrum,–jewelry bugs me, as does make-up, and really, clothing, but I can’t go naked). I buy all my “play clothes” at Target and I’m wearing $15 shoes. Left to my own devices, I prefer to accumulate as little as possible in the way of “stuff” (except for work clothes and shoes). My sister, on the other hand (and my mother) is a big accumulator (and they have the money for it). Every once in awhile, I go shopping with her, and I am in awe of her spending capabilities. Anyway, the point is that I think I am happier when I don’t buy into all that BUYING and HAVING. That is what made me think of you–thinking of how we often try to buy things to fill in that big hole inside of us. And how it doesn’t work.
truthman30
Well, I am glad that at least we have achieved some sort of honest and reasoned debate now HC ..
I have never said meds cannot be useful, they can in certain cases where all else has failed..
They should always be prescribed with attentive monitoring from physicians and they should never be prescribed long term , also physicians, GPs and Pdocs should always warn patients of the side effects and withdrawal symptoms..
Unfortunately, this is not what happens generally..
I do agree HC, that you and I are not that far apart in our views…
:)
Jack2
I apologize for offending you. It’s true that I only possess academic knowledge of depression, and it’s not even close to my academic specialty so what training I have is limited too.
I still think I would prefer to know my disease had a concrete biological origin, but I can only guess what it’s like in someone elses shoes. You never really know.
HorusCat
Hey truthman!
Alert the media! We deserve medals! ;+)
truthman30
Thanks Jack ..
And Thanks HC..
:)
Gabby
You will note that the mental “diseases” that funnel mega bucks into Big Pharma and Big Psych are exaggerated, intensified and/or fixed versions of things that “normal” or even exceptionally “healthy” people experience in life: apathy, grief, anxiety, fear, anger, antagonism, boredom, conservatism, enthusiasm, exhiliaration — even the up/down phenomenon.
“Post-traumatic stress syndrome” (whether from rape or combat) is a perfect example of the foolishness of considering a person’s problem from a “chemical viewpoint”. A moron can see that the chicken came before the egg. The same applies to losing a job and getting “depressed,” to being suspect in an accounting error and being “anxious,” to taking PCP or crack and feeling “everyone is out to get me,” to losing at love and feeling “apathetic.”
Each person enjoys being treated as a stand-alone being worthy of consideration, admiration and respect. People have an inherent sense of honor, justice, right and wrong as regards themselves and others. How do you alleviate the “depression,” “anger” or “paranoia” of years of slavery followed by segregation and second-class citizenship with chemicals? Could you administer a chemical that would make someone cheerful in their circumstances or numb to their situation?
Believers in todays “medicalized” society gaze at our communities and knowingly say that folks taking coke and crack are “self-medicating”. As if the populous have some nerve to resort to chemicals outside the circles of academia and corporate profits. As if the believers have something better to offer other than the possibility of fewer side-effects. Which is why Big Pharma and Big Psych are so very touchy about their own side effects and rely more on public relations strategies and tactics than on science to sell their own dope.
Martin Luther King, Jr., knew all the emotions from apathy to paranoia to anger to exhiliaration and successions of highs and lows. He also knew that he and all his fellow man were worthy of consideration, admiration and respect, and that the chemicals involved in this and in his whole body were worthless and of no account in comparison.
An industry engaged on chemical offerings to man’s emotional, mental and spiritual ills is bankrupt, no matter what their profits.
Dr. Hans J. Kugler, PhD
How about BACK TO BASICS?
Drugs, drugs, drugs!
Over the years - - at ACSM (Am. Coll. Sports Med.) meetings John Greist, MD (Wisconsin Univ.) and many others presented data that showed that a minimum of exercise is the best antidepressant.
John Abramson, MD (Harvard), in his book OVERDO$ED AMERICA states that depression is an exercise deficiency.
Would it make more sense to worry that kids follow a healthy exercise program?
What problem don’t we have a drug for?
TPS? IBS? - - - oops! They must be working on drugs for that: twitching penis syndrome, itchy butt syndrome!
Lisa Van S
Gabby,
Well Stated!