To Give Or Not To Give Antidepressants To Young People

More and more children are being diagnosed with depression. However, whether or not children should be treated with antidepressants is hotly disputed. You can read a Head to Head - where one person writes in favor, while another writes against, in this week's issue of The British Medical Journal (BMJ).


Yes - Children should be given antidepressants


We should not deny depressed children one of the few evidence-based available treatments, says Andrew Cotgrove, Clinical Director and Consultant in Adolescent Psychiatry at Pine Lodge Young People's Centre, Chester England.


The most controversial prescribing has been that of SSRIs (selective serotonin reuptake inhibitors) for children. Nevertheless, objective analysis of studies demonstrates a substantial benefit, when compared to a placebo, for some SSRIs. Guidelines recommend their use for young people with depression and OCD (obsessive-compulsive disorder).


Previous research has indicated that the use of SSRIs raises the risk of suicide related events. However, the risk is tiny and can be lessened even further with careful monitoring, Cotgrove writes.


Although cognitive behavioral therapy, interpersonal therapy and family therapy have some effect for young depressed patients, their effects are very small.


Cotgrove explains that disturbing procedural mistakes, exclusion of evidence in the conducting and reporting of some SSRI clinical trials, have justifiably alarmed doctors and members of the public. However, when one reviews the evidence carefully and objectively, the indications are that antidepressants have a role to play in treating young people with depression and OCD.


Young patients and their parents need to be told of the benefits and risks, given advice and support when choosing an evidence-based treatment. If we removed antidepressants as one of the options we would be taking away one of the few potentially effective interventions for these disabling conditions, Cotgrove concludes.


No - Children should not be given antidepressants


Prescribing SSRIs for young people is dangerous, not ethically sound, and poor value for money, writes Sami Timimi, Consultant Child and Adolescent Psychiatrist, Lincolnshire, England.


Timimi explains that as far as childhood depression is concerned, none of the SSRI studies has shown significant benefits over a placebo. Even so, national guidelines indicate the fuoxetine has more benefits than risks for young patients.


However, fluoxetine's profile is not that different from that of other SSRIs - efficacy is small and there is a potential danger. Timimi does acknowledge that a high placebo response makes it difficult for doctors to accept that SSRIs may be ineffective when faced with a distressed young person.


Timimi adds that a combination of fuzzy reporting and marketing spin have taken precedence over scientific accuracy, which have not helped the situation.


A reason for carrying out the studies in the first place was to validate well established prescribing patterns. It led to a trend which has been hard to undo, in spite of all the evidence. This does not mean we do not reverse it - for that we must, Timimi argues. SSRIs are neither value for money, nor clinically useful, moreover a small but tragic number of deaths may have happened because of their use.


In the majority of childhood cases distress is self limiting and does not need extensive intervention. However, when intervention is needed psychotherapy has shown itself to be effective, Timimi concludes.


"Should young people be given antidepressants? Yes"

Andrew Cotgrove

BMJ 2007;335:750 (13 October), doi:10.1136/bmj.39316.399931.94

Click here to read first 150 words online


"Should young people be given antidepressants? No"

Sami Timimi

BMJ 2007;335:751 (13 October), doi:10.1136/bmj.39316.406470.94

Click here to read first 150 words online