Tarnow Articles

SSRI Antidepressants: What's All the Hoopla About?

In an effort to gain more information regarding the efficacy of antidepressants in treating depression in children and adolescents, the National Institute of Mental Health has spent $17 million over the past six years in clinical trials. The government-financed study has found that the antidepressant, Prozac, helps teenagers overcome depression more effectively than talk therapy alone. However, the combination of therapy and medication was superior to meds alone. This study is crucial at a time when studies financed by pharmaceutical companies are being questioned.

This study demonstrated that after 12 weeks, 71% of adolescents receiving both Prozac and cognitive therapy showed significant improvement. In comparison, 61% of those with Prozac alone and only 43% of those with cognitive therapy significantly improved. This data is comparable to drug manufacturer backed data indicating antidepressants as treatment for childhood depression.

Another extremely important bit of information came out of this study: All treatment modalities decreased suicidality. The additional information gathered as this study continues may provide valuable clues to help identify which treatments are most effective for which group of symptoms, as well as which kids are most vulnerable to the side effects.

To date, concern over possible side effects has caused the pharmaceutical companies of SSRI's such as Paxil and Effexor XR to include detailed lists of concerns that the drugs could increase agitation in children and adolescents. These concerns include an increased risk of suicide attempt, restlessness, increased irritability, and increased mood swings. In addition, there has been a longstanding concern that all antidepressants could potentially cause agitation or mood swings in a bipolar patient. With children and adolescents, there is more of a risk of undiagnosed Bipolar Disorder than in adults. This translates to more of an unpredictable response, as the Bipolar Disorder may not have manifested yet.

Another concern is that the somewhat rare SSRI side effect of akasthesia, or a feeling of restlessness, can occur. If this concern is not discussed in advance, the restless feeling can lead to agitation. The agitation can lead to worsened mood or irritability. Once educated regarding this, the restlessness could quickly be identified and the relayed to the doctor, who would stop the medication or decrease the dose.

In addition, when treating severe depression with extreme fatigue, the period of time when energy improves, but hopelessness and depressed mood remains, is a dangerous time. Any patient should be carefully monitored during this time as the increased energy is sometimes used to carry out suicide plans. These plans could have been present but not acted upon because energy initiative and motivation were too low prior to treatment. This is a risk when starting medications, as well as when a severely depressed patient is released from the hospital with improved energy and motivation.

Obviously, both therapy and medication work together to produce a smooth recovery. As energy improves, the therapist can assist in reframing the negative thought patterns. This helps to create a safer recovery process. The therapist is also involved in rebuilding the interpersonal relationships that are commonly wounded during a patient's depression. Providing an improved support system also helps create a balanced recovery.

The past decade has produced an overwhelming shift from therapy-based treatment to medication alone. This trend is present both in adults and in children. I believe many factors have led to this trend. Strong data from adult studies demonstrated SSRI's as efficacious with minimal medical side effects. Because the medication-only treatment costs less, the insurance companies limited their number of approved visits, somewhat forcing the meds over therapy treatment. The therapy treatments, which are more time intensive, often must be covered by the patient's own resources.

As more data is gathered, it appears the antidepressants will continue to play an important role in the treatment of depression for children and adolescents. However, I firmly believe the standard of care for treating children and adolescents will return to including psychotherapy as an integral role. This will cost more initially, through both additional patient time and finances. However, in the long run, I predict this will actually be more cost effective. The power of therapy, both cognitive (addressing negative thought patterns) and interpersonal (addressing relationship patterns) should not be underestimated. Family therapy is essential for all child/adolescent cases. I believe that improving thought patterns and interpersonal skills aids in the recovery from a depression and also is protective against future depression episodes.

As the risks and benefits of antidepressant use in children are further studied, we hope to have a clearer set of guidelines on which medications benefit which sets of symptoms the most. Until then, vigilant monitoring of mood changes and progress with detailed parent/patient education will be crucial. Once medication has either been initiated or increased, a follow-up visit should be arranged within the month. A course of family and/or individual therapy should become standard. A carefully taken patient and family history will also be necessary to identify patients with Bipolar Disorder. For suspected bipolar patients, mood stabilizers will now be used as first line treatment to prevent the possibility of antidepressant-induced mood problems such as "mania" or "mixed mania" states of intense mood swings. Hopefully, these changes will serve to better maintain the children and adolescent's safety as the psychiatrist and therapist assist in recovery from depression or anxiety.

SSRI's are also used to treat anxiety. Some of the recent data indicates that therapy is as efficacious with longer lasting effects for treating anxiety. Obviously, this would tremendously impact the standard of care for treating childhood anxiety. A recent study compared Zoloft to cognitive behavioral therapy, and found the patients who received "talk therapy" improved more than those treated with the drug. Other studies have shown that a combination of medication and therapy improved even more.

The frequent negative news reports and updated rounds of publicized data can be overwhelming and frustrating. Nevertheless, the studies, including the government-funded NIMH study, all demonstrate that the combined effort of medication and therapy is effective in treating depression within 12 weeks.

Untreated, the natural course of depression can last six to twelve months of more. I hope both parents and professionals utilize the evidence of the antidepressant risk factors to ensure that both children and adolescents are treated by professionals trained in child and adolescent psychiatry and mental health. In addition, the new evidence should push both parents and professionals to maintain frequent contact with close follow up during the course of treatment. The evidence should also solidify the need for therapy in treating children and adolescents.