As published as an OpEd in the New Haven Register, December 5, 2004.

Prozac for Preteens: Antidepressants Can Help

By Dr. Patricia K. Leebens and Dr. Robert L. Trestman

For many years, we believed that children did not and could not suffer from major depression. Now, we know that this is not the case: Childhood depression is all too real.

Recent estimates from studies funded by the National Institutes of Mental Health indicate approximately 5 percent of all children and adolescents suffer with a diagnosable major depression. The illness is characterized by a depressed or irritable mood lasting more than a month, a loss of energy, decreasing concentration, sleep disruption, a sense of hopelessness and potentially thoughts of death and suicide.

Indeed, over 500,000 teenagers in our nation attempt suicide each year.

The last decade has seen a dramatic increase in the use of antidepressant medication in children and teenagers.

The Food and Drug Administration recently examined 24 research studies of nine different antidepressants involving 4,400 youth and concluded there was an increased risk of suicide in young patients taking the antidepressants, when compared to children taking a placebo. The increased risk was about 3 percent.

The panel recommended to the FDA that a "black box warning" (the FDA's highest level of warning) be placed on the package insert regarding such a risk. It also recommended that the FDA not ban the use of antidepressant medication in youth, as the studies supported improvement in the illness being treated by the medications.

As a result of these hearings and data reviews, the FDA announced a public health advisory on Oct. 15, directing manufacturers of all antidepressant medications to include a black box warning of the increased risk of suicidal thinking and behavior in children and adolescents with major depressive disorder and other psychiatric disorders taking antidepressant medications.

These discussions raise multiple issues and concerns. One issue is the need for full and accurate reporting of research studies with positive and negative findings of therapeutic benefit of medications. This can be assured by registering all clinical trials in a national data base prior to their start.

A real challenge, at another level, is the recognition and treatment of major depression. As professionals concerned with the well being of our patients, we want to ensure that a balanced message reaches our youthful patients, their parents or guardians, their teachers and the clinicians responsible for their care. Major depression is, in and of itself, associated with an increased risk of suicidal thoughts and behaviors.

As mentioned above, one of the common symptoms of depression is a loss of energy. In treating depression with medication, the return of energy routinely occurs before mood improves and a sense of hopefulness reawakens. In that period, typically during the first few weeks of treatment, there may be an increased risk of suicidal thoughts and behavior. This well-known risk is something that should lead to improved informed consent in the process of starting medication treatment of depression, and closer monitoring of patients who are begun on such medications. It should not lead to reduced use of medication for people appropriately diagnosed.

One reasonable thought is to avoid the use of medication and focus on the use of psychotherapy (talk therapy). While this is often appropriate for adults and for some children, new studies comparing talk therapy, medication, both or neither in youth with major depression found that psychotherapy alone was of little or no benefit.

While this data is far from conclusive, it does suggest that there is no simple way to replace the potential benefits of medication treatment for depression in youth.

We hope that this debate and the increased awareness of the problem of major depression in our children and teenagers will lead to improved recognition, appropriate diagnosis, and thoughtful treatment recommendations. If treatment recommendations for an individual include the use of medication, appropriate standards for timely follow-up and management need to be in place.

Depression robs individuals of energy and productivity, and sometimes robs them of their lives. With appropriate care this illness can be treated and controlled. The people who suffer from depression and those who love them can benefit substantially and often dramatically. We hope this current debate leads to an improvement in care and the development of treatment standards. The worst outcome would be reduced intervention of this very treatable illness with the inevitably increased risks of suicide in our children and youth.

Dr. Patricia K. Leebens is director of psychiatry, Connecticut Department of Children and Families, 505 Hudson St., Hartford 06106. Dr. Robert L. Trestman is professor and clinical vice chairman of the Department of Psychiatry, University of Connecticut Health Center, 263 Farmington Ave., Farmington 06030-5385.