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April 14, 2004

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Palo Alto Online

Publication Date: Wednesday, April 14, 2004

The Rx Factor The Rx Factor (April 14, 2004)

Despite new warning about antidepressants, local families and psychiatrists say drugs that combat depression in youth are safe

by Jocelyn Dong

When Palo Alto teenager Julia Brown* sleeps over at a girlfriend's house, she packs more than her pajamas -- she takes her bottle of Wellbutrin, too.

As innocent as the medication may sound -- suggesting some peace-promoting form of Motrin, perhaps -- the drug is no over-the-counter happy pill. A popular and powerful anti-depressant, Wellbutrin was prescribed to Julia after she tried to commit suicide (see sidebar) a few years ago.

She credits the drug, along with psychotherapy and another medication called Paxil, with giving her a normal teenager's life.

So it's with some frustration that Julia heard about recent controversy surrounding Wellbutrin and other antidepressant drugs that allegedly trigger suicidal thoughts in some children and adolescents.

Last year, the U.S. Food and Drug Administration (FDA) issued a warning that doctors should closely monitor their young medicated patients for suicidal tendencies. It was sparked by a similar warning from the United Kingdom Department of Health that advised a ban on certain antidepressants for youth under 18. The FDA is reviewing the research that prompted the concerns.

"It's awful that there's this huge scare," Julia said. She's never experienced any problems with the drugs and worries that kids who need medication will now be afraid to take it.

The issue of medication safety comes at a time of simmering public worries over whether overburdened parents too often -- and too blithely -- turn to prescription drugs for help with their kids' every tantrum, sulk and outburst.

At the same time, teen depression and suicide are genuine concerns in Palo Alto. Two high-school boys committed suicide in the past 18 months, leading school and community groups to mount an assault on teen stress through forums on how to handle pressure and by sponsoring no-homework nights.

It's almost a Catch-22 for parents: Are they doing too much -- or not enough?

Ironically, recent progress in identifying and treating depression among children and teens has contributed to this conundrum. Palo Alto school psychologists started seeing an increase in the number of kids taking antidepressants at school about five to eight years ago, according to Linda Lenoir, school nurse for the Palo Alto Unified School District.

But while that trend could reflect the growing pressures on kids, it could also show that health professionals have become more skilled at recognizing depression and anxiety disorders. In other words, it's not that kids are getting worse, but doctors are getting better. Over the past three years, Lenoir added, the number of depressed students seems to have stabilized.

The development of new, improved drugs has also played a role in the increase in kids on medication. Over the past 20 years, the field of antidepressants has taken a leap forward, with new drugs that are more effective and have fewer side effects, according to Dr. Alan J. Rosenthal, a child and adolescent psychiatrist at the Palo Alto Medical Foundation.

Today, about 60 percent of kids diagnosed with depression receive prescriptions, studies show.

So what's at the heart of this controversy over medication safety, and why is it cropping up now? Psychiatrists offer a variety of explanations.

First, antidepressants like Wellbutrin and Paxil haven't been completely tested on children, thus raising doubts about their efficacy and safety. Drug companies conduct trials with adults first, Rosenthal said, and studies on children come later, usually after the drug is already being widely used.

Second, even without FDA approval of most antidepressants to treat illnesses in kids, psychiatrists commonly prescribe them anyway, based on scientific data and their clinical experience with adults. It's a practice called "off-label usage," said Dr. Shashank Joshi, a child psychiatrist and pediatrician with Stanford Medical Center.

Not all health-care providers have been careful when they've prescribed antidepressants, however, Joshi said. Child and adolescent psychiatrists typically are able to spend ample time with their patients both before and after the prescription, but primary care physicians -- who frequently prescribe the drugs -- aren't typically set up to do that, he said. That lack of contact can be dangerous, especially during the first few months of treatment or after a dosage increase, when side effects usually appear.

"Most primary-care providers do a thoughtful job, but occasionally medications are being prescribed willy-nilly, without a thorough psychosocial workup," Joshi said. "We've come a long way, and still have a long way to go."

For that reason, some psychiatrists welcome the FDA advisory, despite the alarm it's causing.

"The warning is good. (Kids) will come to specialized care. Pediatricians and family doctors don't have time and are not comfortable talking about emotional issues," said Dr. Lena Osher, a child and adolescent psychiatrist with the Children's Health Council. She's received many calls from parents asking about the safety of the drugs. None of her patients' parents have taken their children off of the medication as a result.

Joshi has also fielded numerous inquiries on the issue. He tells parents what he already told them when first putting their children on the medications: Be vigilant. At the first sign of agitation or a feeling of "jumping out of one's skin," they should discontinue the drug and call their doctor immediately. Those symptoms could possibly precede suicidal thinking.

In spite of the regulatory-agency warnings, Joshi and his fellow child psychiatrists at Stanford continue to have faith in the medications.

"In general, we're not prescribing any less than we used to," he said.

One significant reason is that studies have shown the drugs' overwhelming benefits. As more antidepressants have been prescribed to adolescents over the past 14 years, youth suicide rates have declined -- about 33 percent across at least 15 countries, according to the American College of Neuropsychopharmacology.

What's more, in the controversial research that now casts doubt on antidepressants, not one child of the 1,700 studied actually killed him or herself.

Barbara Langdon* is one Palo Alto parent who believed so strongly in the power of antidepressants, she fought to get her daughter on them following the teen's emotional breakdown one Christmas. Barbara should know -- she was on Lexapro herself for years.

Initially, a pediatrician refused to prescribe the psychiatric medication. But eventually a psychiatrist did, and the change in the teen's life is like night and day, Barbara said. "It's made a world of difference."

Before, her daughter felt hopeless and struggled in school. Mother and daughter fought constantly. But recently, Barbara said, "she came home and put her arms around me and said, 'I love you, Mom.'"

She, like Julia, is concerned about the antidepressant warnings, saying they might scare kids and their parents off from something helpful.

"I don't want depressed kids walking around. We should be talking about this," Barbara said.

Julia also wants people to give antidepressants a chance. She dismisses the research that reported some kids thought more about suicide after taking the drugs. She figures it has more to do with kids being open to talking about their suicidal thoughts once they're feeling stable, and less to do with new suicidal impulses.

Besides herself, she has five friends who are also on antidepressants.

Julia's mom calls the drugs "a Godsend." They're a vast improvement over old antidepressant medications like lithium, she said, which "had huge side effects. They shortened people's lives."

She acknowledges there are health risks, however, especially since the drugs are relatively new and their long-term effects are unknown.

For that reason, Julia's psychiatrist took her off Paxil last month, leaving her just on Wellbutrin. He didn't want her exposed to chemicals if she didn't need it, she said. So far, the teen has adjusted just fine.

And that goes for her whole life right now, which is pretty much like any other teen's -- full of extracurricular activities, friends and renewed self-confidence.

Having been helped by medical professionals, and antidepressants, Julia now lends a caring ear to other friends who are struggling, and even recommended her own psychiatrist to one girl.

"It's good all around right now," she said. *Names have been changed to protect privacy


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