For Children and Antidepressants, Still More Questions Than Answers by Gina Shaw Being the parent of a child or teenager with clinical depression has never been easy, and over the past few months, itís gotten a lot more confusing. In December, a review of the use of certain antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs)ósuch as Prozac, Paxil and Zoloftódone in the United Kingdom prompted British regulators to prohibit the use of most antidepressants in children. On Feb. 2, at an emotional hearing before an expert advisory panel of the U.S. Food and Drug Administration, the FDA reported that their own clinical review matched the British analysis, indicating a possible increased risk of suicide among children taking these medications. More than 60 witnesses testified at the hearing, including researchers, physicians and parentsósome of whom believed that antidepressants had saved their childrenís lives and some of whom believed that antidepressants had triggered their childrenís suicides. The FDA stopped short of taking regulatory action, pointing out that existing data remain confusing, and appointed a review team at Columbia University to conduct a thorough revi ew of the details of every adverse report suffered by about 4,000 children across 25 antidepressant trials. The report is expected to be released this summeróbut what should worried parents do in the meantime? Some 2 million antidepressant prescriptions were written for children in 2002 alone. Dr. David Fassler, a clinical associate professor of psychiatry at the University of Vermont College of Medicine and the author of "Help Me, Iím Sad: Recognizing, Treating and Preventing Childhood and Adolescent Depression," said he is concerned that the headlines may scare people away from treatment. "I worry that all of this attention may end up frightening some parents and reducing the likelihood that they get help for their children, which would be a tragedy because the reality is that we can help most of these kids," he said. "We canít cure everybody, but we can significantly reduce the extent to which depression interferes with their lives." As recently as the early 1980s, clinical depression was not recognized as a childhood or adolescent illness. Now, we know that it affects as many as one in 33 children and one in eight adolescents, according to the National Mental Health Association. "The good news is we can help most of these kids, but treatment is most effective when it starts early and is comprehensive and individualized to the needs of the child and the family," Fassler said. "Medication alone is rarely appropriate, but it can be helpful and even lifesaving as a component of a comprehensive treatment plan." "I think the FDA is doing the right thing by putting together a team of experts to look at all the data," said Dr. Elizabeth Weller, professor of psychiatry and pediatrics at the University of Pennsylvania and head of the Center for Mood and Anxiety Disorders at the Childrenís Hospital of Philadelphia. "In the meantime, people should not be panicking prematurely and taking their children off medications that are helping them. Depression is really a lethal illness." Both Fassler and Weller pointed out that children under care for depression need to be carefully diagnosed and closely monitored for suicidal thoughts and impulses, whether they are taking medication or not. "My evaluation, for example, lasts at least four to six hours before I can tell the parent whether the child has depression and before I say yes or no to medication," Weller explained. "I treat very complicated cases, but even the average case should take at least two hours to diagnose. You canít make the diagnosis in 15 minutes. Parents should go somewhere where they take time, have a lot of experience, and want you to ask questions." Children on antidepressant medication should also be monitored very closely. "You donít say, ëTake this prescription and come back and see me in six months,í" Weller said. "Children with depression need to be seen once a month for a medication checkup until they stabilize, and psychotherapy is a weekly affair." Fassler also urges parents to be advocates for their children, asking questions, seeking second opinions, and weighing the risks and benefits of all approaches. "But the most dangerous thing to do is not to treat these problems. Data from the Centers for Disease Control and Prevention tells us that by the end of high school, one in 10 teens has made at least one suicide attempt, and for teens suffering from depression, the rates are even higher," he said. "The surgeon general tells us that the majority of kids with serious mental illness, including depression, are not getting the treatment they need. Weíre getting better at recognizing signs and symptoms of depression in adults and overcoming stigma, but we lag behind when it comes to kids." Waiting too long to get help for a child with depression can have long-term consequences. The average episode of depression lasts about nine monthsóor approximately one school year. "If depression goes untreated, the kids fall behind, and they find it hard to catch up socially, academically and emotionally," Fassler said. "Whatís more, 40 percent of these kids will have a second episode of depression within two years. They need to be treated." But many childrenóparticularly adolescentsógo through periods of very dark moods, when they hate the world and believe the world hates them. How can a parent distinguish between ordinary teen turbulence and true depression requiring treatment? Fassler advises parents to look out for four factors: Intensity, duration, change in behavior and interference with the ability to function. "Sadness is a normal, healthy emotion. Depression tends to be much more intense and deeper," Fassler said of the intensity factor. Also, if a child has a bad weekend or a bad reaction to a breakup or not making the team, thatís a normal thing. If extreme sadness continues for a couple of weeks or more, thatís a red flag. "If your child had a headache that lasted for two weeks, youíd take him to the doctor, wouldnít you?" Fassler asked. In addition, parents should keep an eye out for major behavior changes. "Did your child used to be outgoing and now just sits in her room moping? Did she used to love school and now doesnít want to go?" These may be symptoms of depression, Fassler said. Finally, problems functioning can also indicate depression. "If the child is sleeping all the time or not sleeping at all, having problems in school, having problems getting along with their family or their friends, then this is a problem that needs to be looked at with a professional. "Of course, anything may just be a phase, but parents shouldnít have to make that decision themselves," Fassler added. "If a child feels sad, hopeless, helpless, has changes in sleep or appetite or energy, and itís going on for a couple of weeks, itís better to err on the side of getting it checked out." For parents worried about the possible side effects of antidepressants, Fassler said, the FDA hearings made it clear that more research is needed. "We have a lot more information about the safety and efficacy of these medications when used with adults, and since we do have so many children in the country taking antidepressants, itís really incumbent on the medical profession and on the pharmaceutical companies to initiate large-scale, carefully controlled, multisite clinical studies so that physicians and parents have the information they need to make appropriate decisions." Gina Shaw is the medical writer for The Washington Diplomat.