Warnings Slow Antidepressant Use

Government warnings about antidepressants causing suicidal behavior in children and the extensive media coverage that followed have prompted a significant drop in the number of children taking the medicine, new prescription records and interviews with doctors suggest.

In October, the Food and Drug Administration ordered ”black box” labels, the most severe warning, on all antidepressants. The labels aren’t expected to start appearing until this month, but their effect is already evident.

In the last three months of 2004, the rate of patients under 18 who got antidepressant prescriptions dropped 16% compared with the same time period in 2003, according to pharmacy benefit managers Medco Health Solutions.

Even before the black boxes, many pediatricians felt unqualified to diagnose or care for children with serious mental disorders, surveys suggested. ”The black box just adds to their feelings of vulnerability and uneasiness,” says University of Oklahoma behavioral pediatrician Mark Wolraich.

Now, when pediatricians or primary doctors refer kids to a child psychiatrist, fewer parents agree to go, says Ujwala Dixit, a child psychiatrist in Media, Pa. And fewer parents are willing to have their kids take the drugs when they’re recommended, she says.

But getting appointments with pediatric psychiatrists can be tough, even if parents are willing to go, because many states have fewer than five child psychiatrists for every 100,000 children.

Programs are growing to bring pediatricians ”up to speed” on childhood depression. Tennessee and Minnesota are among leaders in such programs. Massachusetts offers primary doctors state-funded free consultations with psychiatric experts on children.

National guidelines for treating depressed kids ages 10 to 18 in primary-care practices will be finished by May and published in professional journals, says Columbia University child psychiatrist Peter Jensen, the project director. Guidelines to help parents get needed help for kids with depression also will be available, he says.

Studies reviewed by FDA scientists show about 2 out of 100 kids become more suicidal because of the medicines. That has encouraged caution. ”I’ve become more vigilant and guarded in prescribing the drugs,” Dixit says.

In another sign of caution, more doctors are giving depressed kids only Prozac because it’s the only drug approved for childhood depression, says San Diego child psychiatrist Gabrielle Shapiro, who reviews prescriptions for managed-care companies.

Several other antidepressants have been widely and legally prescribed for kids because they’ve been approved for adults.

Managed-care companies also are requiring more paperwork to document that a child needs antidepressants, she adds.

Some worry that all these ”speed bumps” might end in more childhood suicides. ”For children who really need treatment, a ‘wait and see’ approach could be dangerous,” Dixit says.

But other mental health experts say prescribing antidepressants for children, which had skyrocketed to nearly 11 million prescriptions written in 2002, needed to come down.

Pills were given to too many kids whose unhappiness stemmed from their environment, not mental illness, says Wellesley, Mass., psychiatrist Bruce Black.

Some have constantly fighting parents or parents who expect too much from them academically. They may be withdrawn because they’re smoking a lot of pot. They may be in schools that are ill-suited to their learning styles, Black says.

Many could benefit from family therapy or ”real world” changes. ”Kids are unhappy for a lot of reasons, and antidepressants often aren’t the solution,” he says.