Issue 5 / 13 February 2012

MANY children and young people with depression who would benefit from antidepressants are missing out on this treatment, according to a leading psychiatrist.

Professor Robert Goldney, emeritus professor of psychiatry at the University of Adelaide, said clinicians were often reluctant to prescribe antidepressants in young people even though there was evidence the treatment was effective for depression in this population.

However, Professor Goldney emphasised that antidepressants were not first-line treatments in adolescent depression, and should be used only if other interventions had failed.

“If non-medical treatments don’t work, it’s logical to pursue antidepressant medications because there’s evidence that they work”, he said.

Professor Goldney made the comments in response to a new analysis of clinical trials data which found that the antidepressant fluoxetine reduced depression symptoms in children but had no significant effect on suicidal thoughts and behaviours.

In 2004, the US Food and Drug Administration (FDA) issued a “black box” warning after meta-analyses of randomised controlled trials showed an increased risk of suicidality in children and adolescents treated with antidepressants. (1)

However, the new research in Archives of General Psychiatry analysed individual longitudinal patient data from randomised controlled trials and found no evidence of increased risk of suicide among youths receiving fluoxetine. (2)

Professor Goldney said this specific finding could be reassuring for clinicians treating young patients with depression.

“I think a lot of experienced clinicians have thought that if suicide does occur it is probably the result of the underlying illness rather than the treatment”, he said.

Professor Goldney coauthored a paper in 2010 which reviewed studies of adolescent suicide, and found that only nine of 574 young people (1.6%) who died by suicide had had exposure to SSRI (selective serotonin reuptake inhibitor) antidepressants. (3)

“And yet we know that probably 50% of those people who died by suicide would have had severe depression. To my way of thinking, and that of my colleagues, these people were not given the potential benefits of antidepressants”, Professor Goldney said.

The new analysis looked very carefully, in a way that hadn’t been done before, at individual patients and individual symptom profiles, he said.

However, Professor Jon Jureidini, a child psychiatrist at the Women’s and Children’s Hospital in Adelaide, said it was important not to overstate the significance of the new research, which only focused on a narrow slice of the available data.

“It doesn’t show that antidepressants are safe in kids. It’s an analysis of one part of the data on antidepressants in kids which doesn’t show a statistically significant increase in risk [of suicidality] for fluoxetine in children.

“At best, it’s a mild reassurance or some cause to reanalyse the totality of the data”, he said.

Professor Jureidini said antidepressants did have a place in the management of young people with depression, but only in serious cases such as when the illness was severe enough to consider an inpatient treatment program.

“Antidepressants shouldn’t be prescribed [for young people] outside specialist child psychiatrist practice — there’s no place for it in general practice.”.

When managing young, distressed patients, clinicians should take a thoughtful approach which really tried to understand what was going on for their patient, rather than automatically turning to antidepressants or cognitive behaviour therapy, he said.

Professor Jureidini led a research review in 2004, prior to the FDA warning, which found that reports of antidepressant trials in children had exaggerated the benefits and downplayed the adverse effects of newer antidepressants. (4)

– Sophie McNamara

1. US Food and Drug Administration, news release 15 October 2004
2. Arch Gen Psych 2012; 6 February (online)
3. Australas Psychiatry 2010; 18: 242-245
4. BMJ 2004; 328: 879-883

Posted 13 February 2012

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