Kids’ use of Prozac debated — (Statesman Journal)

Original article no longer available

Statesman Journal (Salem, OR)

January 25, 1999

Author: Salem Statesman Journal, Lisa Baker, Staff

Thousands of children are being treated with the drug and other anti-depressants

Oregon doctors are prescribing Prozac -type drugs to poor children more often than any other kind – even antibiotics.    Oregon Health Plan records show that state-funded insurance pays for adolescents to get anti-depressants more frequently than all other classes of medications.

Even very young children – those still in elementary school – are commonly dispensed anti-depressants, which along with anti-psychotics are second only to antibiotics in numbers of prescriptions ordered by health plan doctors for young kids.

Health Plan administrators say doctors supplied nearly 10,000 Oregon children with “psychotherapeutics” last year. While the category includes anti-psychotic drugs, most prescription were for anti-depressants.   The popularity of the drugs comes despite the fact that the medicines have not been thoroughly tested or approved for children by the Food and Drug Administration.

In 1997, doctors signed 839 more prescription slips for Prozac and its sister anti-depressants than the year before. While most of the patients were adolescents, a third were 12 or younger, according to OHP records.   The story isn’t unique to welfare insurance. Some private plans also reflect growth in the numbers of children being prescribed anti-depressants.

Regence/Blue Cross officials report a 16 percent increase in anti-depressant prescriptions written for teens between 1996 and 1997, and a striking 29 percent jump for children under 13, all at a time when children’s memberships in the company’s plans were on the decline.

Across the country in 1997, about three-quarters of a million kids were popping Prozac and its sister pharmaceuticals – 130,000 more than the year before, according to IMS America, a pharmaceutical researcher.

Finally getting help

Most pediatricians aren’t shocked by the numbers, which they regard as a positive indication that children suffering from clinical depression are finally getting help they’ve been denied.   They say medications like Prozac may not be specifically approved for children, but are capable of dulling the effects of a disease that had been considered an adults-only affliction.

“The big change is that 20 years ago people thought that if kids were a little down, it doesn’t mean anything” and that the child would emerge from the phase unscathed, said Glen Elliott, a psychiatrist with the San Francisco-based Langly Porter Psychiatric Association.   “Now we know kids can have very serious depressions.”

Child psychiatrists say they’re now better at identifying mental disorders in children. What they’re finding is alarming.

Tim Murphy, program director for Salem Hospital’s Child & Adolescent Psychiatric Medicine clinic, said depression, attention deficit disorder and “defiant behavior” are becoming commonplace, and growing up alongside them are some serious cases of bipolar disorder.

Other experts agreed that mental illness has arrived with a vengeance in elementary schools and that cases of serious disorders have accelerated dramatically in the past five years.

Cathy Jarman, an elementary school counselor for the Salem-Keizer School District who retired last year, said she’s seen children as young as six attempting suicide.

“Last year, there were three who were suicidal – a little boy in first grade who attempted to take some aspirin, and a fourth-grader and sixth-grader who made serious suicide attempts.

“We hear about kids who are jumping off of high bars, or running in front of cars.”

The problem has spurred many doctors to conclude that the use of anti-depressants is a lesser evil – even as they prescribe them “off-label,” or without the FDA’s approval.

Anti-depressants are becoming prevalent enough in children that Oregon school nurses are taking workshops to help them recognize depression and understand how anti-depressants work.

Dee Kathryn Bauer, director of school health services for the Multnomah Education Service District, said psychiatric disease is the fastest-growing category of illness school nurses face.

“Everyone thinks it’s head lice, but truly, reports show us that children – are beginning to have more fear, anger, anxiety and depression.”

Diagnosis a difficult one

Some people are not pleased with the Prozac solution.   Leon Harrington, a Salem child psychiatrist, said that while he has prescribed Prozac for some of his patients, the lack of definitive studies to support the practice means doctors are “kind of going by the seat of our pants.”

Adding to the uncertainty are diagnostic criteria that read like something out of a how-to book for teens who want to fit in with their peers at a time when teen style calls for black clothing and morbid talk.   “There are some kids who may just be influenced by other kids who are morbidly obsessed with leaving this world,” Harrington said. “It makes diagnosis hard.”

It doesn’t help that the diagnosis criteria encapsulate symptoms that a few years ago would have been considered a normal part of being a kid, like irritability, moodiness or fidgety behavior.   They are symptoms easily produced by lack of sleep, said Sandy Jordan, past president of the Oregon School Nurses Association.

“Kids get over-stimulated. They’re doing sports and not eating until 7:30, and it’s 10 or 11 before they go to bed,” she said.   Symptoms need only persist for two weeks for a patient to be diagnosed with depression, although most doctors wait at least eight weeks before prescribing drugs.

Depression’s most familiar markings – and most serious – negative self-image, feelings of guilt, thoughts of death, need not even be present for a diagnosis.  Dr. Greg Clarke, a psychologist and researcher at Kaiser Research Center in Portland, admits the diagnosis criteria are loose. And while clinical depression is defined as a biochemical abnormality, there are no viable tests for it and no way to separate it from a bout of sadness.

Steve Kuhn, team supervisor for the county mental health services department, said untangling situational and environmental cords from biological ones is not something a physician can do on the fly.   “A physician who has 10 or 15 minutes to diagnose and treat isn’t going to be able to unravel it all,” he said.

The inability to separate the issues means doctors may be eliminating appropriate feelings – or changing patients’ personalities – by prescribing drugs.

“It may have an effect on people – who may just be naturally grumpy or shy, not necessarily in the middle of an episodic depression, and that we may be getting a prescription to bring about a personality change.”   While not a medical danger, it may be a moral one, Clarke said.

That moral puzzle was the subject of a 1993 book about anti-depressants called “Listening to Prozac.”    The author, Dr. Peter Kramer, a clinical psychiatry professor at Brown University, questioned whether the pill would be used to make the shy outgoing or to make the passive more aggressive and popular.

But his criticism of anti-depressants for children is more practical than philosophical.   “What I want to know as a parent giving this to my child is, what will my child be like 15 years from now? Will this make this child dependent on anti-depressants forever? Nobody knows that’s the problem.”

Larry Sasich, spokesman for the consumer advocacy group Public Voice, took it further.  He said there is potential for a generation of children to arrive at adulthood drug-affected from early use of anti-depressants.  Clarke points out that decades of adult-based testing should show that anti-depressants are “pretty darn safe,” and that side effects should be weighed against the fallout of unchecked depression – things like juvenile delinquency, alcoholism and suicide.

“The known downsides of depression are much worse than the guessed-at possible downsides of these medications. If I have a child who’s unresponsive, I wouldn’t hesitate to consider medical treatment, considering the known ill effects of doing nothing.”

Diagnosis criteria

Is your child melancholic, irritable? Could it be clinical depression?   Psychiatrists and researchers have come up with criteria that guide them in making a diagnosis of depression.   A child must have at least one of the first two characteristics and at least four of the others to be considered a candidate for medication.

  • Sadness, or in younger children, irritability.
  • Lack of interest in activities that used to bring pleasure.
  • Appetite disturbance: Either eats much more or much less compared with previous custom.
  • Sleep disturbance: Either sleeps significantly less or significantly more than previous pattern.
  • Changes in activity level: More fidgeting or more lethargy.
  • Fatigue, loss of energy
  • Feeling of worthlessness or feeling inappropriately guilty.
  • Difficulty concentrating, feeling “muddle headed.” Sometimes exhibited by dropping grades in school.
  • Thoughts of death or suicide.

Researchers say the traits must be pervasive and consistent, and last at least two weeks, each symptom present most days.   Child psychiatrists say patients who have difficulty functioning because of their symptoms are more likely to be treated with anti-depressants.

A milder form of depression, called dysthymia, is under study. There are fewer symptoms, but longer duration.