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« Ancient feuds are SO yesterday. | Main | What an Iraqi woman wants »

November 21, 2004


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Oh, and did we mention how much we despise TypePad? Once again, we wanted to revise a post, and it won't move.

I am a pediatrician in active practice. Let's attempt to strive for some fairness.

1) The school counsellor did not prescribe an antidepressant. He or she is not licensed to do so. A psychiatrist prescribed the antidepressant. The family is certainly grieving, and the death of the teenager is distressing, but it is intellectual slacking to assume that the physician was negligent. If the doctor had "done nothing," that is simply talked with the patient, and the boy subsequently hung himself, what would be said then? The young man was having difficulties sufficient to lead officials at the school and his parents to judge that significant mental health intervention of some kind beyond that available from the regular school counsellor was warranted. The most common findings in this type of situation are anxiety and depression; suicide in adolescents makes it now the third leading cause of death for those 15 to 19 years old, after accidents and homicide. More than 90% of all suicides are related to a mood disorder or other psychiatric illness, for which medication is indicated.

2) "... but their insurance did not cover that therapist." That is a major problem in pediatric and adolescent medicine. Coverage for mental disorders even with "good" private insurance policies is abysmal, and the low reimbursement rates for mental health professionals has severely limited their availability. I have great difficulty getting mental health services for child and adolescent patients, often in dire need of them.

The antidepressants have all received "black box" warnings from the FDA October 15, 2004 over the issue of suicidal ideation in children and adolescents*. Strict guidelines were prescribed for monitoring possible suicidal ideation when first starting on medication. These include a visit to the doctor each week for the first month of therapy, every other week for the second month, and then quarterly. These monitoring guidelines are also to be followed for each and every dosage change, and also when tapering and discontinuing the medication(!). Many parents will find this regime very difficult or impossible to pay for and thus comply with. Primary care physicians will feel extremely threatened about using any antidepressants in child or adolescent patients, even if no other source for treatment for psychiatric illness is available in the community.

Suicide of a child is the cruelest form of death for parents; illness or accident does not leave quite the same type of deep and lasting scars. I can sympathize with the parents in this case, and likewise understand the temptation for other laymen to jump to conclusions about the specifics of the case and then generalize broadly against psychotropic medications for children and adolescents. Be careful what you wish for. Mental health services for the young are inadequate by any measure in this country, and likely to get demonstrably worse if well-intentioned but poorly-informed opinion trumps good medical practice and research, and the legal system drives physicians to undertreat illness or leave the practice altogether, and pharmaceutical researchers to look elsewhere for research leads.

* Note: Suicidal ideation—contemplation of the act—is not suicide. The large study which led to the black box warning contained NO SUICIDES, only reports of suicidal ideation. This is the first FDA black box warning which did not involve a single death in the study group. It is however recognized that a significant percentage of persons who think seriously about suicide will carry through with an attempt. For Prozac, which is the only SSRI antidepressant labeled for use in children, the actual relative risk of suicidal ideation was 0.92, meaning slightly LOWER risk of suicidal thinking in depressed children on that medication.


Your comments are very interesting, and I'm aware of the difficulties in getting mental health treatment for children and adults. It's a disorganized bureaucratic nightmare, IMHO.

Do you have any thoughts on hospitalization, or group "medication" homes, or some other type of monitored setting, for the first week of treatment with psychotropics? Would, at least, a "watch for these signs" review be advisable for parents whose children are starting these drugs?

Is the brain's reaction to the medication different when the depression is situational rather than a chemical imbalance otherwise induced?

I think our society (including doctors) often looks at a pill as a simple fix for complex problems, and it seldom is. It seems that prescribing a drug based on the mother's description and an assessment tool is too much, too soon.

For what it is worth, remember that I am not a psychiatrist, and speak only from the perspective of a primary care pediatrician in active solo practice.

Hospitalization or other "monitored settings" are at present very expensive alternatives, are very disruptive of the child's life, and in the patient's eyes are often extremely stigmatizing (at a time of life when budding egos are particularly fragile). Recall that the boy in question told his mother, "I'm not crazy." This is the response that many adolescents have when inpatient care is suggested, and often even for any type of medication. Outpatient pharmacological management of mental disease has been the revolution in psychiatric care, and all in all a good one.

I am likewise no neurochemist, so I am not familiar with the literature. My impression is that situational stress reactions alter brain neurotransmitter levels in similar patterns to so-called endogenous depression, and that is why these medications are so effective. One thing is certain: today's management of depression by neurotransmitter manipulation is far more effective than what went before, which was talk therapy, or nothing.

As for diagnosis by talking to the parents and using an "assessment tool," both are not only valid when used appropriately, but may be about all that is available when dealing with the typical non-communicative teen who is in addition severely depressed.

Medication is one part of therapy for mental disorders such as depression. It is an important part, and one that cannot be denied. It is easy for lay persons to fall into the trap of reflexive criticism of medication in general. As one who works with distressed teens with serious depressive symptoms—and they are all over, do not kid yourselves—I will simply urge rhetorical caution and sober reflection. Read about what life was like in the "good old days" before the availability of antidepressants. Talk to parents of adolescents with major depressive illness and get a feel for the real suffering that the children and parents go through. That will help to keep one's eye on the prize.

Thank you both very much, Popeye and Donna, for your thoughtful and informed comments, all well taken. I wrongly suggested the school counselor had prescribed the antidepressant. Re the doctor's dilemma, you are right, Popeye, that in the popular mind you're damned if you do and damned if you don't prescribe an antidepressant. With my facts straight, thanks to your gentle corrections, I still harbor a strong gut feeling that -- as Donna says -- our society often looks to a pill as a quick fix for complex problems.

Just so you know, I live in a Red State, have a son who went to Berklee (now in the Army studying Arabic), and have 3-1/2 cats (three of ours and the neighborhood kitty we feed and shelter in our garage).

You're a good man!

Thanks, Popeye. I certainly understand the 'damned if you do and damned if you don't' aspect, as Sissy puts it. I was lucky with my children in that our first pediatrician was worth 10X her weight in gold. She gave us - the entire family - more than just medical care. Unfortunately, we moved and never found another like her.

My son suffered a closed head injury in an accident when he was 7 and we spent years afterwards being bounced around the "mental health system". He was 'diagnosed' as depressed, bipolar, all the oppositional-defiant variants...even as mentally retarded once!

One psychiatrist was brutally honest with me: "I have to base my diagnosis on what insurance companies are willing to pay for and work around that best I can." Though that was over 15 years ago, I see little evidence that the situation has changed very much.

So, I apologize if I came across too negative about doctors and drugs. We had too few positive experiences. (I count the brutally honest doc as a positive experience, btw.)

I have empathy for parents whose children don't fit "in" whether at school or in the mental health system... or otherwise.


There's no question in my mind whether antidepressants lead suicidal thoughts or not. You can ask any SSRI user and they will give you the same: Yes. I am on antidepressant for social anxiety, it helps me very much but I do sometimes have suicidal thoughts. I am 21 years old, so I am able to tell what's right and wrong. Parents should monitor the kid's progress, they should ask him/her how he/she is feeling. As I have learned it's not just about depression or anxiety but also about moods. These med can help you and mess you up at the same time.

See my blog:

Your blog makes sense to me, NotEasyBeingMe. Perhaps by writing there you will be able to face and overcome the negative feelings that torment you. Everyone has some variation of what you speak of, a combination of your inborn nature -- shyness? -- and the mistakes your parents may have made in rearing you.

Thanks for the comment. I know you used it as a general example but I don't think blaming others solves anything. Life is life and that's is how I see it. Try to deal with what ever is thrown at you. I would rather say "life sucks" than think about who to blame and ask meself "Why Me."

Oh by the way; life sucks.

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