(Still) More on Antidepressants and Children

A new wrinkle in the ongoing saga on antidepressants and children (sorry, I seem to be a bit obsessed by this topic): An item in the New York Times this morning reports that a top FDA official is now on record that these drugs increase the risk of suicide in minors. That's a finding, apparently, that the drug companies kept under wraps, partly at FDA's insistence, despite 15 clinical trials whose data pointed in that direction; FDA itself had suppressed a 2003 meta-analysis that concluded the same thing. Judging from the emotional testimony, recounted in the Times article, of some parents who had lost SSRI-treated children to suicide, the drug companies can look forward to some nasty litigation (the New York State Attorney General's office is already filing suit against GlaxoSmithKline for failing to disclose the clinical-trial results that called Paxil's efficacy into question).

Still, the Times article did a nice job in underscoring the two sides of this story, something that I've perhaps minimized in previous posts on the topic. Suicide is the third-leading cause of death among U.S. teenagers; facing that abyss, parents need to do something. And many parents whose kids do seem to have been helped by these drugs have argued fairly passionately against restricting their use to adults. An example (again from the Times):

But others said that antidepressants had helped millions. Dr. Suzanne Vogel-Sibilia of Beaver, Pa., said that she had brought her 15-year-old son, Tony, to the hearing to represent what she said were the vast majority of patients who had been helped by the drugs.

"Please help me preserve my future," Tony told the committee. "Don't take away my medication."

A study just reported from Johns Hopkins and 12 other medical centers will certainly fuel additional debate here. This study, published in JAMA in mid-August, looking specifically at depressed teens, found that patients undergoing a combination of talk therapy (read cognitive therapy) and Prozac did significantly better than those on either therapy alone. It also found, however, that Prozac alone was better than talk therapy alone, which had results, at least in this study, that were little better than those taking placebos.

(I find it interesting that Prozac specifically was the drug used here; one thing I've noticed in other stories about this topic is that Prozac seems to do better than other SSRIs with these patients, though that may just be my impression. On the other hand, though the study itself was NIMH-funded, the "Financial Disclosures" section of the paper lists the senior author, John S. March, as having "served on the speaker's bureau for Pfizer and Lilly" and having "received research support from Lilly, Pfizer, and Wyeth," as well as documenting a range of relationships between other authors and drug companies. That's not necessarily a reason to doubt the validity of the research -- but I guess one point of this recent controversy is that the drug companies have tended to publish only the positive results from clinical trials, so one at least needs to take these sorts of financial relationships and dependencies into account.)

What's really needed here, it seems to me, is a good deal more subtlety in how we, as a society, approach both the inherently complex and subjective condition we call depression, and the slippery, highly individual transition between "childhood" and "adulthood." Much as the medical community would like it otherwise, diagnosing and treating depression doesn't have the specificity and relative simplicity of applying an antibacterial or antiviral agent to a pathogen identified by a lab test. And the legalistic, age-based definitions we have settled on to mark off adulthood, apply movie ratings, and issue learner's permits don't really provide us with any insight on the plasticity of the childhood brain and the point at which a minor becomes an adult for purposes of antidepressant drugs.

But a more enlightened approach to treating this disease implies taking a very different, more personalized approach to medicine itself -- one that may well prove impossible in an environment where physicians are under constant pressure to cut costs, boost efficiency, and handle larger patient loads with smaller resources. In those conditions, it seems, it's just a lot easier to prescribe a pill and hope for the best.