What To Do for Those Truly Depressed Kids?

Last summer, Psychiatric Services in Advance, published by the American Psychiatric Association, brought out a study with apparent good news. The study showed that psychiatrists prescribed more low-dose “antidepressants” after a black-box warning in 2004 from the FDA on the dangers of suicidality in children than they did before the study.

So, this is good news, right? Clinicians respond to an FDA warning and prescribed fewer high-dose Prozac-clones after the warning than before the warning.

Well, sure, good news, except for two things. First, insiders don’t really believe that the SSRI antidepressants (the Prozac-clones) really work for depression in children; and second, how do we identify which children are really depressed and urgently need treatment?

Now, I am part of an email list that includes a number of very skeptical senior psychiatrists. They don’t believe in Prozac (at least, not for serious depression), and they do believe that a useful diagnostic test for depression, called the Dexamethasone Suppression Test (DST) is a fairly reliable indicator of who is really depressed when the test is positive — which is about 50 percent of the time.

Some very interesting opinions have been expressed on this list in the last 24 hours that I’m going to share with you.

One senior figure said the recent study was a waste of time, “as SSRIs don’t work in children irrespective of dose or type [of depression].” (There is better evidence of efficacy in adolescents than in prepubescent children, but none of the evidence is very convincing — and the research was done studying “major depression,” which is a hopeless jumble.)

Another senior figure said, “Lower dosing of drug...may not be appropriate for authentically depressed children with HPA abnormalities [abnormalities of an endocrine axis involving the Hypothalamus-Pituitary-Adrenal glands]. How do we identify those children who might truly benefit from ECT or antidepressants?”

A third senior figure said, we need a study to compare depressed and bipolar kids with “highly underactive as well as overactive HPAs.” The latter group are presumably much more ill and urgently need effective treatment. He added, “The fact that this has not been done, except piecemeal, is a disgrace.”

This is what very smart, very senior figures in psychiatry are saying about the problem of depression in children: We have no reliable way of judging who is really depressed (and who is mainly sullen and uncooperative). And we have no effective treatments of those who require treatment most urgently.

Six years ago Dr. Max Fink and I actually wrote a book about this. Called Endocrine Psychiatry: Solving the Riddle of Melancholia, it was published in 2010 by Oxford University Press and had little impact. It was more about adults than children, but was certainly applicable to children. In it we argue that an older class of antidepressant drugs, called the tricyclic antidepressants, was the most effective psychopharmacological treatment, and that ECT was the best treatment of all.

I’m not necessarily unhappy that the book had so little impact. Max and I sort of expected it, given that psychiatry as a whole has lost interest in the endocrine system (neurotransmitters are the mechanism du jour, these days), and that old drugs have little chance of being widely prescribed because they are off-patent and are no longer “detailed” by pharmaceutical sales reps.

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So, the book’s lack of impact was a foregone conclusion. But we felt we had to say something to counter the mantra that one hears constantly: “There are no biological tests in psychiatry.”

Let’s get back to the present. Here we are today, unable to sort out kids who really do need help from those whose needs might be less urgent. We have a therapeutic armamentarium that is woefully inadequate. And we have forgotten what does work in treatment, and what works in classification (namely, getting away from “major depression” and “bipolar,” and getting back to classic distinctions in psychiatry between melancholia and everyday dysphoria).

Psychiatry, as a field, has forgotten so much. But it’s the kids who are now paying a price for this.