For Michigan’s Greden, the most persuasive argument for the
drug’s continued availability is the nature of depression.
“Suicidal thinking and occasional attempts are to depression as
fever is to untreated pneumonia. Untreated depression leads to suicidal
thinking and attempts.”
Psychiatrists say they are always cautious about treating young
people with drugs. They emphasize the need for complete evaluation.
“Are they really depressed?” says Kowatch, explaining his
chain of thinking. “Is anything else going on, in school or in the
family? Does the child have a learning disability?”
Who gets treated with antidepressants in childhood? Says Greden:
“It’s the most severely depressed, the ones who struggle most
with impulsivity and suicide.”
Evidence now demonstrates that depression is most likely to begin
in the young, those between ages 15 and 24. “If you can’t
treat it, then the syndrome gets a running start,” says Greden.
“Not making drugs available dooms young people to more severe
disease that is harder to treat. That’s a heavy burden when we have
treatments that work.”
The solution, many psychiatrists agree, is to start drugs slowly
and watch patients carefully. The most dangerous time for suicide is just
after treatment is started. “We don’t fully understand this
yet,” Greden confides. “If you treat moderate to severe
depression it’s like shaking a glass of water. You see a flare-up
of suicidal ideation. No one is sure why.” The SSRIs raise
serotonin levels; impulsivity is associated with low serotonin levels,
not increased levels.
His best guess is that the drugs increase fear conditioning in the
acute phase. The issue is not whether, but how, to use the drugs.
“Clinicians should start with low doses and closely monitor
children. The families should monitor them, too.”
In the long run, treatment lowers the rates of suicide. Columbia
University psychiatrist John Mann, M.D., an expert on suicide, is one of
many specialists to call attention to suicide statistics. As the use of
SSRIs has increased four-fold, there has been a decline in suicides in
the U.S. Although the correlational data do not establish a direct
cause-and-effect relationship, they so suggest that the drugs aid suicide
prevention.
If clinicians have a beef with Paxil, the drug that stimulated
suicide concern, it is that it poses a problem of withdrawal reactions.
“People have difficulty when they stop the medicine
abruptly,” says Richard Kadison, M.D., director of student health
services at Harvard University. This is a concern because
“adolescents are, in general, not the most reliable folks when it
comes to taking medications.”
Still, schools and colleges are generally reaping a “Prozac
payoff.” Taking SSRIs to reverse depression has enabled many young
people to stay in the academic system who in earlier times might have
been forced by illness to drop out of school.
Whether in the longest run drugs are the best way to deal with
depression in young people is a legitimate question now getting serious
attention. At least two studies funded by the National Institute of
Mental Health are exploring whether developmental approaches, alone or in
combination with medication, can combat depression. One is a study of
cognitive therapy versus drugs, the other looks at whether instruction in
specific coping skills, can head off depression in stressed teens with a
family history of the disorder. It’s too soon to know.
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serotonin reuptake inhibitors,
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