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Teens and Antidepressants

Oxford University researchers have found that the majority of antidepressants are ineffective for children and teens. The team, led by Andrea Cipriani, MD, PhD, conducted a meta-analysis of 34 double-blind, randomized trials investigating the risks and benefits of 14 common antidepressant medications in 5,260 participants between the ages of 9 and 18. They ranked the efficacy of each drug according to whether the prescription improved symptoms, whether adverse side effects compelled patients to discontinue the medication, and whether patients experienced an increase in suicidal thoughts.

The results suggest that only one antidepressant — fluoxetine, which many know by the brand name Prozac — offered greater benefits than risks in terms of effectiveness and patient tolerability for this age group. Other drugs included in the study showed only a placebo benefit, and at least one resulted in increased incidences of suicidal thoughts.

The risks and benefits of prescribing antidepressant medications to adolescents have long been debated. Due to biological and physiological shifts, teens notoriously struggle with radical mood swings, which can make it tricky to identify depressive symptoms — symptoms that often manifest somewhat differently in young people than in adults. And because a young person’s brain is still developing well into his or her early 20s, some experts have expressed concerns that prolonged use of antidepressants could have neurological consequences.

The Oxford study, published in the June 2016 issue of The Lancet, may reignite a debate that simmered for years before the FDA added a black-box label warning to prescription antidepressants in 2004 — a response to mounting concerns that the drugs could actually increase the risk of suicidal thoughts in patients under age 25.

Nearly 2.8 million adolescents between the ages of 12 and 17 — or 11.4 percent of that age group — suffered a major depressive episode in 2014, according to the National Institute of Mental Health (NIMH). The NIMH uses the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to define “a major depressive episode” as “a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure,” and notes a change in normal functioning of sleep, eating, energy, concentration, and self-image.

A World Health Organization survey released the same year found depression to be the leading cause of illness and disability in adolescents worldwide. And despite the FDA’s black-box warnings, the percentage of children under age 19 using antidepressants between 2005 and 2012 in Denmark, Germany, the United Kingdom, and the United States rose slightly from 1.3 to 1.6 percent.

“What we’re up against is the marketing enterprise of the pharmaceutical industry combined with wishful thinking on the part of doctors and parents that there might be a good, simple solution for adolescent distress,” says Jon Jureidini, PhD, a child psychiatrist and research leader at the Robinson Research Institute at the University of Adelaide in Australia, in a report by STAT News. “It’s something we need to take very seriously, but we don’t need to make it into a medical condition when it most times isn’t.”

Oxford’s Cipriani argues that patients should not discontinue their medications because of his team’s study, and he maintains that some patients might still benefit from them. “If the patient’s responding to one treatment, they have to keep the treatment, of course,” he says. “But on average, if I have to start a treatment, probably the best one is fluoxetine and not the others.”

Jureidini, who authored an editorial that accompanied the study in The Lancet, cautions that even the evidence in support of Prozac is weak. He argues that most children should not to be medicated for their depressive symptoms.

“The effect of misreporting is that antidepressants, possibly including fluoxetine, are likely to be more dangerous and less effective treatments than has been previously recognized, so there is little reason to think that any antidepressant is better than nothing for young people,” he wrote.

Many experts have expressed additional concerns about the study’s methods and reliability — 65 percent of analyzed trials were sponsored by pharmaceutical companies. These reports could overestimate the efficacy of the drugs in question, while minimizing the incidence or severity of side effects. Further, the researchers noted a lack of reliable data that would have allowed them to assess the risk of suicide for all drugs. At the very least, Cipriani says, more research is necessary to determine the long-term effects of antidepressants in children and teens.

Alternative treatment strategies for depression often involve lifestyle changes — regular exercise, a diet rich in whole foods and free of the processed fare, eliminating inflammatory factors like gluten and sugar — as well as social services and psychotherapy. For more on holistic approaches to treating depressive illness, see “Free Yourself From Depression” from our March 2015 issue.

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