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Diagnosing Infants With Depression

Posted May 3, 2004

There is a huge debate about the appropriateness of diagnosing young children with depression and treating them with adult drugs.
There is a huge debate about the appropriateness of diagnosing young children with depression and treating them with adult drugs.

For many people it is difficult to comprehend how children younger than 5 could be prescribed mind-altering drugs and be taking them on a regular basis, but according to a recent survey by Express Scripts Inc., a private pharmacy benefit manager that researches drug trends, not only are children from birth to age 5 being given antidepressants, it is this age group that has shown the largest proportional increase in the use of antidepressants.

The Express Scripts survey, titled Trends in the Use of Antidepressants in a National Sample of Commercially Insured Pediatric Patients, 1998 to 2002, presented prescription-claims data that showed "the overall prevalence of antidepressant use among children increased from 160 per 10,000 (1.6 percent) in 1998 to 240 per 10,000 (2.4 percent) in 2003, for an adjusted annual increase of 9.2 percent. The growth in the overall prevalence of antidepressants use was greater among girls (a 68 percent increase) than boys (a 34 percent increase). In 2002 antidepressant use was highest among girls aged 15 to 18 years, at 640 per 10,000 (6.4 percent). The trend of increasing overall use of antidepressants among children and adolescents appears to have been driven primarily by greater use of selective serotonin reuptake inhibitors."

The survey concludes that "the growth in the prevalence of use of antidepressant medications among youths appears to be continuing, and the rate of increase between 1998 and 2002 is similar to the rate of increase seen in the period of the second-generation antidepressants (late 1980s to mid-1990s)." This survey comes on the heels of the Food and Drug Administration (FDA) recommending that pharmaceutical companies "change the labels of 10 drugs to include stronger cautions and warnings" due to increasing criticism about the potential for violence and suicide in adolescent and pediatric patients while taking the drugs. The antidepressants that fall under the FDA's recommendation, which also are included in the Express Scripts survey, include Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Wellbutrin, Effexor, Serzone and Remeron.

Naturally, a first impulse is to point the finger at the pharmaceutical companies, but in this instance, because a diagnosis must be made before a prescription is filled, critics are asking how one diagnoses an infant, a 2-year-old toddler, or even a 5-year-old preschooler with depression or any of the other 300 mental disorders? Given that this is at best a purely subjective practice, one might at the very least imagine that diagnosing a child who does not yet speak would be difficult if not impossible.

But according to David Fassler, a clinical associate professor of psychiatry at the University of Vermont: "Depression can certainly begin at very early ages. We can see signs and symptoms of depression in preschoolers, and there are even infants who can experience depression. They may be withdrawn, don't interact, may be reluctant to eat, and they may not gain weight or even lose weight. There are a lot of other medical problems that need to be ruled out in such circumstances, and we sometimes find that there are issues with depression elsewhere in the family, so if there is a parent with depression, it may get expressed in certain ways through the child."

As Fassler sees it: "There are certainly 2- and 3-year-olds who get treated with medication, and it's not surprising to me that this group has shown the largest proportional increase. But the numbers are still relatively small. And [diagnosing] it should only be done by someone who has the appropriate training and expertise and closely monitors the child. If you're talking about preschool kids, then the symptoms would include kids who are withdrawn, sad, irritable, may be tearful, may have difficulty sleeping, they lose their appetite, they look sad all the time and they may be reluctant to play with other kids. Clearly these are not easy diagnoses and you can't do them in a five-minute office visit. It really requires comprehensive evaluation that may take several hours that would involve understanding the child's developmental history, the family history, and really reviewing the medical history closely."

Maybe the infant or toddler is depressed, but couldn't any or all of those "symptoms" be due to many things other than mental illness? "Absolutely," says Fassler, "and that's why they need a comprehensive evaluation. The symptoms can be due to other psychiatric problems like anxiety, ADHD [attention-deficit/hyperactivity disorder], conduct disorder or a reaction to certain medications and certain stresses in the child's life, or it could be a phase or even a mood the child is going through."

Survey Results From Express Scripts Inc.

  • Between 1998 and 2002 overall antidepressant use in children increased 49 percent.

  • The largest year-to-year increase occurred between 2001 and 2002.

  • Antidepressant use increased more among girls (68 percent) than among boys (34 percent).

  • The youngest age group (5 years old and younger) showed the largest proportional increase.

  • In all five years, mind-altering selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed antidepressants.

  • The prevalence of antidepressant use among girls increased 97 percent for SSRIs.

  • The adjusted trend in use of antidepressants among children and adolescents increased at an annual rate of 9.2 percent.

  • Though it does seem hard to imagine the kind of expertise needed to diagnose the difference between the alleged mental illness known as "conduct disorder" and just being a toddler, Peter Breggin, a psychiatrist and author of the Antidepressant Fact Book, tells Insight that regardless of the diagnosis, use of mind-altering drugs on the very young is outrageous. "To inflict these drugs on the growing brains of infants and children," says Breggin, "is wrong and abusive. We're in an era of technological child abuse in which physicians routinely, whether they know it or not, are actually abusing infants and children with toxic substances, rather than addressing their real needs. And if an infant is so grossly apathetic that it is apparent to a pediatrician or a family doctor, then something very disturbing is going on with that child's physiology or that child's life."

    According to this forensic psychiatrist: "These drugs have not even proven to be useful in adults, where the studies are marginal at best, and we now have the FDA acknowledging that in both children and adults the drugs produce a wide variety of behavioral and mental abnormalities. Antidepressants drastically change the functioning of widespread neurotransmitters in the brain, and there is no way to interfere at a stage of rapid growth without disturbing the function of the brain."

    Breggin concludes, "We're talking about an extreme here with these off-label prescriptions [for drugs not approved for children]. This is off-commonsense usage and out-of-reason usage." He adds, "Parents need to reclaim their children from the medical and psychiatric experts when it comes to psychological and behavioral problems, because the answers do not lie in drugs. Don't rely on a physician for a prescription to raise a child."

    The question of whether intervention is needed in the ever-increasing use of mind-altering antidepressants on America's children finally has landed squarely in the lap of congressional lawmakers, and both Senate and House committees are looking into the matter. Rep. Jim Greenwood (R-Pa.), who chairs the House Energy and Commerce subcommittee on Oversight and Investigations, tells Insight that the issue caught his attention when Great Britain acted to ban antidepressants in children younger than 18.

    "What we know," says Greenwood, "is that there have been studies in Europe that have indicated there may be a correlation between the use of antidepressants among children and suicidal ideation, attempted suicide and, tragically, suicide. And it seems to be the case that not all of the studies that drug manufacturers have done have found their way to the FDA - and, of course, that's not necessarily a violation of law, but we think it is important. We want to make sure that these drugs are safe. Once we answer the question as to whether there is a problem, we can decide what action needs to be taken."

    Greenwood explains: "We've requested information from seven of the pharmaceutical companies and from the FDA. Based on what we get back we'll then decide whether to hold hearings. Whether we have to look at diagnosing, my impulsive answer is that certainly the diagnosis and the drugs should be looked at in total. But I'll have to sit down with my staff and talk about this. You're alerting me to [connections between school shooters and prescription drugs] that I'm not aware of, but I am fascinated. I think that the answer is yes, we have to look at both questions - both the diagnosing and the drugs - but I'm sure you have a problem with what came first, the chicken or the egg. Did the shootings happen because of mental disorders or because of the drugs?"

    Considering that the FDA has recommended stronger warning labels for these antidepressants, say critics, one may assume that the federal agency made this decision based on official data. Congress would do well to ask for that data, critics urge. Getting the American Psychiatric Association to provide Congress with the science to prove even one of its more than 300 mental disorders would be unprecedented. But critics argue that until those questions are answered, American children will continue to be "medicated" with mind-altering drugs.

    Kelly Patricia O'Meara is an investigative reporter for Insight.

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