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Sept. 6, 2004, 9:13AM

Prozac concerns intensify

Doctors evaluate if antidepressants in kids can lead to acts of violence

Copyright 2004 Houston Chronicle

Advice for parents of kids on antidepressants:
? Evaluate: Get a good evaluation by a mental health professional with appropriate training and expertise.
? Be an advocate: Ask lots of questions on behalf of your child.
? Be informed: Get as much information as you can about the diagnosis and treatment options.
? Monitor: Work closely with the doctor to monitor your child's response.
? Watch out: Eliminate access to firearms and potentially lethal medication.
? FDA warning: The drugs that are the focus of a new FDA warning are Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Wellbutrin, Effexor, Serzone and Remeron

The fatal shooting last month of a Galveston doctor by his 10-year-old son, who was taking Prozac, is fueling ongoing concerns about the use of antidepressants by pediatric patients.

Most medical experts don't believe antidepressants prompt violent acts. Rather, it's the brew of emotional difficulties prompting the prescription in the first place ? plus access to a gun ? that can boil over into a destructive act.

"Children who are depressed can have violent impulses either self-directed or other-directed as symptoms of their difficulty," said Dr. Jon Sergeant, a psychiatrist for 25 years who heads child psychiatry at Ben Taub General Hospital. "To the best of anyone's knowledge, it doesn't look as though (antidepressants) in and of themselves make children act in a suicidal or violent way."

The Aug. 27 death of Dr. Rick Lohstroh came at a time when the U.S. Food and Drug Administration was already re-examining antidepressant side effects in children. This month, the FDA will hold a public meeting to discuss the issue and take suggestions for labeling changes and possible regulatory actions.

"The general clinical consensus is that the potential benefit of these medications far outweighs the risk," said Dr. David Fassler, a child psychiatrist at the University of Vermont. "There's still plenty we don't know."

Prozac, introduced in 1987 as the first of a new generation of antidepressants, initially spawned worries about teenage suicide. Scientific studies ultimately dispelled those concerns, and last year, the FDA approved Prozac for use in children.

Recent studies have shown that Prozac, combined with psychotherapy, produces the best chance of recovery for children with depression ? better than either drugs or therapy alone.

However, uncertainty persists about side effects in pediatric patients. No one knows the long-term effects of the drugs on a child's brain. In June 2003, a study of Paxil, a drug similar to Prozac, suggested an increased risk of suicidal thoughts in children compared with those taking a placebo.

In March, the FDA issued a public health advisory asking antidepressant makers to warn users of the need to closely monitor for worsening depression or the emergency of suicidal behavior, particularly at the beginning of therapy or when a dose is increased or decreased.

Prozac and nine other antidepressants known as SSRIs ? or selective serotonin reuptake inhibitors ? are the focus of the new warning. The FDA said anxiety, agitation, panic attacks, insomnia, irritability, hostility and impulsivity have been reported as side effects by adult and pediatric patients.

The FDA hasn't concluded the drugs are to blame but said patients with these symptoms might be at increased risk for depression or suicidal behavior.

Deborah Geisler, the 10-year-old boy's mother, said a psychiatrist prescribed Prozac for her son in early August after he was diagnosed with depression and anxiety. He started with a 10-milligram dose and gradually moved to higher doses.

A week before the shooting, Geisler said, the boy started taking a once-a-week, time release dosage of 90 milligrams. He took his second 90-milligram pill just hours before the shooting, she said.

Dr. Andrew Harper, an associate professor of child psychiatry at the University of Texas Medical School at Houston, said such a dose would be "reasonable" for an adult and probably appropriate for a child, although the long-acting form hasn't been well-studied in kids.

Harper said drug side effects of hostility or impulsiveness most likely would result in verbal aggression or perhaps a thrown punch rather than a multi-step plan to use a gun.

"I think it would be extremely rare," Harper said.

Information about whether the boy was in psychotherapy was not available. Geisler and her ex-husband had gone through a contentious divorce, finalized last year, and the shooting occurred when the father arrived to pick up his sons.

"An acrimonious divorce puts a lot of pressure on a child," said James Bray, a Baylor College of Medicine psychologist who focuses on children, stepfamilies and the issue of divorce. "If a child has emotional or behavioral problems prior to the divorce, that kind of stress can accentuate ... those sorts of issues."

Experts highlight two safety recommendations for children beginning treatment for depression or anxiety: Make sure there is no access to firearms or to potentially lethal drugs.

Prozac, Harper said, can strengthen children's resources and enable them to deal with troubling situations, but the drug won't prevent them from reacting to family stress. The drug will neither drive a child to use a gun nor stop a child who is planning to use a gun, he said.



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