Pop the pills away

Prozac has for a long time enjoyed a reputation as the most well
known antidepressant on the market. But it now has another claim to
fame. Since an announcement last month, it has become the only
antidepressant from the group known as selective serotonin reuptake
inhibitors (SSRIs) that should be used to treat depression in
under-18s, writes Katie Leason.

Controversy around the safety and effectiveness of the SSRIs has
been gathering momentum for a while. Last April, the Committee on
Safety of Medicines, an independent group of scientists that
advises the government, set up an expert working group to look at
their safety. In June, it advised that paroxetine (trade name
Seroxat) should not be used to treat depression in under-18s, and a
similar warning followed in September for venlafaxine
(Efexor).

The picture around the remaining SSRIs was completed last month.
After reviewing clinical trial data, the committee found that, for
the treatment of depression in under-18s, there were more risks
than benefits for three and that the fourth could not be accurately
assessed. Consequently it advised that in addition to Seroxat and
Efexor, sertraline (Lustral), citalopram (Cipramil), escitalopram
(Cipralex) and fluvoxamine (Faverin) should not be prescribed for
depression in under-18s. Only fluoxetine (Prozac) was found to have
more benefits than risks.

Although side-effects accompany most forms of medication, those
associated with some of these drugs were disturbing and included an
increased rate of self-harm and suicidal thoughts. Other symptoms
varied from insomnia and agitation to tremor and loss of
appetite.

But despite the drugs being contraindicated, it is vital that
patients already taking them do not suddenly stop without seeking
their doctor’s advice. New patients are unlikely to be prescribed
them, or even Prozac, without the agreement of a specialist, but
individuals responding positively to the treatment may be advised
to finish the course. And the new advice does not affect the use of
Lustral and Faverin to treat obsessive compulsive disorder.

It is estimated that 40,000 under-18s in the UK are on SSRIs, of
whom about half take Prozac. The other main types of medication
used to treat depression are tricyclic antidepressants, but SSRIs
are generally preferred because they do not cause constipation,
blurred vision or dry mouth.

What is the alternative?

The advice from the committee will leave a hole in treatment
options, so what is the alternative?

Ruth Stark, professional officer for Scotland for the British
Association of Social Workers, says more investment in support will
be needed to help the young people through the issues around
depression so that medication is used only as a last resort.

She believes there has been an over-reliance on medication.
Consideration may be given to non-medicine based options such as
play therapy and family therapy for younger children – but
teenagers often find themselves handed a prescription.

“Anything that prevents a child having to take medication when they
don’t need it – and other therapy would work at least as well – is
much better for the long-term prognosis of the child,” she
says.

However, medication is cheaper than labour-intensive psychological
therapy, and may be a quicker option than a referral to the long
waiting list of a child and adolescent mental health service
(Camhs).

But more GP referrals to specialist Camhs could be a consequence of
this new advice on SSRIs. Lee Miller, training and consultancy
manager at charity YoungMinds, says GPs often have only medication
at their immediate disposal and, if this option is limited, may
have to refer on more cases. This may sound like a good thing but,
in reality, Camhs are already oversubscribed.

“Camhs will be under more pressure and have fewer resources
themselves if they are less able to prescribe antidepressants.
There will be more pressure on the other services they have,” says
Miller.

Limited support

Beyond the services that professionals can offer to children and
young people, other support is limited. The charity Depression
Alliance co-ordinates a national network of self-help groups for
people with depression. The meetings are usually informal where
people discuss coping strategies without a medical person
present.

“It’s a discussion with people who actually understand, with nobody
watching them and bombarding them with advice,” says policy manager
Amelia Mustapha.

However, she says there are no self-help groups for children as
they would be difficult to run for this age group. This is equally
true for internet support groups, as it would be difficult to
monitor their safety. She adds that the announcement could also
deter parents from seeking help for their children as they may
start doubting their doctor’s opinion.

The Royal College of Psychiatrists is preparing a formal response
to the committee’s announcement. Child psychiatrists have
long-standing concerns about prescribing for under-18s as they do
not appear in the drug formularies, which are books that contain
drug formulas and how they should be prescribed and used. No drug
is licensed in the UK to treat depression in children, but doctors
prescribe outside the licensed conditions. None of the inhibitors
has ever been licensed for use in under-18s.

The Committee on Safety of Medicines guidance states that child and
adolescent psychiatrists may occasionally decide to use these
contraindicated drugs but that other doctors will need to seek
specialist advice even to prescribe Prozac. If this means that GPs
cannot prescribe SSRIs but that child and adolescent psychiatrists
can, this too would put more pressure on Camhs.

New guideline on depression

The National Institute for Clinical Excellence is developing a
guideline on depression in children that is due in April 2005. It
will set out how the illness should be identified and managed and
will look at the use of pharmacological treatments.

Meanwhile, a legal case is being put together in relation to
Seroxat. About 6,500 individuals or their relatives are complaining
that patients experienced withdrawal difficulties, attempted or
committed suicide or became aggressive. Evidence is still being
gathered but, if an agreement is not reached with manufacturer
GlaxoSmithKline, court proceedings will start.

In the light of the situation regarding the other SSRIs, one cannot
help wondering whether this could be the first of many such court
cases.