Depression cure may be a curse

By REBECCA WALSH

They are the drugs designed to lift the dark cloud of depression, and for some people they work incredibly well.

But overseas studies suggest that for some children and young people the reverse is true. Those studies have called into question how effective the new antidepressant drugs are for this age group and, more worryingly, whether they are linked with suicidal thoughts.

As a result, Britain has effectively banned the use of most Selective Serotonin Re-uptake Inhibitor antidepressants (SSRIs) for young people and the American Food and Drug Administration (FDA) has asked drug manufacturers to place detailed warnings about possible side-effects prominently on their labels.

Despite that, New Zealand authorities have no plans to change the way the drugs are prescribed, saying the studies are inconclusive. They say they will review that this year when more detailed results are available.

More and more New Zealanders are taking antidepressants. Last year about 1800 6- to 18-year-olds took SSRIs, a 605 per cent increase since 1996.

At the same time, 103,606 people aged 19 and over were prescribed the drugs, a 455 per cent increase.

Should we be worried?

Last week in the United States the FDA warned that patients using 10 of the most popular modern antidepressants, including Prozac and Aropax, both SSRIs, should be closely monitored for signs of suicidal behaviour.

It had ordered research into whether SSRIs worked in children after noticing increasing paediatric use of the drugs.

The FDA is still analysing the data but preliminary results suggest that suicidal behaviour and attempts, while infrequent, might be two to three times greater among users of some SSRIs.

About 3.2 per cent of children on the drugs exhibit such behaviour, compared with 1.5 per cent of those given placebos.

Studies in adults have found no link between the drugs and suicide but the agency has included adults in the warnings. In New Zealand none of the SSRIs has been specifically approved for use by people under 18, but doctors have the discretion to prescribe them and do.

After reviewing international concerns, the Medicines Adverse Reactions Committee concluded that given the small number of studies, the limited patient numbers and inconsistencies between studies, it could not make an "accurate determination" of the risks and benefits of SSRIs for under 18-year-olds.

Ministry of Health spokesman Dr Stewart Jessamine acknowledged treatment options for under-18s were limited and said SSRIs could continue to be used, with the support of specialist advice.

The decision, which doctors, psychiatrists and mental health organisations support, will be reviewed this year.

The question of whether suicidal thoughts are sparked by the drugs or the depression itself is difficult.

Dr Allen Fraser, chairman of the New Zealand College of Psychiatrists, is adamant antidepressants do not cause suicide.

"It is the disorder that is the problem rather than the treatment. The treatment may not be working, it may have side-effects, which then add to the despair the patient feels as a result of the illness.

"It is not the antidepressants themselves that cause a person to want to die. That's just too simplistic."

Studies had shown that antidepressants reduced the risk of suicide when compared with no treatment.

Dr Fraser said that rather than saying one group of patients should not be using the drugs, people needed to be aware of what to look for and how to support a depressed person. He also said that medication did not mean "everything is going to be sweetness and light from now on".

Being prescribed Prozac at 16 caused more confusion and frustration for Auckland woman Michelle (not her real name).

Four months after she started taking the drug she began cutting her arms with a razor blade and later tried to kill herself.

Now 32, she believes the reason she was "moody and shitty" was more to do with her family circumstances - she was being sexually abused by her brother - but no one ever asked her what was wrong.

"I think for me the drugs may have worked if they had been done in conjunction with some other work, but there was none of that. The Prozac at 16 was supposed to be the fix. It was going to make me okay."

Doctors and psychiatrists reject suggestions the drugs are being given out like lollipops, but admit it may be easier in some cases to give a patient drugs if access to alternative services is difficult.

Dr Peter Foley, chairman of the GP Council, said he hoped drug therapy was administered alongside psychiatric involvement and other forms of treatment such as psychotherapy, counselling and investigation of a young person's social environment.

"Whether it's their schooling, work, how they feel about themselves, what failings they may perceive, it's a difficult growing-up time of life. We have to look at the whole person and their environment in treating their depression."

But he acknowledged that prescribing drugs was the last resort in some parts of New Zealand, where there might be no option of alternative services such as counselling.

While GPs did the best they could, he said, but they were not funded to spend extra time with patients, which was often what young people with depression needed.

A report released at the beginning of the year by the Health Ministry's Clinical Training Agency found that by international standards New Zealand was short of 118 psychiatrists.

The World Health Organisation recommends a ratio of one child and adolescent psychiatrist for every 50,000 people, but New Zealand has just 25 - a ratio of one to 156,000.

Dr Denise Guy, chairwoman of the Faculty of Child and Adolescent Psychiatry, said more staff were desperately needed at a community level "which is where we would want to be addressing the kind of psycho-social interventions in this age group".

Dr Peter Watson, director of Spinz (Suicide Prevention Information in New Zealand), agreed that drugs were only part of the treatment of young people with depression.

But he pointed out that as well as a lack of services, the common attitude that people could go to the doctor and get a pill to make any problem go away had to be overcome.

"We have become a pill-popping society. We do it with lots of things rather than spending time on some of the other underlying causes."

In 1996 general practitioners were allowed to prescribe SSRI drugs, something which had previously been the sole domain of specialists. At the same time, greater awareness and more open-mindedness about depression, through publicity such as the Like Minds campaign, also had an impact.

Pharmac medical director Dr Peter Moodie said that while a 605 per cent increase in the number of children on antidepressants sounded huge, only about three in every 1000 children were taking SSRIs compared to about 38 in every 1000 adults.

Still, he said, the increase was significant and in May Pharmac's clinical advisory committee would look at whether it should apply restrictions on the drugs to particular groups.

Michelle believes more focus needs to go on why young people are depressed and on providing co-ordinated resources. She now has a therapist who works closely with her GP if she starts to feel ill again.

Often young people think if they don't have suicidal thoughts they can't ask for help, she says, but it should not need to get to that stage.

Spending on antidepressants

* Last year antidepressants came fourth on Pharmac's list of top 20 expenditure groups. $32.7 million was spent on antidepressants ($30.1 million of that was on selective serotonin re-uptake inhibitors or SSRIs).

* A further $40.8 million was spent on antipsychotic drugs.

* Anti-ulcerants topped the spending pool at $52.2 million.

* Worldwide, an estimated US$12 billion ($18.58 billion) was spent on antidepressants in 2002.

* Last year in New Zealand 1786 six to 18-year-olds took SSRIs - a 605 per cent increase on 1996.

* At the same time, 103,606 people aged over 19 were prescribed the drugs - a 455 per cent increase on 1996.

RELATED WEBSITES

www.mentalhealth.org.nz

www.spinz.org.nz

www.medsafe.govt.nz