From Time Magazine - SPECIAL REPORT:
Escaping From The Darkness
Drugs like Prozac, Paxil and Luvox can work wonders for clinically depressed kids. But what about the long-term consequences? By HOWARD CHUA-EOAN
Megan Kellar is bubbly and bouncing and lip-synching to the Backstreet Boys. Get down, get down and move it all around! The sixth-grader is dancing to the synthesized bubble-gum beat at a talent show at the John Muir Elementary School in Parma, Ohio. Get down, get down and move it all around! There is nothing down about Megan, even as she gets down in front of the audience. Her mother remembers a similar effervescence half a dozen years ago. "She'd be singing to herself and making up songs all the time," says Linda Kellar. And sure enough, that part of her is still there. "Megan's such a happy child," the mother of a girl on Megan's baseball team remarked to Linda. Yes, Linda agreed, but there's something you ought to know. Megan is clinically depressed and on the antidepressant Paxil. Says Linda: "She couldn't believe it."
Six years ago, Linda wouldn't have believed that her daughter was clinically depressed either. But shortly after her parents separated, Megan stopped singing. When other kids came over to play, she would lie down in the yard and just watch. At Christmas she wouldn't decorate the tree. Linda thought her daughter was simply melancholy over her parents' split and took her to see a counselor. That seemed to help for a while. Then for about eight months, when Megan was 10, she cried constantly and wouldn't go to school. She lost her appetite and got so weak that at one point she couldn't get out of bed. When a doctor recommended Paxil in conjunction with therapy, Linda recoiled. "I did not want to put my baby on an antidepressant," she says. Then she relented because, she says, "Megan wasn't living her childhood." Linda noticed changes in just two weeks. Soon Megan was singing again. "She's not drugged or doped," says Linda. "She still cries when she sees Old Yeller and still has moody days." But, as Megan says, "I'm back to normal, like I used to be."
Megan Kellar shares her kind of normality with hundreds of thousands of other American kids. Each year an estimated 500,000 to 1 million prescriptions for antidepressants are written for children and teens. On the one hand, the benefits are apparent and important. Experts estimate that as many as 1 in 20 American preteens and adolescents suffer from clinical depression. It is something they cannot outgrow. Depression cycles over and over again throughout a lifetime, peaking during episodes of emotional distress, subsiding only to well up again at the next crisis. And as research increasingly shows, depression is often a marker for other disorders, including the syndrome that used to be called manic depression and is now known as bipolar disorder. If undetected and untreated in preteens, depressive episodes can lead to severe anxiety or manic outbursts not only in adulthood but as early as adolescence.
On the other hand, come the questions. How do we tell which kids are at risk? Has science fully apprised us of the effects on kids of medication designed for an adult brain? Have we set out on a path that will produce a generation that escapes the pain only to lose the character-building properties of angst?
To medicate or not to medicate? The dilemma can be traced back to 1987, when the FDA approved Prozac as the first of a new class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). Prozac had none of the more serious side effects and risks of the earlier antidepressants and worked faster to control depressive symptoms. Prozac and the other SSRIs (they now include Zoloft, Paxil, Luvox and Celexa) had one other advantage over the older, tricyclic antidepressants: children responded to them. One of the few recent studies on the subject showed that among depressed children ages 8 to 18, 56% improved while on Prozac, in contrast to 33% on a placebo. Says Dr. David Fassler, chair of the American Psychiatric Association's Council on Adolescents and Their Families: "Physicians have a lot of experience using the medications with adult patients with good results, and recent research increases their general level of comfort in using them with children and adolescents."
But which kids?
Not so long ago, many psychiatrists argued that children and young teens could not get depressed because they were not mature enough to internalize their anger. Today, says Fassler, "we realize that depression does occur in childhood and adolescence and that it occurs more often in children than we previously realized."
Still, depression is slightly harder to diagnose in adolescents than in adults, and not because teens are expected to be moodier and more withdrawn. They are less likely to realize that they are depressed and thus less likely to seek help. "Younger kids also have more difficulty expressing their feelings in words," says Dr. Boris Birmaher, a child psychiatrist at the University of Pittsburgh. "When kids become depressed, they become irritable, act out, have temper tantrums and other behavioral problems. It's hard to ascertain that these are the symptoms of depression unless you ask them questions in a language they can understand."
Furthermore, the very definition of being a child--what makes him survive and grow--is being able to move up and down emotionally, having a basic elasticity. Says Dr. Peter Jensen, child and adolescent psychiatrist at the National Institute of Mental Health: "A child is more fluid and plastic than an adult. A child may look depressed one day because his dog died but seem O.K. three days later."
But if parents live in a world of family mood swings, that doesn't mean they are prepared to put their own child on mind-altering drugs. That prospect can lead to major soul searching: Will they be thought less of as parents? And if they do agree to antidepressants, will the child still be the one they know?
Donna Mitchell was told her daughter, eight-year-old Sawateos, had attention-deficit hyperactivity disorder, but she also showed signs of serious depression and anxiety, which are often found in combination. Mitchell's first reaction was, "I can pray this away. I thought, Listen, nobody in my family is going on drugs. That's an insult. I figured all we needed was family talks." But two years after the diagnosis, Mitchell has agreed to put her child on the ADHD drug Ritalin. She still resists the idea of antidepressants. It's her preteen daughter who's making the case for doing it. "Mama, it's in our genes," Sawateos tells her.
All this may help explain why it is so hard for the people closest to children to detect that anything is really wrong. Studies show that parents consistently miss the signs of depression. In one survey by researchers at Ball State and Columbia universities, 57% of teens who had attempted suicide were found to be suffering from major depression. But only 13% of the parents of suicides believed their child was depressed.
Diagnosis is critical because depressed children tend to develop increasingly severe mental disorders and in some cases psychosis as teens and adults. Three studies on children who were depressed before puberty show that as adults they had a higher rate of antisocial behavior, anxiety and major depression than those who experienced their first depressive episode as teens. "Prepubertal depression does occur, and those who get it are more susceptible to [the] mania [of bipolar disorder] later," says Dr. John March, director of the program on pediatric psychopharmacology at Duke University. "The earlier you get it, the more likely you will develop chronic depressive and anxiety symptoms."
So how do psychiatrists pick out kids who are depressed from those who are simply moody? In his book "Help Me, I'm Sad," Fassler lists a number of physical symptoms in three age groups--preschoolers, young school-age children and adolescents. Among preschoolers, the signs include frequent, unexplained stomachaches, headaches and fatigue. Depressed school-age children frequently weigh 10 lbs. less than their peers, may have dramatic changes in sleep patterns and may start speaking in an affectless monotone. Adolescents go through eating disorders, dramatic weight gains or losses, promiscuity, drug abuse, excessive picking at acne, and fingernail biting to the point of bleeding.
Fassler cautions that none of these symptoms may ever be present and a whole constellation of more subjective manifestations must be considered. Adults and adolescents share many of the same warning signs--low self-esteem, tearfulness, withdrawal and a morbid obsession with death and dying. Among adolescents, however, depression is often accompanied by episodes of irritability that, unlike mood swings, stretch for weeks rather than days.
Dr. Elizabeth Weller, professor of psychiatry and pediatrics at the University of Pennsylvania, has developed techniques for detecting depression in kids. First she establishes a rapport with a child. Then she asks, for example, whether he still has fun playing softball or whether it is taking him longer to finish his homework--both of which are ways to figure out whether the child has lost motivation and concentration. Crying is another marker for depression, but Weller says boys rarely admit to it. So she asks them how often they feel like crying.
She then quizzes parents and teachers for other signs. Parents can tell her if a child no longer cares about his appearance and has lost interest in bathing or getting new clothes. Teachers can tell her whether a child who used to be alert and active has turned to daydreaming or has lost a certain verve. As Weller puts it, "Has the bubble gone out of the face?"
There are several other complicating factors. Some psychiatrists believe depression in younger children often appears in conjunction with other disorders. "Many depressed kids," notes Fassler, "are initially diagnosed with ADHD or learning disabilities. We need to separate out the conditions and treat both problems." But there's a chicken-and-egg problem here: antisocial behavior or a learning disability can lead a child to become isolated and alienated from peers and thus can trigger depression. And depression can further interfere with learning or bring on antisocial behavior.
But does a diagnosis of depression in a child require medication? Consider Nancy Allee's 10-month journey with SSRIs and other drugs. At 12, she was as bubbly as Megan Kellar is now. She soon developed "a five-month-long headache" and started having nightmares. After about a year in counseling, things seemed to be going better and, her mother Judith says, "we terminated it so as not to make it a way of life." A few months later, Nancy became hostile and rebellious but nothing that Judith considered "out of the bounds for a normal teenager." Then, "without any warning, she [took an] overdose" of her migraine medication, was hospitalized and depression was diagnosed. While Judith thought the overdose was out of the blue, Nancy says, "I'd had depression for a long time. If I'd had bad thoughts, I'd always had them and kind of grew up with them. I was always very bubbly, even when I was depressed. A lot of people didn't notice it. To me, suicide had always been an option."
Nancy was put on Zoloft. When that didn't work, the doctor added Paxil and then several other drugs. But there was a panoply of side effects: her hands would shake, she would bang her head against the wall. A voracious reader, she became too withdrawn and listless to pick up a book. There were times she couldn't sleep, but on one occasion she slept 72 hours straight.
"I was seeing five different doctors, and it was overkill," says Nancy. "At one point, I was taking 15 pills in the morning and 15 in the evening. I wound up burying my medication in the backyard. I didn't want to take it anymore." Then Nancy was tested for allergies, a process that required her to be medication free. "It was like the sky was blue again," says Nancy, who at 18 is still off drugs but sees a counselor occasionally. "The colors came back. It was a total change from the medication stupor. Everything wasn't peachy, but I was able to appreciate doing things again."
Most psychiatrists, despite their enthusiasm for the new antidepressants, write prescriptions for only six months to a year and taper the dosage toward the end. Even Fassler admits, "We try to use medication for the minimum amount of time possible. And with a younger child, we're more cautious about using medication because we have less research concerning both the effectiveness and the long-term consequences and side effects." Says Michael Faenza, president of the National Mental Health Association: "I feel very strongly that no child should be receiving medication without counseling. Medication is just one spoke in the wheel."
The lack of science about the effects of these drugs on childhood development is the reason the FDA has required all manufacturers of SSRIs that treat depression to conduct studies on the subject. Says Dr. Peter Kramer, professor of psychiatry at Brown University and author of Listening to Prozac: "Anyone who thinks about this problem is worried about what it means to substantially change neurotransmission in a developing brain. We don't know if these kids would compensate on their own over time and if by giving them these medicines we are interfering with that compensatory mechanism."
Until we know more, some argue, the risks of such medication are just too great, if only because of the message it sends to children. Says Dr. Sidney Wolfe, director of Public Citizen's Health Research Group: "We are moving into an era where any quirk of a personality is fair game for a drug. On one hand, we are telling kids to just say no to drugs, but on the other hand, their pediatricians are saying, 'Take this. You'll feel good.'"
Teen rebellion can put a twist on even that, however. One New York couple, becalmed by antidepressants themselves and openly concerned about the depression of their 18-year-old, were castigated by their son for their "weakness" and dependence on Prozac. His argument: your drugs change who you really are. In place of their drugs, the young man argued for his "natural" remedy: marijuana.
Indeed, pot and alcohol are common forms of self-medication among depressed teens. Weller estimates that about 30% of her teen patients have used pot or alcohol after a depressive episode, most of them at the urging of friends who said smoking and drinking would make them feel better. A high school social worker in Minnesota decided to look into the case of a troubled girl who was still a freshman at 17. The girl admitted she smoked pot as a constant habit but did not understand why she craved it so much. A psychological evaluation found the girl was suffering from clinical depression as well as ADHD. She was prescribed an antidepressant, which had striking results. It not only elevated her mood and helped her focus but also reduced her desire for pot and tobacco.
"It used to be said that adolescence is the most common form of psychosis," says Kramer, the man who helped make Prozac famous. Then he turns serious. "But if a child has a prolonged period of depressive moods, he needs to be evaluated for depression." Even if little is known about the long-term effects of SSRIs on young bodies, most doctors in the field argue that the drugs are a blessing to kids in pain. Says Duke's March, who is doing a comparative study of the benefits of Prozac and cognitive-behavior therapy: "My clinical experience is that it's worse to risk a major mental illness as a child than to be on medication. If you weigh the risks against the benefits, the benefits are probably going to win."
Susan Dubuque of Richmond, Va., is convinced of the benefits. Her son Nick went through "seven years of testing hell." At seven, ADHD was diagnosed and he was put on Ritalin. "When he was 10 years old, he didn't want a birthday party because he just couldn't deal with it," she recalls. Then, his mother says, Nick "bottomed out and became suicidal, and one day I found him in a closet with a toy gun pointed at his head, and he said, 'If this was real, I'd use it.'" The next day she saw a psychologist who had recently evaluated Nick and was told, "If you don't get him help, next time he'll be successful." Nick was found to be suffering from clinical depression and took a series of antidepressants. "I was worried about my son's killing himself," says Susan, who was called by clinicians a "histrionic mother" and a "therapy junkie," as she spent $4,000 on drugs and therapy for her son. "I would have sold my house if that was what it would have taken."
Nick is better now, and has co-authored a book with his mom: Kid Power Tactics for Dealing with Depression. Susan is happy to have her son back safe--even though there is some stress. "It's so much fun to have an obnoxious 15-year-old," she says, "and I mean normal obnoxious."
--REPORTED BY JODIE MORSE/NEW YORK, ALICE PARK/WASHINGTON AND JAMES WILLWERTH/LOS ANGELES
How to Spot a Depressed Child
The key thing to watch for is drastic changes in teen behavior. Other red flags to consider:
Source: Help Me, I'm Sad by Dr. David Fassler and Lynne Dumas