By ROD MICKLEBURGH
From Tuesday's Globe and Mail
Vancouver
Widely used antidepressant drugs prescribed to tens of thousands of Canadian teens and children are barely more effective than placebos in treating adolescent depression, according to a leading Canadian expert in the field.
The assertion by psychiatrist Jane Garland follows a recent cascade of critical information questioning the risk and effectiveness of prescribing antidepressant medication for troubled young patients.
"The disappointing reality is that antidepressant medications have minimal to no effectiveness in childhood depression beyond a placebo effect," Dr. Garland said in a commentary in Tuesday's Canadian Medical Association Journal.
Dr. Garland, head of the Mood and Anxiety Disorders Clinic at Children's Hospital here, said the lack of evidence showing significant benefits from adolescent use of the drugs is stunning, given the huge increase in such prescriptions over the past few years.
Seven drugs known as SSRIs (selective serotonin reuptake inhibitors) are under fire, one of them is well-known Prozac. Although no national figures for adolescent use are available, in British Columbia, an estimated 6,200 children and teens were prescribed SSRIs in 2002, more than double the number four years earlier. All told, nearly 14 million SSRI prescriptions were written for Canadians of all ages in 2002 and cost $869-million.
Drug manufacturers have come under increasing attack for withholding trial results indicating slight increases in suicidal behaviour, adverse side effects and only minimal effectiveness of SSRIs in children and teenagers.
Several drug tests that came to light last year prompted British authorities in effect to ban prescription of all SSRIs except Prozac to patients under 18.
Two weeks ago, Health Canada issued an advisory to anyone under 18 taking one of seven antidepressants to consult with their doctors "to confirm that the benefits still outweigh the potential risk."
In her commentary, Dr. Garland called the situation a crisis in the treatment of childhood depression, which she said affects one in five Canadians at least once.
She criticized "opinion leaders in child psychiatry" for remaining silent in the face of escalating data on the relative ineffectiveness of SSRIs. "It is disturbing."
Dr. Garland cited one study showing that 69 per cent of clinically depressed young patients improved taking the SSRI drug Zoloft, compared with 59 per cent who improved taking a placebo.
"Essentially, only one in 10 patients receiving [Zoloft] improved, a result described in the report as 'statistically and clinically significant' when it is almost certainly clinically meaningless."
She said some trial results indicate SSRIs may help adolescents with anxiety disorders or particularly severe depression that has resisted other forms of treatment.
"But those with milder, garden-variety depression may be no better off than with a placebo," Dr. Garland said yesterday in an interview.
She said physicians should inform young patients and their parents that medication will not cure depression, although it might improve some symptoms. And they should also be told that psychiatric or behavioural adverse effects are at least as likely as antidepressant effects, Dr. Garland said.
No SSRI has been approved by Health Canada for patients under 18, although the so-called "off-label" use of medications is common in many areas of treatment.
At Children's Hospital, in light of new doubts about antidepressants, psychiatrists are recommending only two for new patient prescriptions: Prozac for depression, and Zoloft for obsessive-compulsive disorder.
Dr. Marshall Korenblum, chief psychiatrist at the Hincks-Dellcrest Centre for Children in Toronto, is concerned but unconvinced by recent disclosures questioning the adolescent use of SSRIs.
"We've had 10 years of experience with some of these drugs, and we didn't hear about them in such negative terms before."
Dr. Korenblum said he has had good results prescribing SSRIs to his young patients. "A reduction in anxiety. A lifting of depression. Normalization of sleep and eating habits."
But he agreed more patient monitoring is needed because of the new data. "Some of the negative tests are alarming and disturbing. . . . I am in favour of closer monitoring and stiffer warnings. But the evidence is not strong enough for an outright ban."
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