Experts say it can stunt growth, damage young brains and even trigger suicide. Yet now the controversial anti-depressant Prozac is about to be prescribed to youngsters of just eight. Jerome Burne of The Daily Mail investigates:
James was ten when he was first put on the antidepressant Prozac. His mother was an invalid, and after his father left home, the pressure of caring for his mother had become overwhelming.Sometimes James would sit and stare into the middle-distance, not responding to anything; other times he’d lock himself in his room. He cried a lot. Increasingly, he refused to go out because he was being bullied at school. “He started showing signs of depression,” says Jude Sellen, a children and adolescent mental health consultant at the charity Young Minds, who was involved with his case. “His situation was very difficult and he badly needed psychological help.” But there was an 18-month wait for therapy, so what he got instead was long-term treatment with an antidepressant. Two years later he is still on Prozac – even though it causes him stomach problems, including diarrhoea and painful cramps, and makes him feel ‘funny’. He also suffers from painful headaches. He wants to stop taking the medication, but when he does, he becomes violent – a potential side-effect of withdrawal from drugs such as Prozac – and his mother insists that he goes back on the pills.James is now being seen by a psychologist and his medication is being reduced. But as Sellen points out, his case shows “how important it is to monitor patients on the drug carefully – and only use it short-term”.
The tragedy is that stories such as James’s are becoming increasingly common. Last week, in a controversial move, the European Medicines Agency announced that depressed children as young as eight could be given Prozac. This is one of a class of drugs known as selective serotonin reuptake inhibitor, or SSRIs – and in America, children as young as three are already being prescribed them. These drugs have already been linked with a raised risk of suicide and patients becoming dependent on them. But some experts are now concerned about giving these drugs to younger children because almost nothing is known about how these drugs might affect their growing brains. “This is ignorance in the broadest sense of the term,” said Dr Glen R. Elliott, a child psychiatrist at the University of California at San Francisco. “We don’t know if this is a good idea or not.” The drugs might also stunt growth. One trial, reported two years ago, found that children given Prozac between the ages of eight and 17 were, on average, 1cm shorter and 1.1kg lighter than those on a placebo.In fact, we don’t really know exactly how SSRIs work to treat depression in adults or children – we believe they increase the amount of the ‘feel-good’ chemical serotonin in the brain, but evidence for this theory is surprisingly thin on the ground. The latest research suggests that they work by encouraging the growth of new brain cells. But whether this is good for a young brain that is already growing fast is also unknown.
What is known is that childhood depression is a growing problem in the UK. About one per cent of children aged five to 11 and three per cent of adolescents aged 11 to 18 are thought to suffer from depression in any one year – with 80,000 five to 16-year-olds suffering from serious depression. Some experts believe that the increase is partly to do with children’s high expectations – they expect life to be rosier than it is. Others suggest that children are being exposed to increasingly stressful and emotional experiences, such as sex. Whatever the cause, the difficulty for parents is knowing if their child is depressed or just feeling a bit down. And giving medication to children who are not seriously depressed is a cause for concern.
The new guidelines from the European Medicines Agency recommend that the first line of treatment for moderate to severe depression should be psychological therapy. Only after four to six sessions can fluoxetine – the name of the chemical in Prozac – be prescribed, and even then it should be combined with therapy. However, there is a drastic shortage of therapists as the case of James shows. He has been on Prozac for two without having any Provision of psychological services across Britain is notoriously patchy. A recent report estimated that 10,000 more therapists were needed to provide effective treatment for depression in all age groups. As a result, the problem of medication without counselling is increasing.
David Cottrell, Professor of Child and Adolescent Psychiatry at the University of Leeds, says: “Far more prescriptions are written for children than there ought to be, and many GPs are not so good at monitoring the effects.” But there is a more deep-rooted problem. In 2003, the Medicines and Health Products Regulatory Authority advised that most SSRIs were not suitable for children, and that only fluoxetine should be given to them. However, research by the Mail has found that doctors are still prescribing the other SSRIs. In other words, while we worry about children being given Prozac, many of them might be receiving other antidepressants that the health authorities have said are not suitable for children.
In a written response to a Parliamentary question by Liberal Democrat MP Paul Burstow, the Department of Health revealed that four SSRIs which the drug regulator has said should not be used are still being widely prescribed.
One of these is Venlafaxine (Effexor), which, not only is unlikely to produce any “clinically important improvement” but, astonishingly, has a rate of “suicide-related events” 14 times greater than a placebo, according to a major review published in The Lancet in 2004. His study looked at all the evidence for the safety and effectiveness of the five SSRIs most commonly used to treat children. And conclusion about one of them, Citalopram (Cipramil, Celexa), was equally worrying: “It is unlikely to produce a clinically important reduction in depressive symptoms” and doubles the risk of suicide.
One of the authors of this study was Professor Cottrell, who at the time explained that the review was unusually reliable because it combined published with unpublished trials. The conclusion of The Lancet review was that only Prozac was suitable, while the others – including Paroxetine (Seroxat) and Sertraline (Zoloft) should be avoided. The intention of the trial was to provide information to guide doctors. But, clearly, GPs did not heed the alarm bells – for as the Parliamentary figures reveal, only around 30 per cent of antidepressant prescriptions written for children under 18 in 2004 were for Prozac. Another 35 per cent were for one or other of the four ‘banned’ drugs (the cost to the NHS for Prozac was £407,107, and for the other SSRIs, £1.6 million). The remainder of the prescriptions were for other forms of antidepressants. “Doctors do seem to be flouting the guidelines,” says Professor Cottrell.
“Doctors are allowed to prescribe drugs that don’t have a licence for that use, and while there will be a small number of cases where these drugs could be relevant – such as anxiety or obsessive compulsive behaviour – a large percentage of these prescriptions should not have been written.” Dr Jim Kennedy, prescribing spokesman for the Royal College of General Practitioners, questions whether doctors are prescribing medication without therapy. “But these figures do raise the question: are there any hotspots where more are being prescribed than should be?” he says. “I think we should be looking in detail at how doctors are prescribing, and if we find a problem, we should re-educate GPs in those areas.”
The Department of Health, while noting the guidelines state that antidepressants should “be used rarely in the five to 11 age group”, says that “it is for clinicians to decide which of these drugs, if any, to prescribe to their patients. “It is important to note that some drugs which may be classified as antidepressants are used for other disorders such as nocturnal enuresis (bed-wetting), anxiety, obsessive compulsive disorder and phobic states.” Most clinicians agree that when faced with the pain of a child who is severely depressed, the benefits associated with antidepressants outweigh the risks. “Most experts recognise that psychological support is very important and should be tried first, but there are cases where a drug can help,” says Professor Cottrell. However, he adds: “Prozac has been the only drug recommended for children here since 2003.” Meanwhile, if children like James are ever to have a real chance in life, much more attention must be paid to providing the kind of psychological support that everyone agrees is needed, and there should be a serious attempt to stop prescribing drugs that are known to be ineffective and dangerous.