Posted by catachrest on August 25, 2004, at 13:07:02
'It's awfully hard to get them off'
Withdrawal can make symptoms worse for some kids with anxiety disorder
Sharon Kirkey
canada.com
Monday, June 14, 2004
OTTAWA - Doctors call it the “socks sign” - anxious children who are so hypersensitive to touch they can’t bear to keep socks on their feet.Every itchy shirt and pant label has to come off too, and they fret obsessively about everything: “Are my parents going to get divorced? Will a bomb drop on us? Will there be an earthquake tomorrow?”
But getting children with an anxiety disorder off the drugs they take to feel better can make their symptoms even worse.
“They can feel irritable, more anxious and dizzy, and these are kids with a very low tolerance for any kind of feeling in their body,” says Dr. Jane Garland, clinical head of the Mood and Anxiety Disorders Clinic at B.C.’s Children’s Hospital in Vancouver.
Even when doctors taper the dose to the point they’re opening capsules and crushing pills, “if you get some of these symptoms, it’s awfully hard to get them off. And that’s not something we anticipated. We thought it would be easier.”
Health Canada is warning parents and doctors to watch for unusual feelings of agitation, hostility, anxiety or impulsive or intrusive thoughts, including thoughts of self-harm, in children and teens coming off SSRIs and other newer antidepressants.
The withdrawal reactions began to surface soon after the drugs hit the market 15 years ago and the medicines now carry a warning label about discontinuation symptoms. But some parents say their doctors never warned them about the irritability, anxiety and depression-like symptoms children can experience when they come off the pills.
Kathryn Graham is one of the founding directors of a support association for parents of children with mental illness. “When I was providing parent support, from 1999 into 2002, we weren’t really aware of the danger of coming off the SSRIs, nor do I recall either myself as a parent, or other parents, being informed of withdrawal reactions until last year,” says Graham, whose 18-year-old daughter, Kaitlin, committed suicide two years ago by overdosing on insulin.
The Ottawa teen had been on SSRIs before she died, but her mother suspects she might have stopped taking her medications because the autopsy toxology report showed no signs of the drugs in her system.
“Most kids stayed on the medications. They were just increased or added to. It was just a big experiment. All our children seemed to start on the same one or two medications and, if that didn’t work, they progressed to something else.”
According to Health Canada, withdrawal symptoms can cause significant sickness and can occur after the treatment is stopped, the dose is reduced or doses are missed. Symptoms include dizziness, vertigo, nausea, vomiting, flu-like symptoms, insomnia, vivid, bizarre dreams, agitation, a “spaced out” feeling and suicidal thoughts.
A frequent complaint is something not seen with any of the older antidepressants, doctors say: electric shock-like sensations that can last a few seconds but can occur throughout the day. According to the University of British Columbia’s continuing pharmacy education program, in the most extreme case reported, the electric shocks lasted 13 weeks.
There is scant research into withdrawal symptoms reported in children. In adults, symptoms usually occur after the person has been on the antidepressants for two to three months, but the phenomenon has been reported in patients who took the drugs for as little as five weeks. And, according to UBC researchers, withdrawal has occurred even with the lowest possible daily dose.
Last year, a U.S. federal judge ordered GlaxoSmithKline, makers of Paxil, to stop running advertisements that claimed "Paxil is non-habit forming." The ruling followed a class-action lawsuit by some three dozen patients who claimed they suffered withdrawal reactions to the drug.
SSRIs are "not addictive, in the sense that you leave your job and rob banks to pay for your habit, or you need escalating doses or get a ’high’," says Garland. "But addictive in the sense that it is extremely difficult to stop them."
Child psychiatrists say withdrawal symptoms, if they do occur, usually last only one to three days and require no treatment. But the reactions can be easily misdiagnosed as a sign the depression or underlying illness is coming back, leading doctors to bump up the dose or re-start the drug. In rare cases, children have been hospitalized.
One six-year-old Ottawa girl was taking an adult dose of Effexor when the medication was cut from 112.5 mg to zero over six days. Her parents say she became agitated, startled easily and suffered a panic attack at school.
No one knows exactly what causes SSRI withdrawal syndrome, but some patients may be more vulnerable than others because of the way their body breaks the drugs down, says Dr. Barbara Mintzes, of the UBC Centre for Health Services and Policy Research.
“Paxil is metabolized by the enzymes in the liver, and about eight per cent of the Caucasian population are poor metabolizers who have an inefficient form of the main enzyme involved.” The result is higher concentrations in the bloodstream at the same dose.
But the greatest risk appears to be with drugs with short “half lives,” meaning the time it takes for half the original dose to leave the body, says Dr. John Walker, a clinical psychologist at the University of Manitoba. Paxil and Effexor, which have among the shortest half-lives, have been found to have high rates of withdrawal reactions, followed by Luvox and Zoloft. Prozac, on the other hand, which has a half-life of four to six days, versus about one day for Paxil, normally doesn’t carry a risk of withdrawal syndrome.
What worries Garland is that some of the children and teens who experienced withdrawal with the newer antidepressants started their medication for reasons that were “pretty soft.”
“They were stressed out about school, and maybe getting behind on their assignments and they started to feel it was getting hard to get up in the morning.
“In fact, they were swamped. And what they needed to do was to work with a school counsellor or teacher and prioritize assignments and make it doable. That should have been the first step, not medication.”
Garland says it is crucial that no child stop his or her antidepressants abruptly. Rather, the dose should be tapered and any unusual symptoms or behaviours immediately reported to the doctor.
Meanwhile, doctors are seeing more babies born with what appear to be SSRI drug reactions.
“There have been case reports of small numbers of infants who seem to have either pharmacological effects of these drugs when they were born, or withdrawal effects from them,” says Dr. Donna Stewart, professor and chair of Women’s Health at the University Health Network and University of Toronto.
In one study involving babies born to women who took Paxil during pregnancy, the babies showed signs of rapid withdrawal. “They looked a little bit like an adult human having withdrawal symptoms," Stewart says. “They were jittery, they cried more, they didn’t suck so well and they tended to get admitted to the neonatal intensive care units for brief periods of time for observation.”
None of the symptoms reported so far in babies exposed to SSRIs in the womb appear to be life threatening, she stressed, and there are no consistent reports of malformations such as heart defects, “that would make one wonder whether there was something bad going on here.”
“One is always in this very difficult situation of having a profoundly depressed woman and trying to decide what the best thing to do is," says Stewart. Depressed mothers tend to gain less weight and their babies tend to be smaller. There’s also some evidence they may deliver prematurely.
“You don’t want to scare her off having her depression treated, because you know there are problems with not treating it, too.”
© CanWest News Service 2004
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