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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by jrbecker on September 29, 2005, at 9:45:28
UK docs told to hold antidepressants for teens
Wed Sep 28, 2005 11:55 AM ET
LONDON (Agence de Presse Medicale) - Antidepressants should not be used as first-line treatment in patients younger than 18 years old -- even for moderate-to-severe or psychotic depression -- Britain's health economics watchdog, the National Institute for Clinical Excellence, said on Wednesday.In children (5-11 years old) and young people (12-18) with depression, psychological therapy such as group cognitive behavior therapy should be the first-line treatment, backed up by advice on exercise, diet, controlling anxiety and methods of improving sleep.
For moderate-to-severe depression, psychological therapies should be prescribed for at least 3 months, but if no improvement is observed after four to six sessions, doctors may consider the addition of fluoxetine (Prozac) to the treatment. In the case of children, the option should be "cautiously" considered, NICE added in guidance to the health service.
If, after a further six sessions, the patient is not responding to either the fluoxetine or psychological therapy an alternative psychological therapy should be considered. If this fails to bring improvements, clinicians can consider sertraline (Zoloft) or citalopram (Celexa). Neither drug is licensed for children and therefore will have to be used off-label, NICE added.
In the case of continued psychotic depression, an atypical antipsychotic can be considered in addition to existing therapy.
The guidance confirms earlier regulatory advice that paroxetine (Paxil) and venlafaxine (Effexor/Efexor) are not recommended in children.
It adds that patients taking the herbal remedy St. John's wort should be advised to stop.
Posted by linkadge on September 29, 2005, at 13:42:45
In reply to UK Docs Told To Hold Antidepressants For Teens, posted by jrbecker on September 29, 2005, at 9:45:28
They would not make this kind of recomendation if there was not significant data to support the decision.
They don't seem to detail their reasoning. For SJW, I wouldn't know their reasoning.
Linkadge
Posted by linkadge on September 29, 2005, at 13:45:14
In reply to that is significant, posted by linkadge on September 29, 2005, at 13:42:45
Posted by linkadge on September 29, 2005, at 13:51:23
In reply to Perhaps Tom Cruise is on the pannel (nm), posted by linkadge on September 29, 2005, at 13:45:14
I am not sure why prozac is still the one that is used. I thought akathesia was more likely on prozac than the others ?
Linkadge
Posted by ed_uk on September 29, 2005, at 14:03:59
In reply to but why prozac?, posted by linkadge on September 29, 2005, at 13:51:23
Hi Link,
As a child, I saw my pdoc for about 2 years before she reached for the prescription pad!
Unlike the other SSRIs, fluoxetine has proved (in clinical trials) to be modestly effective in the treatment of severe depression in children.
Kind regards
~Ed
Posted by linkadge on September 29, 2005, at 15:30:28
In reply to Re: but why prozac? » linkadge, posted by ed_uk on September 29, 2005, at 14:03:59
interesting. I wonder what it is specifically that makes it more effective in this population.
Linkadge
Posted by Phillipa on September 29, 2005, at 18:41:50
In reply to Re: but why prozac?, posted by linkadge on September 29, 2005, at 15:30:28
Since it has stimulating effects maybe it's like an ADD or ADHD child requires a stimulant. Fondly, Phillipa
Posted by med_empowered on September 29, 2005, at 18:43:39
In reply to Re: but why prozac?, posted by linkadge on September 29, 2005, at 15:30:28
I think this is an interesting sign not only of how pill-happy shrinks have gotten in the US, but also of how out-of-step with their international colleagues US psychiatrists often are. If you look at other countries--particularly canada and European countries--the suicide rate is often lower than that of the United States; the overall violent crime rate is also lower...however, overall use of psychiatric medications is lower, and even in more sevre mental illnesses (schizophrenia, bipolar disorder, etc.) the number of medications given to an average patient is smaller, and the duration of treatment is often shorter (ex: based on pretty good data, a number of docs in Europe use very low-dose neuroleptic treatment for schizophrenia and/or opt for neuroleptic-free treatment in certain patients; this has been almost unheard of in the US since the 60s-70s). Sooo...I'm not surprised the panel reached this conclusion; it makes sense, based on the available data, to go for a "precautionary principle"-based approach (avoid widespread use of medication until its *proven* safe and effective, rather than spraying it around until problems pop up, which seems to happen a lot in the US) to the antidepressant issue. With Sain John's Wort...my guess is that since they're focusing on only recommending use of products **proven** safe and effective in kids, the lack of data on Saint John's Wort would lead them to recommend avoiding its use in young people, even if there isn't necessarily evidence to indicate it's problematic. Its a really conservative stance, but its also the safest. In addition, some docs think Saint John's wort operates in an SSRI-esque way; whether true or not, I guess the assumption is that a drug that acts like an SSRI in alleviating depression could also act like an SSRI in increasing suicidality. My own guess would be that until more research is done, people who have had problems with antidepressants in the past should probably steer clear of saint john's wort, unless they have a health care provider who can monitor for problems and address them early on.
Posted by linkadge on September 29, 2005, at 20:59:26
In reply to Re: but why prozac?, posted by med_empowered on September 29, 2005, at 18:43:39
In once sence I feel this is a good step.
I will admit there have been times that I medicated for reasons that (in hindsight) had nothing to do with bad brain chemsitry (other than being a little bit slow in school)
I wish that I had other options. I guess I was really looking for the support that came (or in my case didn't come) with the depression diagnosis.
We don't really care about mental health in this society. I mean we care as long as you can take your pills and get back to work.
We need more than that. I can only hope that fewer pills would change things.
But if one kid can avoid being f*d over by meds, like I have, then the whole thing is worth it.
Linkadge
Posted by ed_uk on September 30, 2005, at 14:34:41
In reply to Re: but why prozac?, posted by linkadge on September 29, 2005, at 20:59:26
Hi Link
Here's another summary of the NICE guidelines.......
Drugs not to be initial therapy for depressed children
Antidepressant medication should not be used for the initial treatment of children and young people with moderate to severe depression, clinical guidelines published by the National Institute for Health and Clinical Excellence and the National Collaborating Centre for Mental Health this week recommend.
Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy, such as cognitive behavioural therapy, interpersonal therapy or family therapy of at least three months’ duration.
If depression is unresponsive to psychological therapy after four to six sessions, a multidisciplinary review should be carried out and alternative or additional psychological therapies considered. Antidepressant medication should only be offered in combination with a concurrent psychological therapy.For those aged 12 to 18 years with moderate to severe depression, fluoxetine should be considered in addition to psychological therapy. For children aged five to 11 the addition of fluoxetine should be cautiously considered. Children with mild depression should not be offered antidepressant medication at all, the guidelines say.
Children and young people taking antidepressants should be monitored regularly, with a focus on adverse drug reactions, and patients and their parents or carers should be informed about the rationale for drug treatment, the delay in onset of effect, the time course of treatment, possible side effects and the need to take the medicines as prescribed. When discontinuing antidepressant medication, it is recommended that treatment is phased out over six to 12 weeks, with the exact dose being titrated against the level of discontinuation or withdrawal symptoms.“NICE guidelines are not retrospective and so prescriptions for antidepressants for under-18s should be challenged sensitively,” Stephen Bazire, chief pharmacist at Norfolk and Waveney Mental Health Partnership NHS Trust, warned. “Although NICE recommends fluoxetine, there will be many occasions when other antidepressants will have to be used and when the use of some SSRIs in conditions such as obsessive compulsive disorder may require higher doses of fluoxetine and other antidepressant drugs,” he added. “Stopping or switching antidepressants will require particular care.”
Kind regards
~ed
Posted by ed_uk on September 30, 2005, at 14:39:48
In reply to Re: but why prozac?, posted by linkadge on September 29, 2005, at 15:30:28
Hi Link,
>I wonder what it is specifically that makes it more effective in this population.
Although fluoxetine is statistically more effective than placebo for the treatment of childhood depression, its benefits are usually minimal.
SSRIs are clearly an effective treatment for obsessive-compulsive disorder in children. Apart from that, their use in children is often dubious.
Kind regards
~Ed
Posted by ed_uk on September 30, 2005, at 14:43:34
In reply to Re: but why prozac?, posted by med_empowered on September 29, 2005, at 18:43:39
Hi
Low dose neuroleptic treatment seems relatively common in the UK at the moment. Most people on haloperidol take the 0.5mg capsules.
Kind regards
Ed
Posted by Shawn. T. on September 30, 2005, at 16:51:21
In reply to UK Docs Told To Hold Antidepressants For Teens, posted by jrbecker on September 29, 2005, at 9:45:28
Those guidelines are terrific. I believe that similar guidelines should be in place for adults who have not been previously treated for depression. For adults who have tried both psychotherapy and medications in the past, clients and their doctors should have an in-depth conversation about the costs and benefits of taking antidepressant drugs before resuming treatment.
Also, randomized controlled trials of St. John's Wort should definitely be conducted in children.
Shawn
Posted by linkadge on September 30, 2005, at 20:53:31
In reply to Re: UK Docs Told To Hold Antidepressants For Teens » jrbecker, posted by Shawn. T. on September 30, 2005, at 16:51:21
I agree, I think SJW holds a lot of potential. The first time I was depressed, I took it, at age 15 or so. It worked.
I think that the AD properties of omega 3 should be tested in childhood depression. I took a lot of meds, but I would say that at the end of the day, the loads of fish oil that I had been taking probably did the most good.
Linkadge
Posted by linkadge on September 30, 2005, at 21:01:43
In reply to Re: UK Docs Told To Hold Antidepressants For Teens, posted by linkadge on September 30, 2005, at 20:53:31
Lithium. Lithium is a darned good drug. It is the only substance I can say reduced my suicidiality.
If a child was very depressed, I would consider a low dose of lithium. Again, because it could help, and it won't f' their mind up.
In hindsight, I wish I had been given lithium when it all started. I'd probaby be exactly where I am now, emotionally, but with many more brain cells.
Linkadge
Posted by Emily Elizabeth on October 1, 2005, at 0:18:07
In reply to UK Docs Told To Hold Antidepressants For Teens, posted by jrbecker on September 29, 2005, at 9:45:28
In general, I like it, but this part makes me nervous, "even for moderate-to-severe or psychotic depression." I have lots of faith in psychotherapy (I'm training to be a therapist!) but that sounds a little extreme to me. My concern is that the research hasn't been done at all with regard to kids who fall into that category, so we can't say that it would work, but we can't say that it wouldn't. There is disturbingly little research w/ kids and meds. Informed consent is such a sticky issue. Plus if you believed that your kid would benefit from meds would you want to put him in a study where he might get a placebo?
This is also interesting b/c it would never happen in the US. The drug companies have such power here. Scary really.
Best,
EE
Posted by SLS on October 1, 2005, at 10:32:32
In reply to Re: UK Docs Told To Hold Antidepressants For Teens, posted by Emily Elizabeth on October 1, 2005, at 0:18:07
> In general, I like it, but this part makes me nervous, "even for moderate-to-severe or psychotic depression." I have lots of faith in psychotherapy (I'm training to be a therapist!) but that sounds a little extreme to me.
Me too.
- Scott
Posted by ed_uk on October 1, 2005, at 14:40:39
In reply to Re: UK Docs Told To Hold Antidepressants For Teens, posted by Emily Elizabeth on October 1, 2005, at 0:18:07
Hi!
>this part makes me nervous, "even for moderate-to-severe or psychotic depression." I have lots of faith in psychotherapy (I'm training to be a therapist!) but that sounds a little extreme to me.
It makes me a bit nervous too. I suppose they're just making the point that since SSRIs are rarely effective for childhood depression, and appear to cause considerably more severe side effects in children than in adults, there isn't that much point in using them as a first-line treatment, however severe the depression is.
Kind regards
~Ed
Posted by med_empowered on October 1, 2005, at 15:16:07
In reply to Re: UK Docs Told To Hold Antidepressants For Teens » Emily Elizabeth, posted by ed_uk on October 1, 2005, at 14:40:39
from what I understand, although there does come a point in depression at which antidepressant treatment is usually advisable, its also true that more severe cases of depression can pose a higher risk of suicidality, so maybe the reasoning is that since SSRIs don't seem to help and can sometimes induce suicidality, using an SSRI might actually raise overall rate of suicide and other forms of self-injury among the more severely depressed. Apparently, severe depression can respond pretty well to therapy,too; the only problem I have with these recommendations is the inclusion of psychotic depression. Psychotic depression usually isn't treated with an antidepressant alone (although apparently this can be done in some cases)...its also often a sign of other problems (especially bipolar disorder) when it pops up in the young...I'm just concerned that the no-SSRI stance for psychotic depression will lead to less effective treatment for the most severe cases of depression.
Posted by ed_uk on October 1, 2005, at 15:22:36
In reply to well...., posted by med_empowered on October 1, 2005, at 15:16:07
Hi Med!
>depression usually isn't treated with an antidepressant alone (although apparently this can be done in some cases)...its also often a sign of other problems (especially bipolar disorder) when it pops up in the young...
Good points :-)
>I'm just concerned that the no-SSRI stance for psychotic depression will lead to less effective treatment for the most severe cases of depression.
They did suggest an atypical AP for 'continued' psychotic depression.
Kind regards
~Ed
Posted by SLS on October 1, 2005, at 16:33:20
In reply to Re: well.... » med_empowered, posted by ed_uk on October 1, 2005, at 15:22:36
All good points.
Logically, I think it makes sense to choose some sort of cognitive therapy first for non-psychotic depression. If it has failed after the suggested time period, one should move on to an antidepressant while maintaining the cognitive therapy. I don't know if the next set of decisions are so simple to characterize. Was there any progress made in psychotherapy since it was introduced? Is the depression itself presenting with severe vegetative symptoms? Was there a significant deterioration in condition as the first antidepressant was removed? If severe psychomotor retardation is present, I would argue for the continued use of antidepressants while contemplating a change in the mode of psychotherapy. As a matter of fact, if severe vegetative symptoms are present, I would probably want to begin antidepressants and psychotherapy simultaneously.
ALWAYS: Tell the patient that any antidepressant has the potential to make them feel worse. If they do, they are instructed to tell their parents and call the doctor. Visits to the doctor should be weekly. Establishing effective communication between the doctor and patient is critical and should be cultivated. It is the best tool we have for illnesses for which there is still no convenient assay for mood state through a biological test.
I don't think that the strict adherence to any one treatment algorithm as simple as the one proposed is in the best interest of those suffering from depression. The risk of suicide is too high in this population.
I guess if I were a doctor, I would not be so afraid to prescribe antidepressants as a first line treatment for those pediatric and adolescent cases that I deem are critical and present with a symptom profile reflecting a biological diathesis. There is nothing that would prevent me from co-prescribing psychotherapy. If a persistent remission of the biological depression is achieved, the antidepressants could then be removed very gradually while psychotherapy is maintained.
I just think that the whole suicide thing can be minimized with education of the patient and close monitoring. Presentations that include severe anxiety, suicidality, or aggression might be well served to prescibe a benzodiazepine temporarily in early treatment. Gosh, there are so many things that have to be taken into consideration. What if the benzodiazepine produces disinhibition? It might lead to an impulsive act of suicide. Ok then, what about the temporary use of low dosages of a drug like Zyprexa? Probably a better choice clinically, but can using a neuroleptic be justified when psychosis is not present? I think so. Are there any irreversible effects that the short term use of such a drug has on the developing brain? Theoretically and microscopically, maybe. Realistically, I doubt it. Of course, I could be wrong.
Psychiatry is best left to psychiatrists I guess. Lots and lots of stuff to consider. I guess that's why I've been doing nothing more than rambling.
And what of the effects that any psychotropic drug has on a still developing brain that has not completed the maturation and pruning processes? For that matter, what about non-psychotropic medications that manage to pass the blood-brain barrier?
And what of bipolar disorder? Treat immediately with lithium or anticovulsants? Why not? What are the consequences of delaying pharmacological intervention in clearly bipolar or cyclothymic individuals? A decaying prognosis? Should depression resulting from a bipolar diathesis be treated differently than depression without one? How do you tell the difference? Is Prozac truly any less apt to exacerbate depression or promote a suicidal state than the other SSRIs? Ok then, what about tricyclics or MAOIs?
NOT ENOUGH DATA
NOT ENOUGH REPEATABLE STUDIES
Psychiatry is often looked down upon as being a "soft" science. If this is true, why is it so hard to practice effectively? It is no longer for lack of intelligent investigators or brilliant contributions. It remains difficult, however, for the as of yet unmanageable complexity of the human brain and all of the biological processes elsewhere in the body that it controls or interacts with. Even the rodent brain remains unmanageable.
Imagine that.
- Scott
Posted by Nickengland on October 1, 2005, at 17:58:49
In reply to UK Docs Told To Hold Antidepressants For Teens, posted by jrbecker on September 29, 2005, at 9:45:28
PRESS RELEASE
Latest NICE guidance sets new standards for
treating depression in children and young people.The National Institute for Health and Clinical Excellence (NICE) and the National
Collaborating Centre for Mental Health have today (28th September) launched a clinical
guideline on the treatment and management of depression in children and young people.
The guideline recommends that –o Children and young people with moderate to severe depression should be offered, as
a first-line treatment, a specific psychological therapy (such as cognitive behavioural
therapy, interpersonal therapy or family therapy of at least 3 months’ duration).
o Antidepressant medication should not be offered to children or young people with
moderate to severe depression except in combination with a concurrent psychological
therapy and should not be offered at all to children with mild depression.
o Healthcare professionals in primary care, schools and other relevant community
settings should be trained to detect symptoms of depression, and to assess children
and young people who may be at risk of depression.
o Attention should be paid to the possible need for parents’ own psychiatric problems
(particularly depression) to be treated in parallel, if the child or young person’s mental
health is to improveAndrew Dillon, Chief Executive of NICE and Executive Lead for this guideline says
“This guideline makes it clear that psychological treatments are the most effective way to
treat depression in children and young people. It’s important that children and young people
taking anti-depressants do not stop taking them abruptly, but we would advise people to talk
to their GP at their next regular review about whether a psychological treatment may be a
more effective treatment option.”Dr Tim Kendall, Joint Director of the National Collaborating Centre for Mental Health
who developed the guideline on behalf of NICE says “This is the sixth mental health
guideline where we have recommended psychological treatments as key treatments for a
mental health condition and the third where we have recommended them as the first line
treatment. The evidence supporting these treatments is robust and it is vital that the NHS
provides psychological therapies to ensure everyone who needs these treatments can
access them rapidly.”Professor Peter Fonagy, Professor of Psychoanalysis and Chair, Guideline
Development Group says “Depression in children is more common than many people
realise and often goes unrecognised. Around 1% of children and 3% of adolescents will
suffer from depression in any one year. It can severely impact on school performance, self
esteem and making and retaining friendships. It can lead to a greatly increased risk of
mental health problems in adult life and at its most serious it can dramatically increase the
lifetime risk of suicide, from 1.3% in the general population to 6%.”Ms Charlotte Dodds, Depression Support Group Co-Facilitator and Carer
Representative on the Guideline Development Group says “Depression
disproportionately affects the most disadvantaged children. Children and young people with
emotional disorders, when compared with children without a mental disorder, were nearly
twice as likely to be living with a lone parent (28% versus 15%), more than twice as likely to
be with both parents being unemployed (27% versus 12%), and more likely to have parents
who were on low incomes, had fewer qualifications and living in social sector housing. I hope
this guideline raises awareness of the issue and encourages more equal access to
treatments for all children and young people with depression, no matter where or how they
live.”Ms Dinah Morley, Deputy Director of YoungMinds says “YoungMinds welcomes the
emphasis on psychological therapies as the best approach to the treatment of depression.
However the very significant shortage of practitioners able to deliver these therapies is a
cause for concern, as is the general lack of awareness of the prevalence of depression in
babies, children and young people. We look to increasing investment in services which
support the mental health of children and young people and to improvements in the training
of all practitioners working with children, to help them in identifying symptoms of depression
and in seeking effective help. Too many children’s lives are blighted by depression, a
condition for which there are effective treatments. We welcome the NICE guidelines as
another reminder that children’s mental health matters and is the business of everybody.”The Committee on the Safety of Medicines issued advice on the safety of antidepressant
medication for children in 2003. The NICE guidance complements and builds on this advice.Notes to Editors
About NICE
1. On 1 April 2005 the National Institute for Clinical Excellence took on the functions of the
Health Development Agency to form the National Institute for Health and Clinical
Excellence (NICE). NICE is the independent organisation responsible for providing
national guidance on the promotion of good health and the prevention and treatment of ill
health.
2. NICE produces guidance in three areas of health:
• public health – guidance on the promotion of good health and the prevention of ill
health for those working in the NHS, local authorities and the wider public and
voluntary sector
• health technologies – guidance on the use of new and existing medicines,
treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with
specific diseases and conditions within the NHS.http://www.nice.org.uk/pdf/2005_022_Depression_in_Children_Guideline.pdf
Kind regards
Nick
Posted by Nickengland on October 1, 2005, at 18:16:32
In reply to Press Release NICE Issued: 28th September, posted by Nickengland on October 1, 2005, at 17:58:49
Sorry to add to the confusion...
But for those interested in the guidelines for the treatment of depression in children (from NICE) heres a 69 page booklet on them.. (I wont copy and paste lol)
http://www.nice.org.uk/pdf/CG028NICEguideline.pdf
-------------------------------------------------
Quick reference guide, 28 pages ;-)
http://www.nice.org.uk/pdf/CG028quickrefguide.pdf
-------------------------------------------------
Even more..
http://www.nice.org.uk/pdf/CG028publicinfo.pdf
Kind regards
Nick
Posted by linkadge on October 1, 2005, at 19:24:42
In reply to Afew more.....lots of reading!, posted by Nickengland on October 1, 2005, at 18:16:32
Especially with all the mouse studies showing that SSRI use in adolecence leads to permanant changes functionality of the serotonergic system.
I wish I was given the option.
I'd be better off having taken no pills.
I agree with ED, in the sence that it is true that they have not fully proven themselves effective in this population.
Linkadge
This is the end of the thread.
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