Of 14 regularly prescribed drugs, only one — Prozac — proved effective enough to justify giving to children and teens, the researchers found.
If medications are given at all, Prozac should be the drug of choice, the study concluded.
“No one should be on any other antidepressant, and I think it’s doubtful that people should be on Prozac, as well,” said Dr. Jon Jureidini, a child psychiatrist at the Robinson Research Institute at the University of Adelaide in Australia, who wrote a commentary that ran with the study. “The case for Prozac is quite weak.”
Prozac was found to significantly benefit children and teens with major depression, though the magnitude of benefit ranged from almost nothing to a dramatic improvement.
Other drugs the researchers analyzed — including Zoloft, Paxil, Celexa, and Cymbalta — showed no benefit over placebo for this age group.
About 3 percent of children under 12, and 6 percent of teens worldwide are believed to have depression. It’s not clear how many of them are on medication.
Forms of talk therapy, including cognitive behavioral therapy, have been shown to be effective against depression in young people, and regular exercise and adequate sleep can also make a difference, Jureidini said. The vast majority of children do not need to be medicated for their depression, he said, but many are.
“What we’re up against is the marketing enterprise of the pharmaceutical industry combined with wishful thinking on the part of doctors and parents that there might be a good, simple solution for adolescent distress,” he said. “It’s something we need to take very seriously, but we don’t need to make it into a medical condition when it most times isn’t.”
A different kind of depression
Questions have been raised before about the usefulness of antidepressants in young people whose brains are still developing. More than a decade ago, the Food and Drug Administration added a black-box warning to a number of antidepressants used by teenagers, saying that they might increase suicidal thinking.
In older people, antidepressants like Prozac are believed to trigger the growth of new brain cells and new connections among them, but there is no obvious biological benefit to the developing brains of children and adolescents.
Depression also looks different in young people, often showing up as aggressive behavior, irritability or poor school performance, rather than an obviously depressed mood, said Dr. Andrea Cipriani, the University of Oxford psychiatrist who led the new study.
Several doctors warned that patients shouldn’t stop taking their medications because of this study. Abruptly stopping medication can cause problems, including suicidal thinking. And some individuals might still benefit from the other drugs, Cipriani said.
“If the patient’s responding to one treatment, they have to keep the treatment, of course. But on average, if I have to start a treatment, probably the best one is fluoxetine [Prozac] and not the others,” Cipriani said.
Medication as the only option
The new paper, a so-called meta-analysis, looked at 34 previously conducted studies. Those studies included more than 5,200 children and teens who took one of 14 antidepressants or a placebo an average of 8 weeks. The study did not consider long-term use of the drugs because there hasn’t been enough previous research to analyze, Cipriani said.
Although several of the studies claimed to include patients as young as 6, Cipriani said there was virtually no data on children younger than 9.
Dr. Carl Bell, a community psychiatrist and clinical professor emeritus at the University of Illinois at Chicago, said that until recently, he doesn’t remember seeing children younger than 13 who were suicidal or severely depressed. “I don’t know what happened, but now I see it all the time,” he said.
In his experience, antidepressants work well on his preteen and adolescent patients.
Bell said he would be happy to refer his inner-city patients to social services and therapy, but they’re “pretty much nonexistent” in the communities he serves. “That only leaves one choice,” he said: medications.
Others raised concerns about the methods used to conduct the study.
Prozac looked the best merely because it has been the subject of the most research, said Dr. Maurizio Fava, a psychiatric researcher at Massachusetts General Hospital in Boston.
“I think the conclusion is a conclusion that is biased,” he said.
Many of the other drugs would have been seen as effective if the study’s authors had properly considered the impact of placebos, he said. Because of the powerful placebo effect in treating depression, only a small number of participants in each of the 34 studies would have shown a benefit beyond the placebo. Only a large study, or multiple studies considering the same drug — as was available for Prozac — would show a benefit, Fava said.
Sixty-five percent of the studies were sponsored by pharmaceutical companies, but Cipriani said he was able to use statistical manipulations to reduce any company bias.
“I think our data are quite robust. However, we cannot rule out the possibility of sponsorship bias,” said Cipriani, who has earned fees as an expert witness for a generic drug manufacturer that makes some antidepressants. Only one of the paper’s 19 authors reported receiving personal and grant funding from large pharmaceutical companies.
More research is needed on the causes of depression in children and teens and on the longterm use of antidepressants, Cipriani said.
“The message is, medication should not be an easy answer to the problem of major depression,” Cipriani said, “But at the same time, we have a tool which is effective, so if needed, let’s use it.”