Nine-year-old Naomi stood in front of the mirror, an expression of rage on her face, her left hand pulling at her hair while with her right she wielded the scissors. Shiny black locks fell to the floor. When her mother, shocked at this act of self-mutilation, tried to intervene, the child pointed the scissors at her and screamed.
Naomi’s behaviour turned out to be the effect of a sudden stoppage of the antidepressant paroxetine, better known under its trade name of Paxil. Paroxetine belongs to a class of drugs called selective serotonin re-uptake inhibitors, or SSRIs, widely used in the past two decades in the treatment of depression, anxiety and other disorders.
Naomi had been diagnosed with depression one year earlier. The treating psychiatrist was not aware that abruptly discontinuing this particular drug can lead to severe psychological reactions, such as Naomi was now experiencing. Other children given SSRIs will exhibit irritability, aggression and even self-mutilation as direct side effects of these medications.
The value of SSRIs in childhood depression has been recently called into question. Studies have not shown any significant benefot over inert placebo substances given to depressed children. On the other hand, these medications clearly increase bizarre acting out in children, as well as suicidal thoughts.
“The mistake we’ve made,” Vancouver psychiatrist Jana Davidson says, “is to apply research done on adults to the treatment of children. We are learning we can’t do that.”
The neurochemistry of a developing young person’s brain is different from that of an adult, says Dr. Davidson, a consultant in the Mood Disorders and Anxiety Clinic at British Columbia Children’s Hospital. “The same chemicals will have different effects.”
As many as one in five young people will have suffered an episode of major depression by the age of 18, a condition with a severe impact on their lives and with a high rate of recurrence. If pharmacology is not the answer, what is?
The dominant medical tendency in the past few decades has been to reduce mental illness to chemical imbalances in the brain — for example, a deficiency of the chemical messenger serotonin. The obvious solution is a drug to increase serotonin levels.
Such biochemical explanations are dangerous oversimplifications. The level, balance and activity of serotonin and other brain chemicals are, throughout a person’s lifetime, affected by emotional stresses. Whether in our jobs or in our personal relationships, our interactions with the environment do much to determine our brain’s chemistry. This is especially true of the developing brains of young children and adolescents whose moods and mood disorders often reflect stresses in their immediate environment.
Treating a child’s depression as merely a chemical imbalance is to deprive her of the most important and most effective assistance: personal contact with a compassionate and preferably well-trained caregiver. This is exactly the kind of support that our inadequate mental-health system has great difficulty providing. Bottom-line economics dictate that it is much cheaper to write a prescription than to offer emotional support to a child and her family — listening to the child, counselling the parents and untangling painful relationship issues.
The evidence for therapy is persuasive. A recent study of depressed 12-to-17-year-olds at Duke University showed that the combination of fluoxetine and cognitive behavioural therapy was more effective than the drug alone in reducing thoughts of suicide. The drug by itself helped to reduce suicidal ideas, but increased aggressive behaviours such as head-banging and self-mutilation.
That a study even has to be done to prove that a therapeutic relationship with a depressed young person is essential may say more about the current practice of medicine and psychiatry than about the nature of depression. Anyone who has ever been depressed or who has been close to a depressed person, child or adult, could have known that.
A psychiatrist colleague of Dr. Davidson’s at B.C. Children’s Hospital puts the case very strongly: “To prescribe drugs and not to offer therapy is nothing less than malpractice.”