To prescribe or not to prescribe?

Despite the possible heterogeneity among some of the studies included in Tsapakis et al's study, ¹ the results, if accepted by the psychiatric fraternity, could lead to further reduction in the use of antidepressants in the child and adolescent population. The use of antidepressants in this group has already decreased by 33% since the Committee on Safety of Medicine's (CSM's) warning against the use of most antidepressants in children and adolescents. ² Although the National Institute for Health and Clinical Excellence guidelines on the treatment of depression among children and adolescents states that medication should only be used in conjunction with psychological interventions, ³ the provision of psychological therapies remain thin on the ground in most parts of the country, which means that medication is often the only option available to clinicians for treatment of severe depression.

Although purely pharmacological treatment would be the least desirable option in depression and research evidence on the efficacy of antidepressants for those with depression in all age groups is either mixed or at best shaky, depending on which side of the debate one is on, ⁴ most clinicians would agree that many patients with significant depression do improve on antidepressants. Although it is too early to judge whether reduction in antidepressant prescribing resulting from the CSM warning has resulted in an increase in depressive morbidity among children and adolescents in the UK, disturbing evidence is already emerging from the USA, Canada and The Netherlands ⁵ on an increase in completed suicide among children and adolescents, which seems to coincide with the reduction in antidepressant prescribing following warnings by regulatory agencies. In a retrospective study done in Canada, a significant reduction in antidepressant prescribing, accompanied by a statistically significant increase in suicide among children and adolescents (relative risk=1.25, 95% CI 1.08–1.44; annual rate per 1000=0.04 before and 0.15 after the warning) was noted in the 2 years following issuance of the warning. ⁶

Given the well-established link between depression and suicide, one can only conclude that clinicians may be undertreating depression in children and adolescents since the emergence of concerns in relation to antidepressants. I feel clinicians should use their own clinical judgement and take into account local resources before making decisions on the course of treatment in juvenile depression. This would help one maintain the right balance between evidence-based practice and what's best for individual patients, especially in an area of practice where research evidence is often ambiguous and contradictory.