A Bitter Pill

The late 1980's into the 1990's were a time of psychopharmacologic transition. Prozac and other anti-depressants of its class, selective serotonin reuptake inhibitors (SSRIs) were touted as an antidote for depression. The widespread treatment with antidepressants in people who had long suffered without reprieve, in many cases, was met with resounding success. Additionally, the 21st century has seen a marked increase in the prescription of SSRIs and other antidepressants to treat children and young adults diagnosed with depression. Because this phenomenon is a modern one, the long-term outcomes of these young people cannot be conclusively addressed. Only time will tell. The fact remains, however, that many young people are taking antidepressants for a range of symptoms. Anecdotally, young people often respond well to antidepressants and credit the drugs with lifting them out of depression and in some cases preventing suicide attempts (1). However, as treating children with anti-depressants is a recent phenomenon, there are no longer term studies that provide information about the effects early interventional use of anti depressants may have on the development of children. What effect might the use of antidepressants early in life have on the notion of development and identity?

There is a fine balance between intervening to enable a child to develop unfettered and using medications as a first-line treatment for childhood depression, where potential lasting effects are unknown. Childhood depression is largely marked by the same diagnostic criteria as adult depression. However, it is only in the last thirty years that mainstream psychiatry has accepted childhood depression as a valid diagnostic category (2). As such, many children who experience the hallmark symptoms of depression remain undiagnosed. This may be attributable to the conflation of symptoms of depression and that, which is considered to be "normal" developmental travails of childhood and adolescents. In Biology 202, the conceptualization of reality was deemed not to be a fixed, objective entity, but a construction of the nervous system. As such, the minds of children, as they develop increasing numbers of connections between various input and output regions of their brains, are as variable as those of adults, in fact infinitely so. If anti-depressants are used as an early intervention to treat depression in children, worlds may open, where the treatment is effective. Indeed, it may well be virtually impossible to measure the impact of long-term antidepressant use given that reality is not fixed. The effects that a given reality has on the unconscious, on experience and on learning are difficult to pinpoint. How might a person, on antidepressants since childhood accurately assess how her reality might have been different had she not taken the medication?

The development and modification of the I-function, the "I" voice within the mind, is an issue with which the Biology 202 class grappled throughout the semester. In terms of learning and the course of development, the I-function seems to be malleable and subject to change from within and without the individual. As this pertains to children and the development of the I-function, medication may, in fact, alter the sense of "I" that a child has. Whether or not this is detrimental is a matter of debate. From the time that antidepressants became widely accepted as a treatment for childhood depression, there has been a pendulum swing. In 2003, after data came to light regarding the increased rate of suicidal ideation in people under the age of eighteen taking antidepressants, almost immediately the number of prescriptions for that age group dropped drastically (3). It is unclear whether the people who might otherwise have been prescribed SSRIs were offered alternative treatments, such as some form of talk-therapy, or not. And, if there are alternative treatment options for young people, to which they may respond equally well as to antidepressants, should the standard of care involve possibilities besides antidepressants, in light of the paucity of data that exists on children and antidepressants later in life.

Currently suicide is the third leading cause of death in adolescents (1). While not all of these young people have depression, depression is the most diagnosed psychiatric illness in children (2). Antidepressants, for some children, have proved tremendously effective at mitigating feelings of lethargy, anxiety and associated symptoms. Clearly the interplay between the chemical component of some depressions and the given "reality" of the individual creates a complicated set of interactions that cannot be reduced to a single answer for the treatment of childhood depression in all children. A compelling argument for the continued use of antidepressants to treat children with depression is that antidepressants work well for a certain segment of the population. The crippling nature of depression and the breadth and depth of its impact on lives makes the fact of a potential antidote a necessary and important option for many people. However, where other treatment options may be effective either alone or in conjunction with antidepressants, it is prudent to consider the effects of antidepressants in children that have yet to come to light.

In some cases, it may be difficult for very young children to communicate their feelings and for older children to express feelings without associated shame and anxiety (2). The necessity for vigilance on the part of those who interact with children, whether parents, teachers or community members in being aware of the vulnerability of children to depression must not be undermined. Because this state of mind, depression, is evolving as a disease category (4), thus as a medico-centric entity, this may have the simultaneous effect of drawing childhood depression into the domain of biomedicine and destigmatizing the experience of depression for children and the parents of depressed kids; while also sensitizing society to the relevance and importance of this issue. This complex interplay may affect the trajectory of the treatment of childhood depression. Given the increased concern about the risks of suicidal ideation in children on antidepressants, alternative methods of treating depression in children are continually being probed. Anecdotally, even if children are able to express their feelings, parents often don't fully comprehend the extent to which despair and anxiety have taken hold. This must only add to the sense of fear and alienation felt by the child. The existing evidence is testimony to the merits of early intervention in giving a child the full range of developmental opportunities without the burden of depression (5)

There are those who enter adulthood, having gone through childhood suffering with untreated depression. One woman, who suffered lifelong depression, until successful treatment with antidepressants, remarked upon her childhood depression having left its mark on her adult self, manifesting in intense and crippling shyness. As such, she may wish she had been able to benefit from the potential that antidepressants afford many people (6). In some sense, the effect of not using medication may shape one's sense of who she is. In this particular instance, untreated childhood depression shaped the reality of this person. This is an area of research, too, that could benefit from more data.

There are many theories about the development of identity in children, including Erik Erikson's theory of psychosocial development. Erikson theorizes that development occurs in eight stages, with each stage marked physical and psychological milestones that are inextricably connected with the social context. Given the myriad social contexts from which children come, it is hard to generalize which factors coalesce to manifest depression in one child and not another. Childhood depression is associated with a greater risk of depression in adulthood and a greater risk of other mental illnesses in adulthood (7). There is a prevailing misconception that children cannot experience depression, because "what do they have about which to be depressed?" Given the complicated nature of depression, involving some combination of chemical, psychological and social factors, it is clear that depression cannot have one single etiology (6). And if children develop a sense of "I" that is mired in feelings of inadequacy, shame, guilt and fear it is understandable that these feelings often do not go away without some sort of outside intervention. Many physicians, despite the suicide risk, are willing to provide children with antidepressants in the hope that medication will ameliorate the feelings that other forms of treatment have been unable to mitigate. And while the potential long term effects may yet prove to be in some manner deleterious, for many it is a tradeoff they are willing to accept in order to facilitate a change in their realities. In short term studies in which the efficacy of antidepressants in children has been studied, the evidence is persuasive that children with major depressive disorder (MDD) experienced relief using SSRIs. The relief is categorized as being "short term" for children and adolescents with MDD. This begs the question: can SSRIs be used as a safe and effective long term treatment?

The long term effects on the development of "I" as a result of early intervention with SSRIs remains unclear. And until a generation has been reared using SSRIs this data will not be known. The fact remains that the use of SSRIs provides some children with varying degrees of depression great relief and affords them the chance to participate more fully in life and perhaps enhance their senses of "I" and create a reality that is more desirable. This may change as more information becomes available to challenge the potential benefits of SSRIs. However, an integrative approach to treating depression, combining medication and talk therapy, in children is warranted when antidepressants are not universally effective and feelings are more nuanced than the medications used to target them.

References

1. http://www.nytimes.com/2008/04/15/health/15mind.html?_r=1&emc=eta1&oref=login

2. http://www.healthyplace.com/communities/depression/children.asp

3. http://pn.psychiatryonline.org/cgi/content/full/40/17/1-a

4. http://www.wingofmadness.com/index.php/Articles/Children-and-Depression.html

5. http://findarticles.com/p/articles/mi_m2248/is_158_40/ai_n14815103

6. Nixon, MK, 1999. Mood disorders in children and adolescents: coming of age. Journal of Psychiatry and Neuroscience. 24:3, 207-209.

7.http://mentalhealth.about.com/gi/dynamic/offsite.htm?zi=1/XJ&sdn=mentalhealth&cdn=health&tm=30&f=10&su=p284.9.336.ip_p736.8.336.ip_&tt=2&bt=0&bts=1&zu=http%3A//jama.ama-assn.org/cgi/content/full/290/8/1033