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Two
years after Health Canada warned about prescribing antidepressants
to children, the number of children and teens who died
by suicide increased 25% after years of steady decline,
major new Canadian research shows. And the increased suicide
rate coincided with a 10% decrease in the rate of visits
to doctors for the treatment of depression in children.
For
the study, researchers tracked what happened in Manitoba
before and after Health Canada warned in 2004 that newer
antidepressants may be associated with an increased
risk of "suicide-related" events in patients
under 18. They found the warning was followed by an
overall 14% drop in antidepressant use among children
and adolescents, fewer visits to doctors for depression,
and - among eight- to 17-year-olds - increased rates
of completed suicide. More than 90% of the children
and teens who killed themselves were not taking antidepressants
when they died.
Published
today in the Canadian Medical Association Journal, the
study is the first to document "such a wide range
of unintended health consequences" from a major
drug warning, the authors say. Lead author Dr. Laurence
Katz, a child and adolescent psychiatrist in Winnipeg,
warns the increased risk of suicide could be a "random
fluctuation." "We can't say the warning, or
the change in antidepressant use or the physician office
visits caused changes in suicide rates," Katz says.
The suicide rate among children and teens was also still
relatively small, from 0.04 for every 1,000 before the
warning, to 0.15 per 1,000 after.
But
Katz worries the widely publicized drug warnings have
led to more cases of untreated depression, and an impact
"beyond what was intended."
The
drop in doctor visits for depression suggests that some
vulnerable children are getting no treatment, including
psychotherapy, at all. He says his hunch is that families
were afraid to go to the doctor for fear their child
would be put on medication. "But that's not the
only treatment for depression. Not going to the doctor
deprives you of all forms of treatment."
The
antidepressant warning involved drugs known as SSRIs,
or selective serotonin re-uptake inhibitors, a class
that includes Prozac, Paxil and Zoloft, as well as serotonin
noradrenaline re-uptake inhibitors (SNRIs), which include
Effexor. The drugs have not been approved in Canada
for children, but doctors have prescribed them "off-label,"
which they are legally permitted to do, to tens of thousands
of toddlers, children and teens for depression, social
phobia, anxiety and obsessive-compulsive disorders.
In 2003 the U.K. banned antidepressants, except for
Prozac, for children. Studies have shown the drug is
safe and effective in children. A year later, Health
Canada warned that people taking the newer-generation
antidepressants may experience behaviour or emotional
changes that may put them "at increased risk of
self-harm or harm to others."
Katz
says he didn't have a problem with the warnings themselves,
but some people leaped to the assumption "that
these medications lead people to kill themselves. "We
don't know that yet. What we do know from those randomized
controlled trials, that there may well be a small subgroup
of children and teenagers with depression who when they
receive a medication do experience an increase in suicidal
thoughts, or even suicidal behaviour."
Muhammad
Mamdani, director of the applied health research centre
at the Li Ka Shing Knowledge Institute at Toronto's
St. Michael's Hospital, says more balanced health advisories
are needed.
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