Friday, September 17, 2004

Antidepressants and children, part three

Medpundit decries the chilling effect of the FDA's new warnings on prescribing antidepressants to children. In previous posts (see below), I've tried to clarify our approach to prescribing. It really hasn't changed all that much; caution and surveillance have always been advised.

What has changed is our perception of risk, and our approach to educating and working with the parents. One colleague e-mailed me: "I tell parents that their concerns (about the meds) are appropriate, and more studies are needed to confirm safety in kids. Nevertheless, I believe they are superior to anything we had previously. I always tell them they, the parents, have the ultimate authority over what is or is not prescribed."

Another says, "I have moved in my own view of the controversy from outright rejection of the a more considered stance. There really do seem to be small studies which show a correlation between antidepressant use in kids and S/I (suicidal ideation)....I still believe that depressed people, including kids, can have S/I... I tell parents that it seems unfair to withhold this potentially very helpful treatment from kids, and that large studies have shown that (antidepressants) help youth depression. I also say that it has always been, and continues to be, that depressed kids who are being trialled on treatment need careful monitoring."

But hear the other issue that Medpundit raises: she is not receiving timely help from her psychiatric colleagues. Her patients are in desperate staits, and there is intense pressure for her to do....something. Prescribe something, consult someone, refer somewhere. But how? We need more than caution and disclosure about med risks; we need to be more available to primary care docs on the front lines.


Anonymous Anonymous said...

Having more health care professionals wouldn't hurt. Ya think?

Do you know how the USA stacks up compared to other countries, in terms of MD-level expertise per capita?

12:47 AM  
Anonymous Anonymous said...

I think you're right that we don't give our primary care docs proper support. Here in Alabama we have a dire shortage of psychiatrists, even in Birmingham (which has the highest density of shrinks) it is a 2 month waiting period for new patients. The psychiatrists down here are also bad about getting back in touch with their referral sources, and often leave them in the dark about what they are prescribing and why.

I finished my general psychiatry residency in June '04 and have been quite successful in my all outpatient practice so far. I send a thank-you back to my referral sources with my recommendations and treatment plan and this has been very well received. Sometimes it is scary to see how much psychiatry gets practiced in primary care with so little formal training. In a perfect world every case of depression would be treated by a psychiatrist, but the fact is there is not enough of us to see all of them. We need our primary care doctors to feel confident in prescribing antidepressants.

As far as the FDA is concerned, I think the black box warnings are going to kill a lot of teenagers who otherwise would have gotten an effective treatment. I know pediatricians down here that are reluctant to prescribe antidepressants now. Seemingly ignored is the fact that as antidepressant use has increased over time the suicide rate has declined, as well as the fact that in the 4,250 patients in the studies cited by the FDA *no one committed suicide*!

I'm also bothered by the catch phrase "close monitoring" of patients on antidepressants. What the heck is that? Does that mean having every patient I have on an antidepressant leave me a voicemail in the morning letting me know they are still here? Or seeing them back in 4 weeks instead of 3 months? Or insisting that they get psychotherapy every week? I can see the trial lawyers just foaming at the mouth over this one....


6:22 AM  

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