Fewer kids on antidepressants

WASHINGTON – The number of American children taking antidepressant drugs fell sharply last year, following months of controversy over evidence that the medications increase the risk of suicidal thoughts and behavior among some children.

The steep decline among children is a dramatic reversal of a decade-long trend of soaring prescription rates for drugs such as Prozac, Paxil and Zoloft, and the pattern of the data suggests the numbers could fall even further.

Activists who had urged the Food and Drug Administration to require a black-box warning about the risks of the drugs said the drop reflects the better decisions that parents and physicians are making after being warned about the medications.

But medical groups such as the American Psychiatric Association and the American Academy for Child and Adolescent Psychiatry warned that the government had unwittingly unleashed an uncontrolled experiment that would cause many depressed children to go without treatment and ultimately lead to more suicides.

The turnaround in prescription trends was reported Tuesday by Medco, which manages drug benefits for about 60 million Americans.

Various studies have shown a three- to tenfold rise in the use of antidepressants among children between 1987 and 1996, and an additional spike of 50 percent between 1998 and 2002. There was a further increase of about 9 percent between 2002 and 2003, but the new data revealed a 10 percent decline last year, said Robert Epstein, chief medical officer at Medco.

The decline, gradual at the start of the year, gathered momentum, Epstein said. While the raw data do not indicate why fewer children were getting medications, Epstein said the fall coincided with FDA warnings last year that culminated in October with a requirement that antidepressant manufacturers place the black-box label on their drugs.

That warning states that antidepressants increased the risk of suicidal thoughts and behavior in short-term trials involving depression and other psychiatric disorders. Doctors who use such medications “in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

Medical organizations said that language was making it increasingly difficult for general physicians and pediatricians to prescribe the drugs. The requirement to closely monitor patients presents a difficult hurdle, said Darrel Regier, director of the division of research at the American Psychiatric Association, because insurance plans often don’t provide the same level of coverage for mental illness as for physical ailments.

Pediatricians renewing their malpractice insurance policies are being asked whether they prescribe antidepressants, Regier said, and they face higher premiums if they say yes.

Epstein said the data indicated that psychiatrists as well as general physicians were writing fewer prescriptions.

David Fassler, a child and adolescent psychiatrist in Burlington, Vt., said that while there may be some inappropriate prescribing for children, there are many more youngsters who need help and are going untreated. He and Regier said untreated depression is a far greater risk for suicide than any risks caused by the medications.