Dr Yen Teck Hoe – May 2008: Anti-depressant warnings for children: when good intentions go bad

For the past few months, there have been a few letters written by non-psychiatrists in our newspapers discussing the danger of prescribing antidepressants to depressed children. What is the real problem? There has been much sensationalization of the recent labeling of antidepressants and warnings issued by regulatory bodies. Following the investigations carried out by the US Food and Drug Administration (FDA) in 2004, which concluded that children and adolescents were at twice the risk of suicidality if they were taking antidepressants than if they were taking placebo pills, “black box” warnings have been issued in the packaging of antidepressants. 

While the purpose was to caution – but not prohibit physicians about the possible risks involved in prescribing the antidepressants, these warnings may actually be doing more harm than good in the treatment of depression and anxiety disorder in children and adolescents. Two years after Health Canada warned about prescribing anti-depressants to children, the number of children and teens who died by suicide increased 25 per cent after years of steady decline, major new research from Manitoba shows. 

And the increased suicide rate coincided with a 10-per-cent decrease in the rate of visits to doctors for the treatment of depression in children. Several studies examining the effects of these advisory warnings on the provision of care, delivery of health services and clinical outcomes have demonstrated that the decreased prescription of antidepressants coincided with both decreased physician visits and a significant rise in the suicide rate among depressed children and adolescents. There are a number of physicians who have raised concerns that this labeling might have resulted in a “black box scare”, creating a barrier to the treatment victims of depression need. [The FDA has since changed its labeling to acknowledge that untreated depression puts people at risk for suicide (2007).] This resulting panic may be due in part to the difficulty faced in evaluating the risks and tradeoffs associated with antidepressants as well as overemphasis on how well these risk estimates apply to individual cases, creating a fear mentality in both patient and caregiver in prescribing and using these drugs. 

Nevertheless, it is clear that the cost of human suffering and economical impact as a result of clinical depression emphasizes the need for both patients and doctors to take treatment seriously. At least two-thirds of people suffering from depression do not get treated due to social stigma, misdiagnosis, or a general misunderstanding or ignorance of the condition – a situation likely exacerbated by this FDA labeling. However, in the face of mounting evidence that untreated depression takes a serious toll on physical health, it is critical that the seriousness of this disease and its consequences on the quality of life is emphasized, and that all parties involved are aware that failure to treat depression has possibly worse outcomes than any side effects caused by antidepressants. 

Treatment has benefited up to 80% of people suffering from depression, enabling them to lead fulfilling, productive lives; without treatment, however, 15% of people living with the condition take their own lives. While there is a surfeit of freely available literature on depression and antidepressants both from institutions and online sources, many of these are technical, often conflicting, and can potentially impair a patient’s ability to make informed decisions. When you put fears in people’s minds without giving them any sense of the level of uncertainty in the information you’re providing, you can have discontinuations of therapy that are unwarranted and potentially you’ll see these increased risks of suicide, or actual completed suicides.” 

It is recommended that persons or the families of persons suspected of suffering from depression should consult their psychiatrists on the benefits and risks of treatment as opposed to obtaining their information from other channels. Medicine in general and more specifically in psychiatry is the balance between art and science, it’s our duty to do our best to care for our patients and their families. 


Thank you! 

Dr. Yen Teck Hoe 

President of MPA 2008-2010