In the United States, five percent of the children are inflicted with the syndrome, depression. This is equal to the adult's percentage rate of depression. According to Dr. Mohammad Shafii and nurse Sharon Shafii, depression as a syndrome or disorder includes intense and prolonged sad moods, loss of interest or enjoyment in everyday activities, increase or decrease of sleep or appetite; fatigue; retardation; feelings of worthlessness; self-blame or excessive guilt; diminished ability to concentrate or think; and morbid thoughts, suicidal ideas, or suicidal attempts. In dealing with children and adolescents with depression, some clinicians have been prescribing anti-depressant medications. Prescribing drugs that have not been thoroughly tested on children and adolescents presents a problem in issuing these anti-depressant drugs. All of these prescribed anti-depressant drugs have been tested on adults and have been commonly used by adults. However, some clinicians do not prescribe these drugs to children on the basis of lack of knowledge on it's effect on children and adolescents. They prefer having these drug effects on children and adolescents thoroughly tested before issuing them to their young patients. There is a sense of urgency in helping depressed children and adolescents, especially since there is a close connection between depression and suicide. Until solid studies on children are performed, the controversy between the clinicians who are in favor of the drugs and the clinicians who are against the drugs continues.
Only recently has depression among children increased dramatically and taken public notice. In the past, it was believed that the experience of guilt was a prerequisite to depression. At that time, psychoanalysts believed that infants and children were unable to experience guilt. Therefore, it was believed that infants and children could not have the depression syndrome. Starting from the 1940's, documents presented the presence of severe depression following maternal deprivation, such as lack of bonding with the mother. Maternal deprivation in childhood led to the development of severe psychopathology, such as profound depression (Shafii 8). Following these documents, more research was conducted which eventually confirmed the existence of depression among children and adolescents (Shafii 116).
Although it is not a fact that suicidal behavior is connected to depression, it can be assumed most of the time. The majority of studies indicate that depression is a major risk factor for youth suicidal behavior (Pfeffer 1986). One of the largest psychological study of adolescent suicide conducted in New York shows a strong relationship between depression and adolescent suicide. This study can be found in Shaffer's article (Shaffer 1988). It involved approximately 173 adolescent suicide victims under 20 years of age. The rate of suicide for males is 14 per 100,000 and for females it is 3.5 per 100,000. The study focused on how the suicide rates for both men and women are affected by different factors. The different factors taken into consideration were major depression, antisocial behavior, family history of suicide and substance abuse. The results showed that major depressive disorder in adolescent male and female suicide victims is a very significant risk factor. For males, a depressive disorder increases the suicide rate by a 7-fold over the base rate and for females, it was a 23-fold over the base rate. This study concluded that major depression is an important risk factor in adolescent suicide. In Louisville, Kentucky, a psychological autopsy found that 95% of the suicide victims compared to 48% of the matched comparison group had at least one diagnosable psychiatric disorder (Shafii 168).
Depression is closely linked to teen suicide and school failure and dropout. Since "suicide rate for children younger than twelve has doubled in the past decade, while the rate for teenagers has risen to equal that of adults," there has been a growing concern for depressed children and adolescents (Portner 12). Depression among children needs to be dealt with quickly, because of it's connection to teen suicide. Between 25% and 34% of depressed children and adolescents attempt suicide and one-third of them are at risk for a fast suicide attempt by the average age of seventeen years old (Kovacs 289). Therefore for depressed children, early intervention is crucial to prevent a suicide. Also if it is not dealt with promptly, there is a greater chance of a "lengthy episode and impairment" (Kovacs 294).
As a way of dealing with depression among these young patients, a quarter of the kids are on medication for depression-related syndrome. In 1996, around 600,000 children and adolescents were prescribed Prozac, Paxil, or Zoloft according to IMS America, a research group (Portner 12). The popularity of these FDA approved drugs is rising, because they have been effective in alleviating depression. Although these drugs help depressed kids cope with their symptoms, they have not been thoroughly tested on children. The professionals disagree on whether the drugs need to be tested on children prior to prescribing them to young patients. Prozac, Paxil and Zoloft are labeled in the Selective Serotonin Reuptake Inhibitors category (SSRI) (Crowley 73). They basically regulate mood by adjusting the brain chemical serotonin (Strauch A1). SSRI's have been approved by FDA for adults. This allows physicians to prescribe SSRI's to children. Currently the drug companies are conducting studies on children to learn of any short and long-term effects. They want FDA to approve the drugs for children, which will allow them to directly market the SSRI's to children. This would give the companies big profits.
Critics fear that the drugs will be misused as quick fixes for symptoms of depression, such as disinterest in school or social activities, learning disabilities or emotional problems. The drugs are not for shortcuts. It is tempting to use them as shortcuts, because they tend to bring faster results than therapy or counseling. Another fear lies with the insurance companies. Since psychotherapy is expensive, insurance companies could resort to drugs too quickly (Strauch 24). Another concern is that excessive prescription or accidental overdoses could occur. Also, some of these anti-depressant drugs are metabolized more rapidly by children than adults. This tends to cause greater withdrawal symptoms between doses (Shafii 221). There needs to be a close watch on any abnormal symptom. Without proper research, it is difficult to know the effects from these prescriptions. Some professionals worry about the long-term effects, especially on the developing brain and nerve transmission (Crowley 73). Some of the side effects are nausea, diarrhea, insomnia, weight loss, sedation and in less commonly, seizures (Portner 12). They feel that it is too big of a risk to prescribe these drugs without more studies on it's effects on children. Instead, they advise their patients to traditional forms of treatment, such as psychotherapy.
Psychotherapy basically consists of providing a consistent and caring human contact, such as spending time with and really listening to the patient. Such love and care can tremendously heal the patient beyond our understanding and knowledge (Shafii 174). The length of psychotherapy varies with each patient. Some patients respond fast to these treatments, while others may take awhile. Also, it is important for both the parent and child or adolescent to be seen by a therapist, preferably the same therapist. This allows the therapist to better understand the family and thereby help the family.
The other professionals feel that depression itself is a risk (Crowley 73). Since the drugs have been effective and have no major side effects, they do not see the point in keeping the SSRI's away from children. So far, one study has been conducted and it has shown Prozac and the other drugs to be effective on children. It was conducted by Dr. Graham Emslie, professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. Based on 96 children ages 7 to 17, over a two month period, researchers concluded that half of the children got better taking Prozac, compared with one-third who improved taking a placebo (Strauch 24). The results matched those found in adult studies of the drugs. Within a year, seventeen children from the study had relapses and three developed mania. Half of the kids who suffered relapses were taking the drug and half were not (Strauch 24). There are other anti-depressants on the market, but they are not as safe as SSRIs. They tend to cause heart irregularities. (Crowley 73). Thus, SSRIs are more popular, specifically Prozac.
In 1996, there was a 47% prescription increase for Prozac between 13 to 18 years old, totaling 217,000 prescriptions (Strauch 24). For 6 to 12 year olds, there was a 298% increase with Prozac, totaling 203,000 prescriptions for that year. Prozac was the most popular among the SSRIs.
Personally, the traditional method of psychotherapy seems more favorable. It can be painful to watch someone whom you care for deeply suffer because of the depression syndrome. However, health should not be sacrificed even though improvement on some drugs have not been thoroughly tested on children and adolescents. Comparisons of medication and placebo do not demonstrate the superiority of medication in most studies, probably because of the high placebo response rate in this population (Shafii 230). Some clinicians feel that there has not been any controlled studies of pharmacological treatment on major depressive disorder in adolescents that has shown prescriptions to be more effective than placebos. Depression as a syndrome is not deadly in itself, but can be if it leads to suicide. With active family intervention and psychotherapy, depression can be controlled. "Depressed children have frequent negative cognitions, and suicidal children appear to have poor family social supports (Shaffii 122). Therefore, having a positive attitude and as mentioned earlier, attending sessions together to the same therapist is important. When the parents provide a healthy, stimulating environment, great improvements can be observed (Shaffii 163).
Although psychotherapy may take a longer time to see changes, it is worthwhile. It is safer than prescriptions and probably just as effective. Currently, there is no knowledge on the long term effects of these prescriptions. It seems that the prescriptions are best for a short term treatment. Unfortunately, depression tends to be a long term syndrome. Psychotherapy is a long term treatment. Therefore, until more controlled studies concerning the drug effects on children and adolescents are conducted, psychotherapy should be preferred over these prescriptions.
This paper was prepared in 1997 for a colloquium facilitated by Stephen Wright, instructor for the Advocates for Children program, part of the College Park Scholars community at the University of Maryland, College Park.