Therapy? Or Pills? A Quandary In Britain

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December 21, 2004

Therapy? Or Pills? A Quandary In Britain

By LIZETTE ALVAREZ

http://www.nytimes.com/2004/12/21/health/psychology/21depr.html?oref=login

LONDON, Dec. 20 - One year after British drug regulators advised against

prescribing a new generation of antidepressants, except Prozac, for

depressed adolescents, British doctors say they are in a frustrating bind.

Warned away from using the antidepressants, they are recommending

psychotherapy for their young patients instead. But under the British health

system, depressed teenagers face a six- to nine-month waiting list for

psychotherapy, a situation unlikely to improve in the short term.

" On the ground, we feel very much abandoned, " said Dr. Dick Churchill, a

general practitioner and senior lecturer at Nottingham University. " The

advice seems to be these kids should be having psychological treatment. But

we don't have ready access to trained services to give them. So we are stuck

in a difficult position at the moment. "

Dr. Hill, an independent child and adolescent psychiatrist and an

honorary consultant to the Great Ormond Street Hospital for Children, said

the advisory was at first greeted with deep concern and bewilderment by

parents, patients and the general practitioners who are on the front line of

medical care here.

" The phone was red hot for days on end, " Dr. Hill said.

The situation has settled since then, he said, but a certain amount of

confusion remains about antidepressants, particularly about those addressed

by the regulators, most of which belong to the class known as selective

serotonin reuptake inhibitors, or S.S.R.I.'s.

" I have a letter on my desk at the moment from a G.P. who thinks he is

unable to prescribe any S.S.R.I.'s for any children, and that included

17½-year-olds, " Dr. Hill said.

The government's warning, issued last December, came on the heels of an

enormous rise in the use of antidepressants and stimulants among young

people here. Prescriptions of the drugs to children in Britain jumped to

700,000 in 2002 from 400,000 in 2000, according to an international study by

a research team from the University of London's School of Pharmacy,

published in November in the journal Archives of Disease in Childhood.

From January 1992 until December 2001, the use of antidepressants for

children rose 70 percent, according to a second study published in the

journal by the same team.

The British government estimates that 40,000 children under 18, or about 1

child in 300, were taking antidepressants in 2003.

Doctors here say the popularity of the drugs could be traced to several

factors, including the availability of newer drugs, greater awareness about

childhood depression and an increase in diagnoses of the illness by family

doctors.

In its 2003 advisory, the Medicines and Healthcare Products and Regulatory

Agency, the British equivalent of the Food and Drug Administration in the

United States, stopped short of an outright ban on prescribing

antidepressants for children. But the recommendation was more sweeping than

the action taken by the F.D.A., which in October toughened warning labels on

antidepressants for children and adolescents but did not tell doctors not to

use them.

Under the British guidelines, general practitioners are advised not to

prescribe any of six newer generation antidepressants for children and

teenagers and to consult with a mental health specialist before prescribing

Prozac, which was exempted from the warning.

The regulators based their decision on data suggesting a link between the

drugs and suicidal thinking and behavior among young people and a lack of

evidence for their effectiveness in treating childhood depression.

In December, the British drug agency weighed in again, this time for adults,

recommending, on the basis of an 18-month review of 600 published and

unpublished clinical trials, that antidepressants not be prescribed for mild

depression. But the officials stressed that the benefits of antidepressants

for more severe depression were well proved, and said that there was " no

clear evidence " of an increased risk of self-harm and suicidal thoughts in

adults.

Psychiatrists in Britain say that for the most part, children and

adolescents who were already taking the antidepressants continued to take

them after the 2003 advisory was issued, but with greater vigilance by

doctors. New patients who visited psychiatrists, as opposed to family

doctors, were given Prozac if medication was required. " Specialists can

still prescribe whatever S.S.R.I. is necessary, but we are using much more

fluoxetine than before, " said Dr. Mark Berelowitz, a child and adolescent

psychiatrist who is a consultant at the Royal Free Hospital in Hampstead,

referring to Prozac.

General practitioners, on the other hand, have grown increasingly squeamish

about prescribing any medication to depressed children.

" The key thing that seems to be happening in my awareness is that most

G.P.'s are fairly reluctant to prescribe any antidepressant to teenagers at

the moment, " Dr. Churchill said. " The guidance from the government has made

everybody wary, even of Prozac. "

In theory, the national health system advocates a holistic approach to

mental health. Troubled or depressed teenagers are referred to mental health

teams that include counselors and psychiatrists, all of them working

together in treating the patient. The problem is the scarcity in the number

of child counselors and psychiatrists, a shortage that has led to long

waiting lists once a referral is granted.

Some experts believe the government's action was rashly taken. The evidence

that the drugs cause suicidal thinking and behavior, they say, is not

clear-cut, and they worry that some teenagers may not be getting the help

they require.

The regulators " may have been flatly overcautious, " said Dr. Coghill,

a senior lecturer in child and adolescent psychiatry at the University of

Dundee in Scotland and a clinician.

" I did prefer the black-box warning that the U.S. came out with, " Dr.

Coghill said. " I think that was more considered. It addresses the concerns

but does point out that the number of children and young people who will

have these reactions are very small. "

But many family doctors say that they were never altogether comfortable

dispensing medication for depressed teenagers, but that often they felt they

had no choice.

Still, the turmoil surrounding the use of antidepressants has had some

positive repercussions. Psychiatrists say there is now a greater emphasis on

consulting with child psychiatrists before prescribing medication.

And for the first time in a long time, the government now is focusing on the

need for psychotherapists and psychiatrists for young people, and promising

to steer more money into psychotherapy, a critical component to mental

well-being, doctors say.

" The national guidelines, which are about to be published, are going to say

that we should almost always be trying psychotherapy first, and medication

should be in addition to that rather than something used on its own, " Dr.

Berelowitz said.

He added, " If my child was depressed, I would be very unhappy if a family

doctor started him on medication and didn't arrange for a specialist opinion

and specialist psychotherapy. "

Dr. Sue , an adolescent forensic psychiatrist at the University of

Lancashire in Manchester, said that " child psychology in the U.K. had been a

Cinderella " for too long.