Interview with Dr. Adelaide Robb

SUSAN DENTZER:

Let's talk about major depressive disorder in children. How does it manifest itself? What are the symptoms that you see when patients walk in and are eventually diagnosed with MDD?

ADELAIDE ROBB:

Well, some children who present to the hospital rather than to the clinic may come in after a serious suicide attempt. So by then the child is very depressed. They may be doing poorly in school, they've stopped playing with friends, they're crying all day long, their grades are dropping, they think they're a bad, terrible, worthless person and they want to die, and the child may actually act on that. We've had children as young as 6 try and hang themselves or overdose on medication. So it's not something to be taken lightly.

If we're talking about children who you would see in a regular office practice, who haven't become so severely ill they want to kill themselves, you're talking about children who may have stopped doing as well in school, so they may go from an A student down to a C student. They may have stopped doing soccer practice or ballet because they don't want to bother anymore, or they're too tired.

You may notice your child changes their appetite and may eat a lot and gain weight, or stop eating and lose weight. They may start sleeping all day long, even more than the average teenager. So changes in sort of normal daytime behaviors like sleeping and eating and socialization is one of the early tip-off signs.

Another one would be giving up favorite activities, or giving away prize possessions. So the 17 year old who gives away his laptop because he doesn't need it anymore rather than because Grandma bought him a new one for his birthday would be another warning sign.

SUSAN DENTZER:

How widespread do we think Major Depressive Disorder is in children, in adolescents?

ADELAIDE ROBB:

If you believe the surgeon general's report, one in five Americans will suffer from a mental illness, and it's one of the more common ones. Depression in children is as high as 1 to 2 percent, and in teenagers it's closer to the adult rates of anywhere between 3 and 8 percent, depending on how you define it.

SUSAN DENTZER:

Do we have any firm knowledge at this point about how many children who have been diagnosed with depression are on medication?

ADELAIDE ROBB:

I think it's a much smaller number of children who are diagnosed with depression (than) who have it, and of the ones diagnosed, not everybody gets medication. So many people with only mild to moderate depression may decide to use therapy first, may use, if they have seasonal mood disorder may use light box therapy as a way to treat their winter depression, or they may use group therapy or family therapy as other ways, besides medication, to get help. And it is a much smaller group of children who actually come for medication.

SUSAN DENTZER:

And what are the symptoms that would lead a physician to prescribe medication for those children?

ADELAIDE ROBB:

I think anytime you are unable to function, you need to get treatment. So if you aren't even getting out of bed to go to school rather than only making a C, it's time to do something with medication.

If you've had a serious suicide attempt and wound up in the hospital from them, it's time to use medication. Or if you need to be hospitalized because you're so dysfunctional you're not eating and taking care of things like shower and brushing your teeth on weeks on end, then a child is fairly dysfunctional and needs medication because therapy takes longer to work than medication does.

SUSAN DENTZER:

Now, of all the selective serotonin reuptake inhibitors, only one, Prozac, has been approved for use in children. What do we know about the way children respond to Prozac?

ADELAIDE ROBB:

Children have side effects on Prozac just the way adults do. Now, there are some side effects like sexual dysfunction or inability to have a sex drive, or inability to function sexually that's a big problem for adults on Prozac, but it's not a problem for teenagers on Prozac. And there are other side effects on Prozac that are more problematic in kids, so feeling revved up or agitated, or having difficulty sleeping tends to be much more of a problem for kids and teenagers than it does for adults. And that problem can be worse if kids and teenagers are drinking a lot of caffeine.

So if you have a teenager who has one latte a day from Starbucks and they're on Prozac, they might not fall asleep until 2 o'clock in the morning. And it's very important when you're talking about side effects to remind people not to use caffeine because that tends to make many of the side effects worse.

SUSAN DENTZER:

From your perspective, what is the extent of the data that shows or does not show any link to suicidality among these drugs?

ADELAIDE ROBB:

Well, again, there's two issues. First of all, major depression has a rate of suicide as high as 10 percent. So untreated, if you just had a bunch of teenagers who weren't on any medicine and weren't in any therapy, up to 10 percent of them would attempt to, or succeed in killing themselves.

On medication, in all of the studies that we have data in the public domain about, whether it's at a research meeting, or on the FDA Web site, or in the paper in the respective Journal, the rate of suicide, even in the Paxil, which is the one that caused all this controversy, is 3.4 percent. Now, that's already two-thirds reduction in the rate of untreated depression. So it hasn't made it go above the baseline of without treatment.

The concern, I think, from the British regulatory perspective was the rate of suicide attempts on placebo was 1.6 percent. So the kids on placebo did better than the kids on depression in terms of wanting to hurt themselves.

One of the things that we've always been taught in psychiatry is when you have a very depressed, unhappy person, and you start them on medicine, the first one to two weeks on therapy, when they're feeling a little better, is when they're at highest risk of wanting to kill themselves. And the reason is they finally have enough energy to get out of bed and go to the store and buy the Tylenol or the razor blades, not because the medicine makes them worse, because the medicine makes them well enough to finally do it. They may have been thinking about killing themselves for four weeks before they started medicine, but it's only after the medicine makes them a little bit better that they can actually go out and do something.

So I think that when you start a child or an adult on an antidepressant, you need to monitor them very closely, especially for the first two to four weeks of therapy, to make sure they're sleeping okay, their thoughts about suicide haven't gotten worse, they're not staying up all night getting agitated and thinking about hurting themselves, because you can change something. If you need to hospitalize them, you can hospitalize them. If you need to switch their medicine, you can do that. If you need to reduce the dose until they get used to the side effect of insomnia, you can also do that.

However, for most of the world who gets their antidepressants not from a psychiatrist but from their general practitioner, first of all, general practitioners don't get a lot of training in medical school and very little training at all in residency on how to diagnose and treat psychiatric illness, and they're so busy taking care of other things, they don't have a half an hour to sit down with a mentally ill patient and say, "Okay, you've been on Prozac for two weeks. How are you sleeping? What percent of the time are you thinking about killing yourself? Have you made any plans? Have you collected pills or bought a razor blade? What are you going to do to stop yourself from doing that? What keeps you alive?"

They're just not trying to do that. But if they're giving out the prescriptions and their patients are carrying out these acts, then it looks like people are being really irresponsible when, in fact, they're just not trained to diagnose and treat this, just the way I wouldn't take care of somebody two days after a heart attack and prescribe their heart medication. For me it's the same kind of thing, that you should be taking care of seriously ill people, and I think suicidally depressed people are seriously ill, by a specialist, not a generalist.

SUSAN DENTZER:

So you're saying the issue here is not the drugs per se, it's how they are prescribed and how they're being used.

ADELAIDE ROBB:

And how they're being monitored, and how quickly they're being adjusted. Exactly.

So I think the issue is not so much that the medicines cause suicide, it's that whenever you treat depression there are periods of time, especially at the onset of treatment, when people may become energized enough to hurt themselves before they feel happy enough to realize it's not worth doing that. And during that period of risk after the initiation of treatment, they need to be closely monitored by somebody with expertise in the treatment of depression.

SUSAN DENTZER:

Much of the controversy over what has shown up, or not shown up, in the (antidepressant) studies under consideration has to do with vague references to things that patients may have experienced. There doesn't seem to be a lot of specificity about what really was a suicide-related impulse or a suicide-related event.

ADELAIDE ROBB:

Right, and that's an excellent point to make. When we had our first meeting about this last year at the American Academy of Child Psychiatrists meeting in Miami, they actually had some of the people from the pharmaceutical companies come up and talk about their drugs, as well as Dr. Loffron [ph], who is from the FDA and the child psychiatry branch, and one of the things that was reported as a suicide attempt in the Paxil study was an eight year old who was upset and hit himself in the face and said, "I want to die." That was coded as a suicide attempt.

If I saw somebody who had smacked themselves in the face when they were upset, I would not admit that person from the emergency room to the hospital.

Another case that was coded as a suicide attempt was a teenager who scratched on the back of his hand with a paper clip and said I want to die. Scratching your hand with a paper clip doesn't kill you, but that was coded as a suicide attempt.

So part of the issue is what is coded as a suicide attempt on a piece of paper that collects side effects in a study may not, in fact, be a suicide attempt. So the FDA is actually taking all the raw data, all the written documentation that the sites keep and sending that to Columbia University so they can go through and read the descriptions of these events and decide is this a true suicide attempt or is this, you know, self-destructive behavior or self-mutilatory behavior, like picking at your skin is not a suicide attempt, but it may have been miscoded as one, so that they can clarify what's a true act intended to end your own life with the belief that it would be successful, which is what most of us would think a suicide attempt was.

SUSAN DENTZER:

At the FDA advisory committee hearing which you were a participant in and you testified, in effect, at that, spoke at that, there were a number of incidences recounted. Parents told stories — one case of a 13 year old who started on an antidepressant, went into the room and hanged himself. There were a number of very poignant, horrible stories told. What would explain that kind of behavior, and what about these parents who believe that there is a causal link between the fact that their children were on these drugs and then committed suicide?

ADELAIDE ROBB:

Well, first of all, I feel terrible for every parent who has lost a child to illness, especially to depression or bipolar disorder, and I don't in any way wish to discount their suffering. But I think that what we didn't hear a lot of at the FDA was all the people whose children's lives had been dramatically and markedly changed by going on an antidepressant because they're doing well, and there is still a shame to having mental illness in the United States, and so if you've got a kid who's at National Cathedral School in the tenth grade who is doing great on Prozac, you don't want to stand up in front of Congress and all the people you go to work with and say, "Guess what? My kid's depressed and they're on medicine, and they're doing fine," because nobody needs to know. You want to keep it private.

So I think what we didn't hear a lot about were all the people who did so much better, and I think that that was the sad part, that all the people who had lost children came forward, and all the people whose lives we helped didn't. So I think that while some people will have a bad reaction to almost any medicine, and the antidepressant may not have helped their child and they did go on to kill themselves, we don't hear all the people who are saved. And I worry, as a clinician, that what all of this information about how bad medicine does is it makes kids more reluctant to say to their parent, "I don't feel good. I need help." And it makes parents more reluctant to go to a doctor and say, "I think my child is depressed. We need to do something," because they think that the treatment is going to kill you, so why go get treatment. And I think that's really the wrong message to put out to the American public. And I think that that's the message that's been coming out.

I know when I take care of kids, and in the beginning we would talk about antidepressants and side effects, we had a balanced decision about upset stomach, difficulty sleeping on caffeine, you may have some tremor or some shakiness, and now we spend a lot of time talking about the FDA data, what to look for, what are the periods of risk, and is it worth staying on the medicine or is it not worth staying on the medicine. And many of my patients have been on medicine for six months, and one of the things I can certainly tell parents now is, "Well, your child has done well for six months. They're not going to want to kill themselves tomorrow because we're out of the period of risk."

But it still makes people hesitate to seek treatment. And when we treat kids for cancer and we know that some of them are going to die of the side effects of chemotherapy, parents don't usually say, "Well, chemotherapy kills you. I don't want to treat my child's cancer." But now they're starting to say that about treatment for depression, and I just think that's the wrong message.

SUSAN DENTZER:

So what's the best advice to give parents, and patients and families as we await [the evaluation of antidepressant data]?

ADELAIDE ROBB:

I think the first thing to do for parents is that if you have a child that you're worried about having or suffering from depression, that you go and see a child mental health care specialist, and by that I mean a child psychiatrist if you're thinking about medicine, or a child psychologist or social worker if you're thinking about therapy.

If you live in a part of the country where that's not available — and there are many parts of the country where there are not a lot of pediatric trained mental health care specialists — then you would want to go see a general psychiatrist before you went to the pediatrician or GP — general practitioner.

When you first start on medicine, you want to go thoroughly over side effects that you can expect, what are common side effects that will get better over time, and also what are serious side effects like a rash all over your body would make me tell patients to go to the emergency room; or not being able to sleep for a whole night would be another thing where we might want to change the dose, or try a different kind of medicine.

You should also learn what the warning signs are for suicidalidiation and for suicide attempts. If your child starts giving away all of his favorite possessions, and stops playing with his friends, and just sitting in his room writing poems about killing himself. That's a worrisome thing as well. And your child needs to feel comfortable enough telling you when they feel bad or want to hurt themselves, that you're not going to punish them for that, that you just want to help them, because sometimes it's hard to talk about that with doctors and with family members.

I think the other thing to note is that the period of greatest risk is when you increase the dose in medicine, or change it, and when you first start on medication, and those should be times when you are monitored closely by your physician.