Treating Children with Depression: How Will History Judge Us?

An investigative report by the BBC recently found that the number of antidepressant prescriptions to children with depression under 12 in England, Scotland and Northern Ireland has risen 24% over the past 3 years (from 14,500 to almost 18,000 prescriptions).

Drugs may not be the most effective way to treat depression (more of which later), but pity the children who were treated for depression before antidepressants were invented.

From Bloodletting to Lobotomies to Overprescriptions

Bloodletting was the standard treatment for “melancholia” in ancient Greece. This was followed by burning in medieval Europe and locking people up during the so-called “age of enlightenment” in Europe.

Last century, Sigmund Freud improved things a bit when he introduced psychoanalysis as a treatment for depression. The problem was that he thought cocaine was a good way to treat his own depression.

Then things got worse again. In the 1950s and 60s depression was sometimes treated by lobotomy (removing part of the brain) and electroconvulsive therapy or ECT (an electric shock that can be so strong it induces a seizure in the patient). ECT is still used today as an effective therapy (together with agents that prevent seizures) for some cases of treatment-resistant depression, where the patient is at imminent risk of harm.

Looking back at these (mostly bonkers) therapies, you might feel a little shocked yourself. Today things seem more scientific. Now we have psychological therapies, such as cognitive behavioral therapy, and antidepressant drugs. These are much better than lobotomies and burning.

Typical drugs for treating depression are selective serotonin reuptake inhibitors (SSRIs), such as Prozac (fluoxetine) and Zoloft (sertraline). In spite of having been studied extensively, there is controversy about how effective they are — if at all — relative to placebo. Their effects may be higher for people who are severely depressed. Certainly anyone with severe depression should be treated by specialists using the best available interventions. Not treating serious depression may cause serious harm.

Prescriptions for Children with Depression Are Climbing

But not everyone who gets the drugs has severe depression. The drugs are prescribed for 1 in 10 adults in most developed nations, and prescription rates for young depressed people are climbing in the US and UK. Many people getting the drugs don’t have severe depression, and there is even more controversy about how effective the drugs are relative to placebo in children with mild or moderate depression. According to the best evidence currently, there was little evidence that the drugs improved self-rated depression at all, relative to placebo for children with depression.

Worryingly, the drugs are often not being prescribed in an evidence-based way for young people. Whereas guidelines in the UK state that antidepressants should only be prescribed within child and adolescent mental health services (CAMHS), many GPs prescribe them. This means that children are unlikely to be getting the supervision needed to avoid unnecessary harm. And the harms can be serious.

Significant Adverse Effects for Children with Depression

Trials show that antidepressant drugs increase the risk of suicidal ideation (i.e. having thoughts about suicide), compared with placebo in young people. Other likely adverse effects include nausea, sexual dysfunction, and sleepiness.

Given the limited benefits and potentially serious adverse effects, why have numbers of antidepressant prescriptions for young people risen so much? We don’t yet have a good answer to this question. It could be that increased loneliness, caused by young people spending too much time staring at screens, is causing more depression that needs to be treated.

Another possibility is that funding is being cut to mental health services, which leaves GPs with the difficult task of having to help young depressed people, but not having the option of sending them to mental health services.

A Gentler Approach

Until we find out why the numbers of antidepressant prescriptions have risen, why don’t we use safer options? Trials show that exercise seems to be as good as the drugs for most mild to moderate depression. And the side effects of exercise are likely to be good things, such as reduced cardiovascular disease and higher sex drive in men and women.

Another safer option is face-to-face socialising. Studies with hundreds of thousands of people show that contact with friends, family and social groups is associated with less depression. (This doesn’t include contact via social media, which seems to increase the risk of depression.) And a side effect of maintaining close relationship is that you’ll live an average of 5 years longer.

So it’s common sense: the right treatment for staring at a screen too much isn’t a pill that increases the risk of suicide, it’s to get some exercise, preferably with friends.

Fifty years from now, are we going to look back at the widespread prescription of antidepressants for mildly depressed young people the same way we look at beatings, lobotomies and cocaine? My guess is “yes.” But I doubt that exercising and hanging out with friends will ever be viewed in a negative light, so if you have mild depression, why not give it a try?

An earlier version of this article was published in The Conversation. Reprinted by permission of the author.

By Jeremy Howick
Oxford Empathy Programme

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