Antidepressant use in adolescents
Biology 202 Web Paper 2 Sophie Balis-Harris 4/5/10
Recently I read an editorial in New York magazine concerning the advisability of adolescent antidepressant use that sparked my interest. This article, titled Pilloried focused on the effects these drugs may have on the character and emotional development of children who use them. It seems that the question raised in Pilloried of how antidepressants effect children’s identity has been all but ignored, while many news outlets have discussed at great length the controversy over possible links between increased thoughts of suicide in young adults and antidepressants. However it would seem that in order to truly understand the benefits and disadvantages of juvenile antidepressant use, we must evaluate them not simply on the most noticeable, short term side effects but also the long term impact it may have on younger patients. In my paper I would like to explore the long term effects of antidepressants on young people.
Though depression tends to be a somewhat ambiguous concept, clinically depression is a disorder characterized by feelings of sadness, hopelessness, and worthlessness along with fatigue or irritability that lasts for over two weeks (1). Depression is often linked with low levels of serotonin, a neurotransmitter which effects mood and sleep regulation, appetite, gastrointestinal function, sexuality and pain (2). Currently the two most popularly prescribed drugs designed to treat depression are selective serotonin re uptake inhibitors (SSRI’s), and tricyclic antidepressants (3). The scientific community still has a somewhat shaky understanding of how all antidepressants work, however SSRI’s are understood to function by blocking monoamine transporters from reabsorbing serotonin. This allows the serotonin more chances to be recognized by receptor cells (3). Tricyclics work in a similar manner, however they also affect the re uptake of norepinephrine and dopamine; neurotransmitters which effect functions such as movement and attention (3).
Suspected links between suicidal thoughts or behavior and adolescent antidepressant use have caused much controversy in the US and abroad. Following the death of five participants in an Eli Lilly antidepressant drug trial in 2004, the FDA stated that there was a link between antidepressant use and suicidal ideation in young people (4). Black box warnings were put on antidepressants, which caused child antidepressant use to fall by 10% (4). However, several studies were conducted that concluded antidepressant use in adolescents can still be very beneficial, and safe with monitoring of the patient. A study conducted by John March of the Duke University Medical Center showed that while close to 15% of adolescents taking SSRI's with no concurrent therapy reported suicidal ideation, only 6% taking SSRI's while undergoing cognitive behavioral therapy reported such thoughts (5). A study published in Munich reaffirmed a small risk of suicidal thoughts or behavior in adolescents, however stated that the risk can be manageable and should be measured against other ill effects of depression (6). While most health organizations and providers warn parents to closely monitor children on antidepressants, generally it has been accepted that antidepressants are safe for people under the age of 18. Currently, approximately 2.5% of Americans under the age of 18 use antidepressants, a relatively high number compared to the mid 90's when about 1.4% of American children used antidepressants (4).
While apprehension over the risk of antidepressant caused suicide has mostly dissipated, there are still largely unaddressed concerns of the effect of these drugs on the still developing mind of adolescents. Though the human brain was once thought to have stopped developing around puberty, it is now known that the brain continues to develop well into the twenties (7). During childhood there are different periods of overproduction of gray matter, then followed by a selective waning of gray matter, one of these overproduction periods occurs before puberty (7). Activities that the individual engages in during their adolescent and teen years will strengthen related neuronal connections while other synapses are pruned away (7). This is often referred to as the “use it or lose it principle”. In addition to gray matter production and loss, the cerebellum and corpus capsollum also develop significantly during the teen years. The fact that the brain is developing in such key areas during adolescence has been cause for concern, as some believe the change in serotonin levels may cause averse reactions in the long term. A neurologist at McGill university stated:
“serotonin acts as a growth factor during the first years of life. It encourages the formation of connections, or synapses, between neurons, and it is crucial for the acquisition of a normal response to anxiety-producing events in adulthood. It is also found elsewhere in the body, where it performs a variety of other functions. Drugs that alter serotonin during these critical developmental years could alter brain function in unpredictable ways...” (4)
This suggests that children who use antidepressants may not develop adequate skills to handle anxiety, or stressful situations. The “use it or lose it” principe applies in this situation- researchers fear that because the teen years are so important developmentally if these response skills are not developed during that time, they may not develop properly at all. A study conducted at Columbia attempted to confirm this theory, by introducing rats to prozac at very young ages and testing their stress levels through adulthood (4). The rats eventually exhibited extremely high levels of stress as they reached adulthood. Though the connection between stress levels in rats and humans is tenuous, the researchers involved with the study still urged caution in the use of antidepressants in children (4).
In the end, it seems as if there needs to be a broader discussion of the long term effects of antidepressants on young people. Though many ill effects of antidepressant use are questionable, it seems almost undoubtable that these drugs will significantly impact the identity of patients who begin using them at young ages. The very purpose of these drugs is to alter the way ones mind works- it seems that this effect would be amplified when the mind in question is still undergoing major physical changes. Children who grow up on anti depressants are denied the opportunity to have any real understanding of themselves outside of medication. In addition, children who are medicated have no way of understanding the full scope and long term effects that they could possibly have when choosing to go on these drugs . This is in no way meant to deny the value of antidepressants, as they are certainly necessary and lifesaving in many instances. However because these drugs are so effective in such a short period of time our society often forgets that they are not the only option available. As a result of this medication is increasingly becoming the default response in cases of depression. Currently over half of adolescents taking antidepressants are not in therapy, despite that cognitive behavioral therapy is often just as effective as antidepressant use over a period of four to eight months (5). In light of the fact that we do not fully understand the way antidepressants effect the developing brain, it would seem prudent to reinstate talk therapy as the primary treatment for depression in children and teens, and reserve drug treatment for the most severe cases.