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Children's Depression-Drug Use May Rise, Guideline Critics Say
By HOLLISTER H. HOVEY DOW JONES NEWSWIRES
January 26, 2005

New federal mental-health guidelines could lead to more schoolchildren taking 
branded drugs to treat depression, according to some critics of the program.

In the next few weeks, federal agencies will issue final guidelines taken 
from the President's New Freedom Commission on Mental Health recommendations. 
Millions of dollars in grants for states to revamp such programs will follow. 
But critics fear all this will culminate in more children being prescribed 
antidepressants or other branded pharmaceuticals.  Treating young people with 
antidepressants has come under intense debate because the powerful drugs, 
while helpful to many, can lead to suicidal thinking.

It's a potentially big market for drug companies and one that grew strongly 
until recent warnings about the increased risk of suicide for children on 
antidepressants. The number of children taking behavioral medicines in the 
U.S. jumped 20% from 2000 to 2003, according to Medco Health Solutions Inc. 
data. Spending on hyperactivity drugs increased threefold for children under 
five over the period.

The government and some psychiatry groups say more drugging isn't the 
commission's intention. Recommendations so far propose "quality screening and 
early intervention" in the likes of primary health-care facilities, schools, 
criminal-justice and child-welfare systems.

"Both children and adults will be screened for mental illnesses during their 
routine physical exams," the commission's report, which came out in 2003, 
recommends.

The recommendations "never called for universal or mandatory screening 
without parental consent," said Kathryn Power, director of the Department of 
Health and Human Services' Substance Abuse & Mental Health Services 
Administration's Center for Mental Health Services.

"We were flabbergasted at the way in which some of the controversy was going 
on about screening. ... If parents want and desire that their child should 
have an assessment, they should be allowed to do that. It's a health service 
that's no different from a hearing screening or a vision screen."

Late last year, Congress approved an omnibus appropriations bill that 
included $20 million of grants that states could apply for to revamp their 
mental-health programs. These changes would likely have to adhere to the New 
Freedom Commission guidelines that the government will eventually recommend.

"The problem is that we don't know which recommendations that they're going 
to take," said Karen Effrem, a screening opponent who sits on the boards of 
EdWatch, the Alliance for Human Research Protection and the International 
Center for the Study of Psychology and Psychiatry.

"There's no discussion about protecting families from coercion to screen," 
Dr. Effrem said. "There's no discussion about what happens if parents say no. 
There's no widespread protection against medication coercion, either."

Ms. Power, who is heading the review of the commission report, said that the 
final guidelines from the federal agencies should come out within about a 
month. Separately, the government is in the process of making the grant 
application forms that the states and Indian tribes can submit in hopes of 
receiving $1.5 million to $3 million to transform their state mental-health 
programs.

"They have to show that they have a vision to change their infrastructure," 
Ms. Power said.

Many see the government's goal in simple terms: Screen for children with 
possible problems and get them counseling or support services first.

David Fassler, a member of the American Psychiatric Association's Board of 
Trustees and a practicing child and adolescent psychiatrist in Burlington, 
Vt., said the goal seems to be early detection of signs and symptoms of 
mental illness so children "get comprehensive evaluations and appropriate 
intervention when necessary. Different states will approach this in different 
ways."

Critics welcome early detection -- after all, suicide is the third-leading 
cause of death among young people, according to Centers for Disease Control 
and Prevention statistics. But it's the likely treatment that worries them. 
They say doctors, schools and parents have been too eager to medicate 
children as a quick fix for alleged mental problems and that this could 
increase under the guidelines. In some instances, parents have been 
threatened with child-abuse charges for refusing to put their children on 
psychiatric drugs and schools have suspended children for not taking their 
medicines.

During that 2000-2003 period in which Medco noted the jump in children on 
behavioral medications, spending on antidepressants was up 25% and the use of 
antidepressants rose 27%.

That growth stalled last year. In October 2003, the Food and Drug 
Administration warned about reports that some children who were taking 
certain antidepressants had shown increased risks of suicide and suicidal 
thoughts. In September, an agency advisory committee recommended that 
antidepressants carry the government's strongest warning that the drugs can 
make teenagers become suicidal and that it's unsure if these drugs even work 
on children.

Prozac, which is made by Eli Lilly & Co. and now competes with generics, is 
the only antidepressant approved for use in children, but doctors commonly 
prescribe other drugs.

In the aftermath of the suicide warnings, Medco data showed that the number 
of children under 18 on an antidepressant in the first quarter last year fell 
18% and 5% more in the second quarter.

Part of the controversy around the pending government guidelines stems from 
the commission report highlighting the Texas Medication Algorithm Project, 
which has been criticized because of conflicts of interest linked to the 
pharmaceutical industry, Dr. Effrem said.

The TMAP has led to the creation of a flow chart recommending that doctors 
prescribe the newest medications first for psychiatric disorders.

"The Texas Medication Algorithm Project illustrates an evidence-based 
practice that results in better consumer outcomes, including reduced 
symptoms, fewer and less-severe side effects and improved functioning,"the 
commission report says. "However, too few consumers benefit from this 
practice because it is not widely used."

The flow chart recommends that children diagnosed with major depression first 
receive a selective serotonin re-uptake inhibitor, or SSRI, which includes 
drugs such as Prozac, Pfizer Inc.'s Zoloft and Forest Laboratories Inc.'s 
Lexapro and Celexa. The SSRIs are the same drugs the government linked to 
higher risks of suicide in young people.

The commission's report came out long before the suicide warnings were added 
to these drugs. It's unclear if this would be a part of the government's 
final recommendations.

Write to Hollister H. Hovey at hollister.hovey AT dowjones.com1
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