Experts Answer Your Questions on Antidepressants

April 19, 2007 — -- Previously on "World News With Charles Gibson," we asked you for your questions about antidepressant use in adolescents. Here are some of the questions we received on our message board, with answers from two depression experts.

Dr. John Constantino is an associate professor of Psychiatry and Pediatrics at Washington University School of Medicine.

Dr. Richard D. Todd is professor of Psychiatry and Genetics and director of the Division of Child Psychiatry at Washington University School of Medicine.

Question From WorriedDad:

My 10-year-old daughter has been on Zoloft for over two years, even though I have expressed concerns. She has never been depressed. She has gained an abnormal amount of weight. I worry about all the other side effects besides suicide. No tests are run by the doctor who prescribes this medication to check on what this is doing to her physically. What can I do?

Answer:

Although there are no standard tests for physiologic response to antidepressant medications, excessive weight gain is important to take seriously.

It would be reasonable to discuss these concerns with her doctor and for her doctor to consider tests of her thyroid and liver function, as well as to consider a discontinuation trial of the medication given her relatively young age and the duration of time on the medication.

Zoloft is a medication that treats not only depressive symptoms but also anxiety-related symptoms and obsessional symptoms. If her doctor's clinical judgment is that she is not depressed because she has been on the medication all this time, it is important to consider that and to watch closely for any deterioration in her condition if a discontinuation trial is pursued.

Another important option for her if she needs the Zoloft is to switch to a "sister" medication in Zoloft's class, which might be less likely to incur weight gain. Fluoxetine, Duloxetine and escitralopram would all be worth considering on that basis.

Question from subodot:

My question has to do with the 39 percent that improved on placebo pills. This culture wants a magic bullet for everything -- I've known people who were prescribed Prozac as part of a weight loss diet. The deeper psychological issues often go ignored. What are some statistics about intensive therapy alone in depression, where the depression issues are really dealt with and there are no meds involved at all?

Answer:

The placebo response is universally observed in treatment trials of adults and children with depression, and it speaks to many of the psychological issues that influence or sustain depressive states.

It is true that psychotherapy (specifically cognitive-behavioral therapy) can be very effective for the treatment of depression. It is very reasonable to attempt a trial of cognitive behavioral therapy before proceeding to psychotropic medication, except in more severe cases when a child's life is on the line.

Question From DJ9020:

My daughter suffers from major depression, social anxiety, and OCD. She has been on Zoloft and Effexor. The Zoloft did not work very well. Effexor was somewhat more effective but did not address her OCD. She is now on Lexapro and seems to be making some improvement. In addition, she is also in therapy.

However, I would like more information on the long-term effects of these medications on children and teens. It seems like there is not much information about that, and many of these medications have been around long enough to have some data on that.

Answer:

I couldn't agree more. This class of medication does address all three symptom domains experienced by your daughter, and therefore is a very reasonable choice.

Research on psychotropic medications in children has lagged just as research on medical therapies for children historically lagged behind those in adults, until pediatrics slowly emerged as its own field of research.

Even for adults, long-term studies of the effects of psychotropic medication are few and far between (although progress is being made). Long-term follow-up studies are critical, but they are expensive and are weighed against the urgency of other research needs on limited budgets for funding research.

The bottom line is we don't know for sure the long term effects of most medications. We are sure of the long-term negative consequences of depression, severe social anxiety and obsessive compulsive disorder (OCD). Conversely, postmarket monitoring of the safety of most of these medications has not revealed common or frequent problems.

Question From Travis anon:

Every drug I have tried for depression has changed my personality in a slightly different way, and they always had a dramatic tranquilizing effect. I've heard similar stories, and I believe drugs are a potentially dangerous dead-end for young people whose problems should be remedied by taking time out for soul-searching and if necessary, psychotherapy. What are your thoughts?

Answer:

There are times in every life when soul-searching is a very important thing to do. And depressive conditions can be influenced by many factors, including life events, that must be dealt with and adapted to in their own way if they are ever going to stop influencing an individual to suffer from depressive symptoms.

But it is also true that untreated depressive symptoms can make it nearly impossible for an individual to conduct the necessary soul-searching and adaptation to life circumstances that allow a person to move on with his or her life. For example, it is common for depressive symptoms to incur an overwhelming sense of hopelessness, poor concentration, loss of energy, or major distortions in perspectives on everyday life situations that result in conclusions being drawn from illogical assumptions.

Also, you raise an important point that different individuals have different reactions to various psychotropic medications, and that these reactions can be negative and sometimes severe.

All medication use requires a careful appraisal of the risk-benefit ratio before the medication is started.