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Which Kids Need Antidepressants?

Children With Milder Depression May Get Little Help From Antidepressant Drugs
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WebMD Health News

Jan. 1, 2009 -- Medication helps depressed kids, but only those whose symptoms are severe enough to warrant treatment with antidepressants, analysis of clinical trial data suggests.

The study is a careful analysis of data from 12 published and unpublished clinical trials in which newer antidepressant drugs were studied in children aged 6 to 18 with major depression.

There was a big problem with these studies: A placebo -- fake pills -- helped nearly half of depressed kids get better. Antidepressant drugs did only a little better, resulting in substantial improvement for 59% of kids vs. 48% for placebo.

Does this mean the drugs don't work very well? Or is something else going on? That's what Jeffrey A. Bridge, PhD, of Nationwide Children's Hospital in Columbus, Ohio, and colleagues tried to find out.

The researchers analyzed all the data collected in the various studies. They found that kids enrolled in multicenter clinical trials were much more likely to respond to placebo than were kids in smaller trials. They also found that kids in larger trials tended to have less severe depression than kids in smaller trials.

This, they suggest, may mean that antidepressants are most helpful to kids with at least moderately severe depression. For kids with milder depression, the drugs' benefits may not outweigh their risks.

"If confirmed, these findings raise questions about the benefit-to-risk profile of antidepressants in treating depressed pediatric patients with mild functional impairment," Bridge and colleagues conclude.

Doctors who treat children for depression should pay close attention to this finding, suggests an editorial by Graham J. Emslie, MD, of the University of Texas Southwestern Medical Center in Dallas.

The study "emphasizes the importance of a careful and extended evaluation prior to initiating medication to make sure that the depression is of sufficient severity to warrant medication treatment," Emslie says.

Emslie makes another major point: The large placebo effect seen in these studies does not mean there's no such thing as child depression -- nor does it mean that these children don't need "vigorous treatment."

Bridge and colleagues suggest that kids with milder depression may benefit more from specialized psychotherapy than from antidepressants as an initial treatment option.

Just how severe must a child's depression be before antidepressant therapy is indicated? Unfortunately, the study can't answer that question. Emslie suggests that future trials be designed to find out which children are most likely to need antidepressant treatment.

The Bridge study and the Emslie editorial appear in the January issue of the American Journal of Psychiatry.

The Bridge study was funded by a grant from the National Institute of Mental Health. Bridge and one of his co-authors have presented at a conference supported by pharmaceutical companies; that co-author has also participated in drug company-sponsored forums. Emslie receives research support from and is a consultant for several drug companies; a reviewer for the American Journal of Psychiatry found no evidence of company influence in his editorial.

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