Jimmy Spence was in fourth grade when his strange new behavior started: He
began jerking his head and limbs uncontrollably and making strange blowing
sounds with his mouth. During lunch at his school in Milford, Conn., his arm would suddenly jump and smack into someone next to him. Jimmy would hang his head in embarrassment as the kids around him laughed.
Partly to control these tics, a psychiatrist prescribed an antidepressant,
Wellbutrin, which Jimmy began taking twice a day. Ironically, the tics were
most likely a side effect of another medication Jimmy had started taking
three years earlier, when he was 6: Ritalin, the stimulant taken by
millions of American kids who are considered hyperactive.
Looking back, it's hard to say exactly when Jimmy's problems began. When he was 3, his mother and father separated. He felt suddenly lonely, and
thought he didn't fit in with his parents' new partners. Entering school
didn't help; in class he was restless, unable to concentrate or stay in his
seat. His teacher urged Jimmy's mother to seek professional help and when
she did, the psychologist diagnosed Jimmy with attention deficit hyperactivity disorder (ADHD) and suggested Ritalin. Within a week, Jimmy was taking two pills a day.
Jimmy disliked the medications. The Ritalin left him with wild mood swings when it wore off in the afternoon. And he dreaded the sense that everyone
at school knew about his problems. "The kids were always making fun of me," he remembers. "It would be like, 'That kid's stupid, he's on Ritalin.'"
Jimmy begged his mother to stop the Ritalin, and at one point, she agreed.
But school officials told her that if she didn't keep Jimmy on medication
he would not be allowed to attend school for more than half a day. Nancy, a single mother, gave in.
Later, when the Wellbutrin was added to Jimmy's daily regimen, it had little effect. The twitching continued, one time jerking his head so
forcefully that the school nurse feared he would snap his neck. Jimmy went
to therapists, psychiatrists, even a neurologist, but never saw anyone long
enough to form a connection. He was variously diagnosed with ADHD, bipolar disorder and a mood disorder. Another doctor took him off Ritalin and put him on a different stimulant, Cylert, while continuing the antidepressant. Still the tics continued.
By the fall of 1996 Jimmy, then 11, was in a funk. He hated going to
school in the morning, and came home nearly every day to hide in his
bedroom and cry. "I felt like nobody liked me, everything was just like --
like downpours," he says. One afternoon, his mother went into his room and
found a note scrawled on the wall. "Somebody help me, I want to die," it
said. She called the psychiatrist Jimmy saw occasionally, who switched him
from Wellbutrin to Zoloft, an antidepressant similar to Prozac. But within
a week, Jimmy degenerated. He ran in the street, ignoring traffic, threw lit matches around the house and imagined conversations that never occurred.
Alarmed, his mother grappled with questions she'd been asking herself for years. Were these medications really helping her son? Should
she continue to make him take them, or challenge the school and medical authorities who seemed so confident of their course?
A decade after it vaulted into our consciousness, America's love affair with Prozac (and other new antidepressants) has worked its way down the age ladder. Last year, more than 2.5 million prescriptions for antidepressants were written for children and adolescents, according to IMS Health, a research firm that tracks prescription drug sales. That's a jump of nearly 60 percent since 1993 -- despite the fact that most of these drugs have not been approved by the Food and Drug Administration for use with children, and that no one knows what the long-term effects might be on developing brains. Prozac and its chemical cousins, the so-called serotonin selective re-uptake inhibitors (or SSRIs), have led the charge: SSRI prescriptions for kids nearly tripled in the last five years.
Many children have no doubt been helped by these drugs. But it also seems clear that powerful medications are being given far too easily to some
children, fueled by a variety of forces, from managed care to overworked parents. In a culture addicted to drugs, but reluctant to address
children's pain unless they start shooting up schools, it's become easier
and cheaper to deal with troubled kids by medicating them than by providing the personal attention of a sympathetic professional.
These days, antidepressants are being prescribed not just by psychiatrists but by pediatricians and family doctors. In a survey released last month by
researchers at the University of North Carolina, nearly three of four pediatricians and family practitioners in North Carolina said they had
prescribed antidepressants to children or adolescents; nearly a third
had recently (within the past six months) prescribed the medications to kids between 6 and 12. And, more alarming, only 8 percent of the doctors said they were adequately trained in the management of childhood depression; just 16 percent said they were comfortable treating depressed kids.
In an unpublished study from 1996-97, researchers with Kaiser Permanente, the nation's largest HMO, found that more than 65 percent of children under 15 who were seen for depression in Kaiser clinics in Portland, Ore., were prescribed antidepressants by their pediatrician or family doctor. But perhaps the most shocking research finding is this: In Michigan, in 1996, investigators looking through records of state Medicaid patients found 157 children aged 3 or younger who had been given any of 22 different psychotropic medications for attention deficit disorder.
To Peter Jensen, the associate director of child and adolescent research with the National Institute of Mental Health, the idea of
pediatricians dispensing antidepressants is troubling. "The average pediatric visit is now 13 minutes," Jensen says. "The kind of evaluation
that's necessary to tell whether a child is clinically depressed goes beyond what a pediatrician in an office practice has the time or training to do."
For years, research on the safety and effectiveness of these medications for children has lagged behind their use. In recent years, that's changed
somewhat and most experts now believe that SSRIs are safe for kids -- in the short run. Psychiatrists like them because they see them as "clean" drugs that regulate mood by adjusting levels of the brain chemical
serotonin, while leaving other systems of the brain untouched. They're difficult to overdose on, and they cause relatively few immediate side effects -- most commonly anxiety, nausea, and insomnia.
Some parents like the drugs because of their alluring promise to "fix" kids, while perhaps sparing a family in turmoil the emotional rigors of
counseling. And managed-care companies may like medications most of all, for one simple reason: They appear to be cheaper than therapy.
Indeed, many psychiatrists, pediatricians, and therapists say they feel
pushed to use medications both by managed care and by the difficulty of
getting a child into therapy. "The pressure to use medication has increased
enormously," says Joe Woolston, medical director of the children's
inpatient psychiatric unit at Yale/New Haven Hospital in Connecticut.
"Every single day, we have at least one case where the managed-care
reviewer says to us, 'If you don't start the child on medications within 24
hours after admission, we will not fund another day of hospital.'"
"For some of these children these medications may be lifesaving," says
Peter Jensen. "For other children, the psychological treatments may be more
appropriate. But if there are constraints -- financial considerations or
managed care saying you have to use a drug -- well that's really unethical.
Phoebe Cirio, a child psychologist in St. Louis, says most managed-care
companies initially authorize a therapist to spend four to six sessions
with a child; the therapist must then convince case managers to authorize
more treatment. "If you can't say clearly that such-and-such symptom is
better, they'll say, 'Well, maybe we need to refer to a psychiatrist for
assessment of underlying depression.' Managed care sees this as a cheap way
to get rid of the problem. They think of antidepressants as equivalent to
antibiotics--let's get in there and kill the germs." Psychologists can't do
effective therapy that quickly, Cirio adds. "You have to talk to the
parents, to establish rapport with the child," she says. "Four or six
sessions is a totally inappropriate time frame."
Mary Lou Sharrar, an Oakland, Calif., therapist who works extensively
with children, says she's gotten so much pressure to limit the number of
sessions with young patients, and to refer them for medication, that she
now avoids working with children on managed-care plans.
Managed-care executives see things differently. Saul Feldman, a
psychiatrist and chief executive officer of United Behavioral Health, which
manages mental health and substance abuse benefits for 15 million people around the country, credits managed care with putting a stop to a widespread abuse in the 1980s, when thousands of children were inappropriately hospitalized in for-profit psychiatric hospitals. He acknowledges that some managed-care firms may try to rush kids out of therapy. "But," he adds, "I think it's absolutely inappropriate to push kids onto meds if the sole objective for doing so is economic. That's unethical and it's not done here."
Jerry Rushton, the pediatrician who led the North Carolina survey, says he
and his colleagues in primary care often feel trapped when they try to plan
treatment for children. When they see a child in pain, they want to provide
immediate help. But they know if they refer the child for therapy, it can
take months to get approval and to set up an appointment; insurance
benefits can be denied; the child and parents may not follow up.
"It's a dilemma," Rushton says. "You don't want to harm kids by giving them
medications when we're unsure about the effects. But you also don't want
them to go untreated and put them at risk for suicide or failure in school.
So sometimes you start them on the meds and you wait and you hope."
So far, three drugs -- the SSRIs Luvox and Zoloft, and an older
antidepressant, Anafranil -- have been approved by the FDA for children and adolescents suffering from obsessive-compulsive disorder. Typically, fewer than half of the children on these drugs improve. A study of Zoloft reported in the Journal of the American Medical Association last year found that 42 percent of the children taking the drug improved, compared to 26 percent on placebos. No medications have been approved for children diagnosed as depressed.
But drugs don't have to be approved for children to be used by them; any
drug that has cleared the FDA for one group of patients can be prescribed to anyone for any reason at a doctor's discretion. This so-called "off-label" prescribing of antidepressants to children is based on research that is quite limited. So far, the best study of depressed children was led by Graham Emslie of the University of Texas Southwestern Medical Center. His 1997 report found that when Prozac was given for eight weeks to 96 depressed
children between 7 and 17 years old, 56 percent showed improvement,
compared to 33 percent taking placebos. But even with the improvement,
two-thirds of the kids on Prozac still had significant symptoms of
depression at the end of the eight weeks. And, says Emslie, "The children
who got medication seem as likely to have a recurrence as those who
didn't." Hardly a ringing endorsement.
But how applicable are these studies to real-world conditions? Clinical
trials in research settings include extensive visits between children and
clinicians. Such visits, Emslie says, are an important part of the
therapeutic process. But in the busy world of managed care, doctors
frequently dispense medication without providing therapy or meeting
regularly with the patient -- because they don't have the time or the
training. Jimmy Spence, for example, was taking stimulants and
antidepressants, but would often go months at a time without being seen for
an evaluation, much less for psychotherapy.
More studies are under way, funded by drug companies and the NIMH. They will seek to show that the drugs are safe in the short term and are at least moderately effective. The studies should provide greater insight into how the drugs work in the short term. But they could also be a double-edged sword: If the testing leads the FDA to approve antidepressants for children, doctors will prescribe them more often. And that could further erode support for counseling in favor of a pharmaceutical fix.
Government approval would also free drug companies to direct their
marketing efforts at children. Some would argue that they already are. Eli
Lilly, the maker of Prozac, has waged a peppy -- and controversial --
advertising campaign, placing simple, high-contrast advertisements in
women's and children's magazines across the country. One featured a
child-like drawing of a dark cloud with the slogan "Depression hurts" next
to a bright sun and the slogan "Prozac can help."
Some families view the new antidepressants as godsends. When Robert Schwartz, a
Long Island dentist, walked into the office of child psychiatrist Harold
Koplewicz five years ago with son Alex in tow, Schwartz was a desperate man. Then
4 years old, Alex was a dark-eyed boy with a winning smile and an
affectionate manner. But he could hardly speak, had not yet mastered toilet
training and often would get so agitated he'd clench and unclench his fists for
minutes at a time. He fixated on switches and buttons, turning them on and off
repeatedly, but couldn't focus on building blocks or other children's toys long
enough to play with them.
Alex's problems first came to his parents' attention when he was an infant. His pediatrician noticed that Alex's growth had slowed substantially
starting at the age of 5 months. He ordered a blood test, which revealed a
thyroid deficiency. Alex began taking synthetic thyroid medication, but his
growth and development were already delayed. At 6 months, he couldn't roll
over; at 10 months, he couldn't crawl. Not until he was 18 months old was he
able to walk on his own.
Alex continued to miss developmental milestones, and his parents grew
increasingly concerned. They took him to numerous clinicians, including a speech
pathologist, psychologists and a neurologist. He was diagnosed with a pervasive
developmental disorder, a condition that can severely retard a child's social
and communication skills. He started attending a special education preschool,
but was making little progress. Then his father took him to see Koplewicz.
Koplewicz read Alex's file and reports, and within five minutes of meeting him,
was recommending a treatment plan centered around the use of Ritalin to help
Alex focus his attention. The next morning, just before dressing him for school,
Schwartz gave his son the first half-pill. The impact was almost immediate. "It
was like a metamorphosis occurred before my eyes," his father recalled. "I gave
him the first pill at 8 a.m. and within 20 minutes, he wanted to pull up his
pants by himself, which is something he'd never done before."
But the Ritalin also intensified Alex's anxiety: He began to urinate in his
pants, and to jump at the sounds of traffic. To moderate the anxiety, Koplewicz
added a low dose of liquid Prozac to Alex's growing drug regimen.
Since then, Alex's progress has been slow but steady, held back for a while by
his parent's divorce three years ago. Today, Alex, now 9, goes to a special
education program in his local school district and, twice a week, attends an
after-school social and recreation program. He also sees a psychologist two or
three times a month, who works with him on ways to modify his behavior and
assists his teacher with classroom strategies. But the central component of his
treatment continues to be medication: He's now up to four drugs a day, a
combination of antidepressants and stimulants.
"Without the medication," says his father, "he'd still be where he was at 4,
or we might have to be considering an institution." He continues to see
Koplewicz every two or three months so the doctor can adjust his medication.
"It's like a recipe," says Schwartz, "and you're constantly tweaking it to try
to get the perfect combination." Alex, his father says, will probably need
medication for the rest of his life.
What if he stops taking them? Koplewicz is blunt in his warnings of what can
eventually befall children who need medications but don't take them. "Bad things
can occur. You will drop out of school 10 times more frequently if you have ADHD
[that goes untreated]. You are at higher risk of killing yourself if you're
depressed without an antidepressant. You will more likely do substances --
medicate yourself -- if you're depressed and don't get treatment. There is an
adverse effect to not taking medicine which I don't think parents recognize."
Koplewicz makes these pronouncements from his perch as director of New York
University's Child Study Center, where he has emerged as one of the leading advocates of psychiatric medications for
children. He argues that medication is the best way to help many children who
have what he calls biologically based brain disorders. "There are 5 or 6
million kids who could potentially benefit from SSRIs," Koplewicz says. "I
actually think we're not medicating kids enough."
Koplewicz and his staff see thousands of families each year, many of whom (like the Schwartzes) have spent years trying to navigate the
disjointed services offered by school districts and public mental health
programs. By the time they get to the NYU center, many parents are mired in guilt
and despair. The charismatic doctor, who has written a book called "It's
Nobody's Fault," has a message they find appealing: "I say that psychiatric
illness is not caused by bad parenting. It is not that your mother got divorced,
or that your father didn't wipe you the right way. It really is DNA roulette:
You got blue eyes, blond hair, sometimes a musical ear, but sometimes you get
the predisposition for depression."
But some psychiatrists and many psychologists -- even those who believe in the
judicious use of medications for children -- worry that the drugs are being overused.
"Many people feel the pressure to make a change and have a result quickly," says
Mark DeAntonio, a psychiatrist who directs the adolescent inpatient unit at UCLA
Neuropsychiatric Institute. "It's faster to write a prescription than to sit
down and talk to people and find out what's really going on."
Morris Johnson, a child therapist and former intake director of the Philadelphia
Guidance Center, sees a place for medications in extreme circumstances -- "if a
kid is acting out, or trying to kill people in the family. But if you don't get
to what's causing those symptoms in the first place; the kid just ends up coming
back once the medication runs out. Medication is being used as a replacement for
therapy and I think that's a major mistake."
And then there's the question of long-term effects: Will these drugs cause
problems down the line? Joan Moreau, a child psychiatrist in Williamsport,
Pa., has prescribed the new SSRIs to children as young as 6, but not
without some real worries. "What if 20 years after people start taking them,
they get senile or lose the capacity to reproduce?" she asks. "We just don't
know because the medications aren't older than 10 years."
Because of these concerns, Moreau tries to wean children from medications as
soon as she can, and encourages parents to use psychotherapy as well. "If you can
help someone change the way they think and feel, that will serve them well in
the long term," she says.
As she watched her son Jimmy falling apart, Nancy Spence wrestled with how best
to help him. In the end, she made the decision Jimmy had been requesting for
years: "I said, 'I want him off all these medications. I want to know who Jimmy
really is.' It had been six years and I'd had enough."
It took three weeks to wean Jimmy from the medications. Within a week, he began
to feel better, and to feel his depression lift. Today, two and a half years
later, Jimmy is still off antidepressants, but takes a blood pressure medication
to control his tics.
In the kitchen of his small, tidy home, Jimmy sits, listening to the rap group
Wu-Tang Clan on a headset. He answers some questions, haltingly at first, but
after a while, the stocky adolescent opens up, raising his head from beneath his
baseball cap to make occasional eye contact. Pushing the headphones off his
ears, he walks over to the kitchen cupboard and pulls three old pill bottles off
the shelf. "These medications," he says, setting them down on the kitchen table,
"they made me uncomfortable to where I just didn't like me."
Today, Jimmy said, he feels happier and more in control, though he still copes
with bouts of depression that tend to strike near the winter holidays. "I'm
popular, I like school better and I like my life better," he says. Then he
pulls the headphones back down and moves his head slightly to the music.