The Antidepressant Debate: A Pediatrician's View

In 2002, when I was practicing general pediatrics, I was called to our local emergency room to see a teenager who had attempted suicide by ingesting a variety of pills. She was a patient of a pediatrician who did not have admitting privileges at our hospital, so I did not have a prior relationship with her. After she had been medically stabilized, I took a detailed history.

She was an athlete and top student who had been struggling under the pressure of college applications when her pediatrician, several weeks before this incident, had placed her on the antidepressant paxil. Both the girl and her mother described behavior that was totally different from her usual self. She had gone out drinking with kids who she hardly knew. She was impulsive and agitated. I was alarmed by this sudden change in behavior, so alarmed that I ordered a CT scan to be sure that her symptoms were not caused by a brain tumor.

I now understand that she was experiencing a side effect of paxil. While there had been growing evidence that these drugs had the potential to cause suicidal ideation and behavior, as is well documented in Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial by Alison Bass, it was not until 2004 that the "black box " warning describing the risk of suicidality in pediatric patients was instituted. in 2002 I was unaware of these findings, and had in fact prescribed these medications to a number of teenagers in a way that in retrospect seems cavalier and risky.

In today's New York Times Sunday Dialogue Seeking a Path Through Depression's Landscape there is minimal mention of children. Marcia Angell, in her letter in response to Warren Procci's letter (which was written in response to last Sunday's op ed In Defense of Antidepressants) states:

Many have devastating side effects, especially in children and when used long term. Studies generally show that the benefits are small.

I follow these discussions with interest, but I believe the problems of psychiatric medication use in children is of a different magnitude. It is not simply a question of the relative merits of psychotherapy or medication, or of the potentially serious side effects. Rather it is a question of what is not done when psychiatric medication is used to treat symptoms in children.

Last summer I attended a wonderful course entitled "Keeping The Brain in Mind." Teacher Francine Lapides referred to psychotherapists as "neuroarchitects." In the course of a long-term trusting relationship with a patient, one in which a therapist is attuned to the patient's experience, often in a way that the patient's own parents were not, the brain may actually change. This kind of a relationship can change the way a person manages and responds to stress. The patient may learn, at the level of biochemistry of the brain, to think about feelings and regulate and manage difficult experiences.

Listening to this material as a pediatrician, I thought about parents as the original neuroarchitects. When a child is struggling, whether with sadness, anxiety or explosive behavior, supporting parents efforts to understand and manage their child's experience can offer parents the opportunity to help their child in safe and meaningful ways. This is not to say that the problem is the parent's fault. But when parents themselves have the chance to tell their story in a supportive non-judgmental environment, I have found that this fortifies them to be present with their child in a way that helps the child manage his or her particular vulnerabilities. This kind of emotional presence with a troubled child is very hard work, and parents need the time and space to be heard.

In a sense, psychiatric drugs can deprive parents of this opportunity. Drugs place the problem squarely in the child. In my pediatric practice, I meet with parents and bill under the child's name. It is not therapy for the parents or the child, but rather support for the relationship. Certainly many excellent child therapists work with parents in this way. But when symptoms are treated with medication, it may be difficult to find the motivation to do this hard work. Thus the opportunity to use the loving caregiving relationship to help a child learn to manage his or her own feelings may be lost.

Without this opportunity, I wonder how many of these children will end up ten, twenty or thirty years from now telling a therapist about how their parents didn't understand what they were feeling. This missed opportunity is, in my opinion, a potentially tragic side effect of prescribing psychiatric drugs to young children.