Tuesday, July 03, 2007

Antidepressants and children: a low class Scientific American article

Scientific American's standards have slipped over the decades, but, judging by a recent article, Scientific American Mind is another step lower. This article on antidepressants and children reads like it came from People magazine.

That's a shame, because buried behind the purple prose and inappropriately entwined with the acute affects of antidepressants, are some important questions and even a bit of science. We have good theoretical reasons, and some animal model evidence, to suggest that prolonged use of psychoactive medications in children may permanently alter brain development. How brain development is altered, and whether that alteration will be for the better or worse in a particular child, we don't know.

I've believed this to be true as long as I can remember, but now it's becoming common wisdom. The question is what to do with the science and with the lack of knowledge.

The answer is fairly simple. Be humble, be cautious, and take measured and appropriate risks.

In other words, if a house is on fire, it's reasonable to climb out a window. If it's not, take the door. If a child and their family is facing severe suffering and risk, then assume risk responsibly and use the medications we have. If other interventions will work, use those. It's not rocket science.

More specifically, the common practices good clinicians follow apply:
  1. Old medications with abundant experience are generally preferred even when newer medications have some modest advantages.
  2. Use an effective dose, but avoid pushing the dose. Trade-off some marginal benefit for a reduce dose and course.
  3. Inform patients and family. This usually works: "If this were my child, I would use this medication. I would do so even knowing that there are risks of lifelong impacts on brain development, I don't know if those would be bad, neutral or even beneficial impacts." Of course if a physician wouldn't give the medication to their own child they should maybe rethink their therapeutic plan.
  4. Stay informed, hopefully by something much better than (yech) Scientific American Mind.

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