Volume 16, Number 4
A Watchful Eye on SSRIs
Hopkins clinicians respond to concerns about young
adults and antidepressants.
It was after David Malid* couldn't write a book report on Mrs. Dalloway that things began to unravel, his mother explained at a Psychiatry Grand Rounds recently. Her son, somewhat anxious by nature, had slowed his homework to the proverbial snail's pace. When his grades sank and he "started to shut down," she called the family pediatrician.
Malid's now stunningly well, and Kastelic's care showcases how she and her colleagues, with their specialization in that age group, routinely give teenagers and early twentysomethings their lives back. But Kastelic's approach also reflects Hopkins' response to today's concerns about prescribing antidepressant drugs for non-adults -- the suggested link between selective serotonin reuptake inhibitors (SSRIs) and suicide that a spate of U.S. and European trials have prompted.
Kastelic, who diagnosed Malid's depression -- it was neither senior angst
nor a learning problem -- set the teenager on a course of Prozac and cognitive
behavioral therapy. It's the best approach, confirmed by a recent national
study she and Hopkins colleague John Walkup, M.D., helped conduct.
And Kastelic closely monitored the young man's response to medication, involving
his parents in his care from the start. Both patient and family were asked
to call her should agitation or other worrying signs appear. "We do have
more families bringing in newspaper articles about SSRIs. Even if they didn't
we'd still bring it up," she says. Among Hopkins clinicians, discussion on the drugs has increased. No fewer than three recent Grand Rounds focused on antidepressants for young adults. In one, Psychiatry Director Ray DePaulo, M.D., raised questions about data linking SSRIs and suicide attempts. "No actual suicides occurred in any of the studies the FDA reviewed, although an increase in suicidal ideas and self injury was noted in the early weeks on the medication." So where's the balance point between the known benefits of SSRIs in this group and the risks? "We don't know yet," DePaulo says. "What's obvious, however, is our need for answers. Our care of young people with major mood illness and research into their best treatment go hand-in-hand."
Mark Riddle, M.D., a pioneer in the use of SSRIs in children, suggests what may be behind the suicidal ideas. "An activating effect comes with these drugs that's more common in younger patients. It helps get a patient going. But prompting action before healthy mood returns may be an unwanted side-effect. That, too, needs study."
All agree that typical SSRI prescription is a good thing gone wrong. More than 80 percent of prescriptions come from physicians without a psychiatric specialty, let alone one in adolescent mood disorders. "We've seen patients who've gotten antidepressants without a proper diagnostic workup or proper monitoring," Kastelic cautions. "These are serious medications for potentially fatal diseases. They must be taken seriously."
That's the rule in the inpatient program Kastelic runs at Hopkins hospital, where patients teenaged through early 20s are treated for mood disorders such as depression and bipolar disorder. It's true in Psychiatry's outpatient care as well."We specialize. We team with patients and family," she explains. "It makes a huge difference."
For information, call 410-614-4948.
* not the patient's real name