In the previous literature, almost nothing worked reliably for depression in adolescents. Here, the results for Prozac match or even exceed those seen in the treatment of adults. The fly in the ointment is the tendency toward suicide. The Times reported five suicide attempts among the subjects on Prozac, compared to just one among subjects on no medication—despite an overall decrease in the suicide attempt rate among all the subjects in treatment. In particular, psychotherapy seemed to mitigate the risk of suicide attempts in the drug treatment group.
How any of this news will affect clinical practice is unclear. The use of antidepressants in the young has always been a matter of "hard cases make bad law"; even in the absence of encouraging data, there are good reasons why doctors and parents have favored trials of medication treatment for adolescents with depression. Adolescents with early-onset depression fall behind their peers socially and developmentally. Some, like street kids treated in urban clinics, can ill afford any additional vulnerability. And occasionally, the disease does respond dramatically to medication.
If the NIMH data stand up, they may lead to yet more aggressive prescribing. And although psychotherapy has not shown great effectiveness against teen depression in recent studies, the fear of medication-induced suicide may help to keep therapy in the mix—a sad reason for what might be a very good result. (I would hate to see a treatment for an adolescent that does not include the offer of counseling.) Still, it increasingly seems that medication use is critical in the treatment of severe depression.
If medications, on some fronts at least, are looking better, the drug companies are looking ever worse. Thoughtful doctors now discount positive outcome studies funded by corporate money, because they suspect that comparable negative studies may have been suppressed. Information control is a game of diminishing returns.
In a well-regulated society, all pre-marketing research on patients would be made public as a drug moves toward approval. Post-marketing follow-up would be taken out of corporate hands entirely. Years ago, I proposed that pharmaceutical houses be assessed a fee based on the sales of a new drug. That money would be put to use by the Food and Drug Administration or National Institutes of Health or a comparable agency, to fund studies of emerging side effects and of uses in under-researched populations, such as children.
Drug companies might well come to favor such proposals, as a means of shedding liability. Besides, it is not clear that painstaking studies by neutral parties would judge the medications to be less useful or more dangerous. So far, in fact, the better research has tended to find stronger drug effects. The approach that pharmaceutical houses have taken—controlling research, and then (allegedly) manipulating the flow of information—looks venal. In terms of their own interests, it may also be foolish.
TODAY IN SLATE
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