Jagged Lit­tle Pills

As the num­ber of chil­dren and teens on an­tide­pres­sants grows, so does skep­ti­cism about the drugs’ ef­fec­tive­ness

The Walrus - - CONTENTS - By Patricia Pear­son

Last win­ter was dif­fi­cult for Clara, my nine­teen-year-old daugh­ter. Like me, she is a high-func­tion­ing neu­rotic — my phrase for what clin­i­cians call peo­ple with Gen­er­al­ized Anx­i­ety Dis­or­der. Waves of dread of­ten wash over us, but we keep our foot­ing. There’s a quick-step­ping alert­ness to our de­meanour, like that of hur­ry­ing sand­pipers on the tide’s edge. We take flight and set­tle. For var­i­ous rea­sons, Clara had been un­happy, and her un­hap­pi­ness in­ten­si­fied her nat­u­ral anx­i­ety. Her GP pre­scribed the an­tide­pres­sant Cipralex, but it didn’t calm her. In­stead, it made her feel numb. Insomnia be­came a prob­lem, as if she’d had too much caf­feine. So that spring, the doc­tor sug­gested a new drug, Trin­tel­lix, which Health Canada ap­proved in 2014 for the treat­ment of “ma­jor de­pres­sive dis­or­der” in those over the age of eigh­teen.

I re­mem­ber sit­ting in my Honda look­ing at the sam­ple pack­age, with Clara be­side me, and not­ing the pack­age’s black-box la­bel, which warned of a height­ened risk of sui­ci­dal think­ing and be­hav­iour in chil­dren, ado­les­cents, and young adults.

“Why this drug?” I asked, “You don’t have ma­jor de­pres­sive dis­or­der.” “You’re not a doc­tor,” Clara said, with trade­mark teenage scorn. Fair enough. Doc­tors know what they are do­ing. I had my doubts, but I was no longer her guardian. She swal­lowed her first cap­sule of Trin­tel­lix that evening.

One week later, while I was in a Kingston ho­tel room, she mes­saged me through Face­book. “Can I check my­self into a hospi­tal, is that a thing peo­ple do?”

“Why?” I typed. “What’s up?” “I gen­uinely want to kill my­self, and I’ve never had that thought be­fore.” She was fright­ened by this turn in her mind.

I tossed aside my lap­top, called my hus­band — who was work­ing at home — and urged him to whisk her to the emer­gency depart­ment at the Cen­tre for Ad­dic­tion and Men­tal Health (CAMH) in Toronto. Af­ter in­ter­view­ing Clara, the CAMH staff au­tho­rized im­me­di­ate dis­con­tin­u­a­tion of Trin­tel­lix. For two days, we had her sleep in our bed on a sort of im­promptu sui­cide watch, un­til the alien pull to self­de­struc­tion re­ceded.

Over the en­su­ing months, as Clara worked with a kind ther­a­pist to re­solve what was trou­bling her, she re­sumed be­ing a sand­piper. It’s not per­fect, as those of us with anx­i­ety would agree, but for the mo­ment, it felt safer.

There was just one thing left to do now that my daugh­ter had been pre­vented from killing her­self: at­tempt to un­der­stand why she had wanted to do so in the first place.

Be­tween 2010 and 2013, an­tide­pres­sant pre­scrip­tions for Cana­dian chil­dren un­der eigh­teen jumped by 63 per­cent — in to­tal, more than five mil­lion were is­sued in that time. The num­ber comes from a re­cent study pub­lished in the Cana­dian Jour­nal of Psy­chi­a­try in which re­searchers tal­lied drug-store trans­ac­tions from across the coun­try. The ma­jor­ity of those pre­scrip­tions were for se­lec­tive sero­tonin re­up­take in­hibitors (SSRIS), a pop­u­lar class of an­tide­pres­sant med­i­ca­tion de­signed to treat de­pres­sion, anx­i­ety, and ob­ses­sive-com­pul­sive dis­or­der by boost­ing the lev­els of sero­tonin in the brain. The ba­sic the­ory has been that more sero­tonin — some­times known as the feel­good chem­i­cal — can help strengthen the brain cir­cuits that reg­u­late mood.

“Our study could be a good-news story,” says Mina Tadrous, the study’s se­nior au­thor and a re­search as­so­ciate at the On­tario Drug Pol­icy Re­search Net­work, “in that doc­tors are iden­ti­fy­ing more teens with men­tal health chal­lenges. But the bad­news story would be that it’s much eas­ier to give a pill than talk.” Tadrous wor­ries that the uptick in pre­scrip­tions might be

a phe­nom­e­non called “in­di­ca­tion creep,” which oc­curs when doc­tors have the dis­cre­tion to re­pur­pose drugs in­di­cated for other uses, lead­ing to an in­crease in of­fla­bel — or un­ap­proved — pre­scrib­ing. Health Canada has never of­fi­cially ap­proved SSRIS for chil­dren un­der eigh­teen. Yet some doc­tors be­lieve the ben­e­fits of off-la­bel pre­scrib­ing out­weigh the risks. So what, in fact, do we know about the risk-ben­e­fit ra­tio of SSRI use in young peo­ple?

The path to un­der­stand­ing the ef­fi­cacy of SSRIS in treat­ing mood dis­or­ders in the gen­eral pop­u­la­tion has been a muddy one. Prozac was the first to come to mar­ket, in 1987. An ar­ti­cle re­port­ing that “in­tense sui­ci­dal pre­oc­cu­pa­tion” might be one of the ad­verse re­ac­tions to the drug was pub­lished soon af­ter. Phar­ma­ceu­ti­cal com­pa­nies, how­ever, had much to gain by tout­ing SSRIS as per­son­al­ity-fix­ing mir­a­cle drugs. Sev­eral of those drugs — Paxil, Zoloft, Ef­fexor — came down the pipe­line in fairly rapid suc­ces­sion. From 1988 to 2008, the rate of an­tide­pres­sant pre­scrip­tion in the United States in­creased by nearly 400 per­cent. Part of this in­crease came from the fact that sales reps, ea­ger to max­i­mize sales, per­suaded doc­tors to pre­scribe off-la­bel.

In the mid-’90s, the Eng­land-based com­pany Smithk­line Beecham (now called Glax­osmithk­line) funded a land­mark clin­i­cal trial, known as Study 329, which ex­plored the safety and ef­fi­cacy of Paxil for ado­les­cents. Pub­lished in 2001, Study 329 re­as­sured doc­tors that Paxil was an ac­cept­able rem­edy for an­guished teens. Sales soared. Skep­tics, how­ever, raised ques­tions.

Some of the study par­tic­i­pants, it emerged years later, en­tered the trial only mildly de­pressed, but wound up hos­pi­tal­ized once on Paxil. In 2004, Jane Gar­land, then a pro­fes­sor of psy­chi­a­try at UBC, wrote that “the au­thors dis­missed this re­sult by stat­ing that th­ese psy­chi­atric ad­verse ef­fects were not at­trib­uted to the med­i­ca­tion — de­spite the fact that nu­mer­ous re­ports of ag­i­ta­tion and sui­ci­dal be­hav­iour in young peo­ple treated with SSRIS have ac­cu­mu­lated since the 1990s.” In­deed, enough ev­i­dence had ac­crued from clin­i­cal tri­als and law­suits that both the US Food and Drug Ad­min­is­tra­tion and Health Canada man­dated a warn­ing for pe­di­atric pre­scrip­tions of SSRIS — a warn­ing they ex­tended to cover eigh­teen-to-twenty-fouryear-olds in the early 2000s.

Nev­er­the­less, Study 329 be­came goto proof of the ben­e­fits of such treat­ment — un­til, that is, re­searchers got hold of 77,000 pages of pre­vi­ously undis­closed data from the Paxil study. They re­an­a­lyzed the orig­i­nal trial find­ings and pub­lished their re­sults in 2015. Paxil, they found, was not only in­ef­fec­tive in treat­ing ado­les­cent de­pres­sion when com­pared to placebo — it was dan­ger­ous. Of the ninety-three young peo­ple who took Paxil, at least twelve be­came sui­ci­dal while on the drug. (Those al­ready think­ing about end­ing their lives had been pre­cluded from join­ing the trial.)

A sim­i­lar mis­in­for­ma­tion cam­paign seems to have sur­rounded another oft- cited study about SSRI safety and young peo­ple. In 2004, For­est Laboratories funded an ado­les­cent trial of its drug citalo­pram ( Cipralex), the med­i­ca­tion that made my daugh­ter feel numb. Its aim was to win FDA ap­proval for ado­les­cent use, which it did on the ba­sis of this study. But when a team of re­searchers re­viewed the raw data last year, it found emails in which em­ploy­ees dis­cussed how to mas­sage the citalo­pram study’s find­ings. Phar­ma­ceu­ti­cal com­pa­nies have been known to run drug tri­als, hire writ­ers to care­fully script the pre­sen­ta­tion of re­sults, and only then at­tach a prom­i­nent psy­chi­a­trist as the os­ten­si­ble study au­thor so that they can pub­lish in pres­ti­gious jour­nals. Ac­cord­ing to the re­anal­y­sis, the mas­saged study “failed to men­tion” that five of the sub­jects on citalo­pram de­vel­oped “po­ten­tially dan­ger­ous states of over-arousal.”

How has the in­dus­try so suc­cess­fully main­tained its nar­ra­tive of safety? Lisa Cos­grove, a Bos­ton-based psy­chol­o­gist and the co-au­thor of Psy­chi­a­try un­der the In­flu­ence (2015), has pointed out that nearly 70 per­cent of the ex­perts in­volved in pro­duc­ing the most re­cent edi­tion of the Amer­i­can Psy­chi­atric As­so­ci­a­tion’s Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders (DS M-V) have fi­nan­cial ties to the phar­ma­ceu­ti­cal in­dus­try in the form of funded re­search or fees for speeches pro­mot­ing cer­tain drugs. What is es­pe­cially strik­ing about the DS M-V, wrote Cos­grove in an ar­ti­cle for Amer­i­can As­so­ci­a­tion of Univer­sity Pro­fes­sors, is that “at­ten­tion to ad­verse side ef­fects of med­i­ca­tions is vir­tu­ally nonex­is­tent.” A ref­er­ence book con­sulted by busy GPS, who do the bulk of psy­chi­atric pre­scrib­ing, that does not ad­dress the risks as­so­ci­ated with med­i­ca­tions is, she writes, “un­bal­anced and raises ques­tions about in­dus­try in­flu­ence.”

The sidelin­ing of side ef­fects can pro­duce the impression that they are too rare to off­set the ben­e­fits of a drug. And the med­i­cal com­mu­nity is wary of de­priv­ing peo­ple of treat­ment that could be ben­e­fi­cial. “We don’t al­ways do well in healthcare with com­mu­ni­ca­tion of risk,” Tadrous says. “We don’t want to scare pa­tients away.” Health care pro­fes­sion­als want to heal, and the fear of dis­suad­ing young peo­ple from tak­ing what are gen­er­ally viewed as heal­ing meds can be strong.

Yet, by re­ly­ing on in­dus­try-funded re­search that can some­times over­play the pos­i­tive treat­ment im­pacts and ob­scure the po­ten­tial harms, doc­tors can in­ad­ver­tently be­come care­less. A case in point is the story of John David Wood, an am­bi­tious univer­sity stu­dent who found a psy­chi­a­trist in Toronto will­ing to pre­scribe an at­ten­tion deficit dis­or­der (ADD ) drug to help him fo­cus, even though he didn’t have ADD . Ad­der­all was all the rage in col­lege dorms when late-night es­says were due. Wood pow­ered his way to­ward an un­der­grad de­gree and then quit the drug cold turkey in 2004, not hav­ing been made aware of pos­si­ble with­drawal ef­fects by his doc­tor, who him­self may not have fully un­der­stood those ef­fects.

Wood ex­pe­ri­enced a psy­chotic break. Ac­cord­ing to his mother, Julie, an ER doc­tor also missed the with­drawal ef­fects and de­cided that Wood had a ma­jor men­tal ill­ness. The doc­tor then pre­scribed Celexa, an an­tipsy­chotic, and two seda­tives. Wood protested that the new drug cock­tail pro­duced se­ri­ous side ef­fects, but to no avail. He re­mained on the drugs for years but even­tu­ally got off them. Dur­ing

Decades ago, grief re­sult­ing from a trau­matic life event wouldn’t have been linked to a bi­o­log­i­cal ill­ness. Now, pro­claim your distress, and re­ceive your pill.

a par­tic­u­larly bad time in 2008, he went back on the stim­u­lants, and this time, felt worse. “My son,” Julie says, “re­al­iz­ing he was get­ting sui­ci­dal thoughts, went to North York Gen­eral. They told him to go sit down and wait like ev­ery­one else, and they did not watch him, and he walked out af­ter two hours with­out any­one tak­ing any no­tice and later jumped in front of a sub­way.”

Julie and her hus­band, Peter, now help run a web­site called rxisk.org, which pro­vides in­for­ma­tion about ad­verse drug events. “Par­ents mostly never fig­ure out that drugs were re­spon­si­ble,” Julie says. “The news sto­ries al­ways say, ‘De­spite the fact that she was on med­i­ca­tion,’ she took her own life. Or, ‘Even though he was be­ing treated ...’ The me­dia can’t tease apart the story.”

Ac­cord­ing to rxisk.org, the FDA re­ceived 212 com­plaints of sui­ci­dal thoughts re­lated to Trin­tel­lix — the drug pre­scribed to my daugh­ter — be­tween 2013 and 2016. The fig­ure is slip­pery, be­cause we don’t know how many peo­ple ex­pe­ri­ence side ef­fects they don’t re­port, or how many rec­og­nize that their med­i­ca­tion may be af­fect­ing their be­hav­iour.

David Healy is an Ir­ish psy­chi­a­trist who be­gan track­ing the side ef­fects of SSRIS since their first ap­pear­ance over thir­ty­five years ago. In the late nineties, he re­cruited twenty psy­cho­log­i­cally healthy vol­un­teers to ex­am­ine the dif­fer­ence be­tween SSRIS and older an­tide­pres­sants. Dur­ing the study, he un­ex­pect­edly wit­nessed two of the vol­un­teers who were tak­ing Zoloft de­velop sui­ci­dal fix­a­tions. Later, he was part of the team that an­a­lyzed the undis­closed doc­u­ments from Study 329, and he has served as an ex­pert wit­ness at tri­als re­sult­ing from law­suits filed by pa­tients’ fam­i­lies in the af­ter­math of sui­cides. When I emailed him to ask why he thought SSRIS would trig­ger sui­ci­dal­ity, he re­sponded: “We know al­most noth­ing about how psy­chotropic drugs in­ter­face with some­one’s un­der­ly­ing prob­lems.”

Neu­rophar­ma­col­ogy is a field in its in­fancy. Neu­ro­trans­mit­ters were first iden­ti­fied less than a cen­tury ago, and new ones are still be­ing dis­cov­ered. An SSRI may lead to reg­u­lated lev­els of sero­tonin, but, ac­cord­ing to Tadrous, “There’s also a chance it’s hit­ting neu­ro­trans­mit­ters we don’t know about.”

Mean­while, the ev­i­dence that SSRIS have a com­plex im­pact on de­vel­op­ing brains keeps mount­ing. In 2015, Is­raeli psy­chi­a­trists pub­lished a pa­per de­scrib­ing “Ss­ri­in­duced ac­ti­va­tion syn­drome” in chil­dren and ado­les­cents — a host of psy­chi­atric changes, in­clud­ing anger, panic, ir­ri­tabil­ity, and ma­nia, that ap­pear to be ac­ti­vated by this class of drug. Among those changes is a con­di­tion called akathisia, which is marked by emo­tional ag­i­ta­tion and, some­times, phys­i­cal rest­less­ness. Think of ’roid rage mixed with dread: a revving ef­fect that leaves a pa­tient so su­per­charged that sui­cide be­comes plau­si­ble as an es­cape route.

“Pre­scrib­ing an an­tide­pres­sant to some­one who is suf­fer­ing,” Kelly Bro­gan, a New York psy­chi­a­trist, re­cently ob­served, “may be like hold­ing out a knife to some­one who is fall­ing off a cliff.”

One win­ter af­ter­noon, I paid a visit to Elia Abi-jaoude at Toronto’s Hospi­tal for Sick Chil­dren. Like Healy, the young psy­chi­a­trist par­tic­i­pated in the re­anal­y­sis of Study 329. Orig­i­nally from Le­banon, he stud­ied medicine in Win­nipeg. “We’re not stop­ping to ask what this thing is we’re call­ing de­pres­sion,” he said. “We’re con­flat­ing suf­fer­ing with men­tal ill­ness. You go into sub-sa­ha­ran Africa and peo­ple are bro­ken, they’re in dire cir­cum­stances, and we say they have de­pres­sion. Re­ally? Are you se­ri­ous? Be­fore, de­pres­sion was im­pos­si­ble to miss. When you saw the per­son, you thought, ‘There’s some­thing wrong here.’ To­day, you can have a per­son func­tion­ing rea­son­ably well; they may be suf­fer­ing or strug­gling, no ques­tion, but

they’re func­tion­ing, and yet we tell them they have a men­tal ill­ness.”

I thought of Clara as she’d been be­fore she took Trin­tel­lix, which was orig­i­nally in­tended to treat only those with ma­jor de­pres­sive dis­or­der. She was work­ing as a sales as­so­ciate at a cloth­ing store, alert and charm­ing, go­ing out for sushi af­ter shifts, in con­stant touch with her friends, com­ing home with amus­ing anec­dotes about cus­tomers.

“We are pathol­o­giz­ing ado­les­cence,” says Abi-jaoude, who is con­cerned by the num­ber of young peo­ple re­ferred to Sick­kids for de­pres­sion who may just be strug­gling through dif­fi­cult life ex­pe­ri­ences. “I’m not say­ing de­pres­sion doesn’t ex­ist,” he says, “only that de­pres­sion isn’t al­ways a jus­ti­fied la­bel. Kids come in, and within days, they do well. They’re smil­ing; they en­gage with the team.” He points to re­search that sug­gests the ther­a­peu­tic re­la­tion­ship be­tween coun­sel­lor and pa­tient ac­counts for 30 per­cent of treat­ment re­sponse. Peo­ples’ ex­pec­ta­tions of get­ting bet­ter ac­count for an ad­di­tional 15 per­cent. “The lion’s share,” he says, “is sim­ply life cir­cum­stances chang­ing.”

In the early 2000s, Abi-jaoude was fas­ci­nated by the find­ings of Irv­ing Kirsch, an Amer­i­can psy­chol­o­gist. Kirsch was in­ter­ested in study­ing the placebo ef­fect, but be­came frus­trated with the drug com­pa­nies, which re­fused to make all the data from their clin­i­cal tri­als pub­lic. Af­ter the FDA re­leased both pub­lished and un­pub­lished stud­ies in re­sponse to a pe­ti­tion he filed, Kirsch dis­cov­ered that SSRIS weren’t sig­nif­i­cantly out­per­form­ing place­bos. In­deed, the dif­fer­ence in re­sponses to place­bos and an­tide­pres­sants was neg­li­gi­ble. Kirsch re­ported his find­ings in an in­flu­en­tial 2008 ar­ti­cle, and the fol­low­ing year wrote a book, The Em­peror’s New Drugs, in which he ar­gued that in­stead of be­ing a first-line treat­ment, an­tide­pres­sants should be a last re­sort. Af­ter 60 Min­utes aired an episode on th­ese find­ings in 2012, Jef­frey Lieber­man, the for­mer pres­i­dent of the Amer­i­can Psy­chi­atric As­so­ci­a­tion, claimed Kirsch’s work was “mis­lead­ing to peo­ple and po­ten­tially harm­ful.”

“Ev­ery­one cir­cled the wag­ons,” re­calls Abi-jaoude. “‘This is a psy­chol­o­gist with an agenda!’” But af­ter re­view­ing Kirsch’s ev­i­dence, Abi-jaoude be­came con­vinced he was right and wrote his own pa­per in 2011. In it, he de­tailed the ag­gres­sive mar­ket­ing strate­gies for SSRIS and con­sid­ered the ways in which SSRI stud­ies were ma­nip­u­lated. Kirsch’s find­ings have since been repli­cated in other stud­ies, in­clud­ing a 2016 re­view of thirty-four clin­i­cal tri­als of SSRIS for the pe­di­atric pop­u­la­tion that con­cluded that the drugs “do not seem to of­fer a clear ad­van­tage.”

“I’m very aware that this is a hard mes­sage to sell,” Abi-jaoude said. “A lot of my col­leagues have used an­tide­pres­sants and seen their pa­tients get bet­ter. It’s hard to see there may be another rea­son they got bet­ter.” For in­stance, many regress to­ward their mean, in that they even­tu­ally re­turn to their own emo­tional base­line. Decades ago, grief re­sult­ing from a trau­matic life event such as a di­vorce or job loss wouldn’t have been linked to a bi­o­log­i­cal ill­ness. Symp­toms had to be un­duly se­vere or pro­longed be­fore clin­i­cal de­pres­sion was de­creed. But the DS M now stip­u­lates a two-week thresh­old. Walk into the doc­tor’s of­fice, pro­claim your distress, and re­ceive your pill.

By the same to­ken, as a cul­ture, we tend to un­der­es­ti­mate the power of placebo. But there is am­ple ev­i­dence that when pa­tients be­lieve they are get­ting treat­ment — even when that treat­ment in­volves pills con­tain­ing only in­ert sub­stances —

they can also ba­si­cally heal them­selves. Ac­cord­ing to on­go­ing re­search at Har­vard, place­bos prompt the brain to re­lease en­dor­phins. Other el­e­ments of the brain’s re­ward sys­tem, like dopamine, are ac­ti­vated as well, re­sult­ing in a re­duc­tion of symp­toms of de­pres­sion, chronic pain, mi­graine, and other con­di­tions. Re­gard­less of what SSRIS can or can­not ac­com­plish as chem­i­cal agents, the very act of tak­ing them tends to trig­ger this placebo ef­fect. In other words, both the placebo and the drug can make peo­ple feel bet­ter on the ba­sis of ex­pec­ta­tion of re­cov­ery. What this means is that an­tide­pres­sants aren’t just fail­ing to do bet­ter than placebo in clin­i­cal tri­als: in the treat­ment of de­pres­sion, they might in fact be act­ing as place­bos.

“We have to be care­ful” when dis­cussing SSRIS and place­bos, says Abi-jaoude. “There’s a whole so­cio- cul­tural as­pect to this.” When peo­ple be­lieve med­i­ca­tions are go­ing to work, he says, “they are more likely to work. They have been ad­ver­tised so much that peo­ple ex­pect that they’re go­ing to get bet­ter. I want to be mind­ful of that when I cri­tique them. This is part of our cul­ture. It is how we’ve con­cep­tu­al­ized suf­fer­ing.”

The day af­ter I saw Abi-jaoude, I went out for lunch with a young woman who then worked as a peer coun­sel­lor at Stella’s Place, a Toronto non-profit that of­fers men­tal health ser­vices for teens and young adults. In Canada, ac­cess to such ser­vices is ex­tremely lim­ited. The av­er­age wait time is over 100 days, and, as Lind­say Ranger told me over eggs and hash browns, “When you’re younger, it’s the first time your men­tal health cri­sis has hap­pened, and the worst time, be­cause you’ve never ex­pe­ri­enced it be­fore.”

Stella’s Place is a ser­vice for young peo­ple with a range of men­tal health chal­lenges; there, they can en­gage in cre­ative ac­tiv­i­ties and one- on- one coun­selling while they wait to see a psy­chi­a­trist. But many are un­able to wait. “For young peo­ple, the nar­ra­tive has been, ‘If you need help, you need to go to the ER,’” Ranger ex­plains. “The wait­ing lists are so long to see psy­chi­a­trists that, some­times, it is the only way you can be treated in un­der a year.” This, then, is how teens are fun­nelled into the phar­ma­ceu­ti­cal maw. “When I was young,” she says, “I didn’t know you could be given some­thing other than SSRIS.”

My daugh­ter, un­able to find a psy­chi­a­trist af­ter her run-in with Trin­tel­lix, had gone to her GP. As she was now leery of drugs, CAMH sug­gested a group ther­apy ses­sion, but the wait­ing list was about eight months long. She ended up pay­ing to see a pri­vate psy­chol­o­gist, but many vis­i­tors to Stella’s Place don’t have that op­tion, which is why most peo­ple seek­ing men­tal health treat­ment wind up at their fam­ily doc­tor or in the ER. In­deed, a 2012 sur­vey by Statis­tics Canada found that only 65 per­cent of pa­tients who sought out ther­apy felt their needs had been met. In con­trast, among those who wanted med­i­ca­tion, 91 per­cent re­ported get­ting the drugs they needed. In other words, if you’re a pa­tient, it’s cheaper and faster to get pills, and if you’re a doc­tor, it’s eas­ier just to pre­scribe them. And this de­spite re­search that sug­gests it might ac­tu­ally be more cost-ef­fec­tive to cover men­tal health ser­vices: in some cases, ther­apy works just as well as med­i­ca­tion, and it can pre­vent re­lapses and re­duce the num­ber of doc­tors’ ap­point­ments and ER vis­its.

Glob­ally, there are a cou­ple of de­vel­op­ments that point to­ward health­ier ap­proaches to the treat­ment of men­tal ill­ness in young peo­ple. One is per­son­al­ized

medicine based on ge­netic test­ing. As part of its re­search into psy­chotropic drugs, CAMH of­fers a cheek-swab test that can swiftly de­ter­mine which, if any, agents a pa­tient can me­tab­o­lize. Its find­ings in­di­cate that the pres­ence of cer­tain liver en­zymes may af­fect how dif­fer­ent peo­ple ab­sorb psy­chi­atric drugs . Af­ter the cheek swab has been an­a­lyzed, a re­port is pro­vided that lists the an­tide­pres­sants and an­tipsy­chotics that might work best for the in­di­vid­ual—and, im­por­tantly, which med­i­ca­tion to avoid. Clara now knows about the test, and is con­sid­er­ing tak­ing it in the near fu­ture.

Also in­trigu­ing is the pre­ven­tion strat­egy, cog­ni­tive be­havioural ther­apy (CBT), which teaches peo­ple how to break the feed­back loop be­tween neg­a­tive thoughts and feel­ings by show­ing them where their think­ing leads them into trou­ble. First de­vel­oped by Amer­i­can psy­chol­o­gist Aaron Beck in the 1960s, the ap­proach’s ef­fec­tive­ness has been borne out in dozens of stud­ies. A 2011 re­view of fifty-three stud­ies in­volv­ing more than 14,000 Aus­tralian youth at risk for anx­i­ety and de­pres­sion showed promis­ing re­sults for CBT.

How does it work? When I was Clara’s age, I wor­ried about se­rial killers. On any given day, I might find my­self won­der­ing, “What if there’s a man out­side my win­dow?” This thought would cre­ate a surge of adren­a­line, a sud­den phys­i­cal ten­sion. That re­ac­tion would then fur­ther alarm my mind, which would add a new cat­a­strophic thought: “What if I can’t reach my par­ents?” Cue the shal­low breath­ing. And around in a cir­cle I’d go, feel­ing anx­ious feel­ings and think­ing anx­ious thoughts. CBT teaches you to rec­og­nize what you’re do­ing be­fore it spi­rals out of con­trol. It’s now con­sid­ered a first-line treat­ment in the United King­dom: more than 500,000 pa­tients re­ceive the ther­apy each year, and 43 per­cent of them re­cover from their anx­i­ety and de­pres­sion.

This could be the most ef­fec­tive — and least toxic — in­ter­ven­tion ever de­vised. If chil­dren were taught to reg­u­late their cat­a­strophic thoughts and phys­i­cal sen­sa­tions, many could self-reg­u­late be­fore their mood in­ten­si­fied and be­came “di­ag­nos­able.” This would take us back to the time when we dealt, med­i­cally, with only se­ri­ous clin­i­cal de­pres­sion and other se­vere men­tal ill­nesses.

The day that Clara first showed me her packet of Trin­tel­lix, we were driv­ing to the coun­try, to the sim­ple A-frame cot­tage built more than a cen­tury ago by my great­grand­fa­ther. Here there is al­ways heal­ing in the quiet, even if we’re only stay­ing overnight. And what do we re­turn to? Twenty-four-hour news cy­cles, in­ces­sant so­cial-me­dia use, job in­se­cu­rity, global warm­ing. What’s not to dread?

On World Health Day this year, Dainius Pūras, a doc­tor and a rep­re­sen­ta­tive for the Of­fice of the United Na­tions High Com­mis­sioner for Hu­man Rights, made a pow­er­ful state­ment. By fo­cus­ing so in­tently on the bio­med­i­cal model of treat­ing de­pres­sion, he ar­gued, we are di­vert­ing re­sources from the “so­cial and un­der­ly­ing de­ter­mi­nants” that may have a larger and more last­ing ef­fect on men­tal health: eco­nomic in­jus­tice, po­lit­i­cal op­pres­sion, so­cial vi­o­lence. “Men­tal health ser­vices, pol­i­cy­mak­ers, med­i­cal stu­dents, and med­i­cal doc­tors have been mis­in­formed,” he de­clared. While there’s an im­por­tant role an­tide­pres­sants can play in ad­dress­ing se­vere de­pres­sion, the use of psy­chotropic med­i­ca­tion as first-line treat­ment, he said, is “un­sup­ported by the ev­i­dence.” Be­fore off-la­bel SSRI pre­scrip­tion rates rise any fur­ther, per­haps it’s time to set aside the pill bot­tles.

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