Not long after this photo, my GP put me on antidepressants – and I think it was the right decision
Most parents would be horrified at the thought of mental health drugs for children. But amid fears they are being over-prescribed,
Eve Simmons offers a very different view
ITOOK antidepressants for the first time a few weeks before my 16th birthday. It was three weeks into my first and most gruelling episode of allconsuming, paralysing anxiety. Seemingly from nowhere, I became gripped by disturbing, intrusive thoughts. I was destined to commit murder, would die alone, was a psychopath and so on.
They played over and over, leaving little space for anything else. I barely slept or ate. Eventually
my mother took me to see our family GP. I tried, through wailing tears, to explain the turmoil in my head. She looked at me and said: ‘You don’t have to put up with this. I can give you something that will help.’
The doctor prescribed daily 10mg of fluoxetine, or Prozac as it’s commonly known, and wrote a referral to my local child and adolescent mental health service, where I would be offered talking therapy.
The unsettling thoughts didn’t vanish immediately, but within a few weeks they lost their sting. As the knot in my insides loosened, I could focus on more important matters, such as my upcoming GCSEs. When the exams finished,
I became distracted by a new hairstyle and saving up for a pair of trainers. My irrational thoughts no longer had much airtime. After a couple of months, I felt like a normal teenager again.
Six months later, with the help of my GP, I tapered off the medicine (an oral solution, which doctors give children) without any problems.
I thought of all this last week when I read reports of a new Governmentfunded review that showed GPs are giving antidepressants to children against medical guidelines.
The National Institute For Health And Care Research had noted that 75 per cent of 12-to-17-year-olds who had been prescribed psychiatric drugs had not seen a mental health specialist, which breaches NHS advice. The report also commented on the astronomic rise in the number of teenagers taking the pills – more than doubling since 2005 to record highs of one million a year – and highlighted serious side effects of antidepressants, such as suicidal thoughts, and raised doubts as to the benefits.
A raft of commentators voiced their outrage about the findings. One psychotherapist said that offering drugs to children instead of therapy is a ‘terrible indictment upon our society’. I disagree.
Of course, the prospect of a child being medicated – indeed, a child being mentally unwell – is alarming. I dug out an old school photo, taken at about that time, and I look, well… so young. But I wasn’t too young to be plagued, quite inexplicably, by dark thoughts.
THERE’S a tendency to want to protect children from adult things, but if a child was suffering something serious, such as cancer, no parent would deny them medication that would help. Why should serious mental health problems be any different?
As far as I’m concerned, the GP who offered me the medication is the only reason I passed my exams. It did its job: it got me over a hump and I was able to move on with my life. There was no downside.
I asked my mum, Michele, what she had thought at the time.
‘I sought advice from our family doctor, who I trusted and knew well, and she recommended that medication was likely to help you,’ she said. ‘Of course, I’d rather it hadn’t been needed, but when your child is basically terrified of life, unable to go to school and is too anxious to even leave her bed, you know she needs help.
‘And if your doctor says something will make her feel better, you take it. I knew you couldn’t go on the way you were. And in the end, the medicine helped.’
Was I just one of the lucky ones? Roughly one in six children aged six to 16 has a probable mental health problem, according to the latest NHS survey data. It’s one in four among 16-to-17-year-old girls.
The most common conditions are anxiety and depression. Prescribing watchdog the National Institute for Health and Care Excellence (NICE) states that all under-18s with these conditions should be forwarded to child mental health services for psychological therapy, such as cognitive behavioural therapy (CBT), where patients can talk through their problems. Medication for depression should be prescribed only if a psychiatrist deems it necessary and the patient is undergoing therapy.
There are also strict instructions on which drug to use – fluoxetine in the first instance, as more studies have been done on it in young people. Only if this doesn’t work should others be tried.
A number of reports over the past decade have shown that GPs work outside of these guidelines. ‘I have prescribed antidepressants to 16- and 17-year-olds,’ says Professor Dame Clare Gerada, president of the Royal College of General Practitioners. ‘In the past, I would have called local child services for advice before prescribing, but I wouldn’t necessarily do that now. All too often, I won’t get through on the phone.
‘I’ll always make a referral, but children can be waiting six to eight months before they see a psychiatrist, and some need help right away.
‘So what’s the alternative? Do we offer medication that I know will work, or do we leave them to deteriorate and, in the worst-case scenario, kill themselves?’
Several reviews have found that fluoxetine is effective for treating depression, including in children. Other analyses have found other antidepressants, like sertraline and escitalopram, also work in children – albeit less well than fluoxetine.
For anxiety, these drugs – collectively known as selective serotonin reuptake inhibitors, or SSRIs – improve symptoms in nearly twothirds of patients, according to a 2009 review of 22 trials. In younger patients with mild symptoms – who make up the vast majority of cases – talking therapies might well be the more appropriate intervention.
‘About four out of five children who feel anxious or depressed will get better after a period of talking about their situation, without medication,’ says Dr Ian Goodyer, Professor of Child and Adolescent Psychiatry at the University of Cambridge who was involved in writing the guidance. ‘So long as a GP could be confident in spotting moderate to severe illness and monitor the patient closely, I would support their decision to prescribe fluoxetine to a teenager.’
He realises this is not ideal, adding: ‘There is a huge gap between what NICE recommends and the situation doctors face on the ground today. We made the recommendations, back in 2005, with the view that patients would be supported by specialist mental health teams who would be best placed to do the prescribing. But since then, child and adolescent mental health services have been decimated. The last I heard, the average wait to see a child psychiatrist in our local area is ten months. So GPs have their backs against the wall and don’t know what else to do.’
CBT is recommended for most mental health problems, and sessions involve helping patients recognise and stop their unhelpful thought patterns.
A 2019 analysis of 31 trials, published in the journal European Psychiatry, concluded that it had a ‘small effect’ on symptoms of depression and anxiety. But regular extended check-up chats with a doctor worked just as well, the studies show – and in years gone by, GPs might also have been able to offer more one-on-one support like this. But that’s no longer the case, says Prof Gerada.
‘Fifteen years ago we were able to deal with unhappy, anxious children in our GP practice. You’d give them longer appointments and ask them to come back every fortnight, get the parents involved and maybe even contact the school.
‘Usually this support was enough to resolve the issue, but we simply do not have the resources today.’
It’s also important to note that not everyone finds CBT or talking helpful. I found that it made me feel worse. At my first session, I was asked to write the scary thoughts on bits of paper, which frightened me further. I emerged tearful and exhausted.
I did talk about my thoughts and feelings to other doctors involved in my case, and in many ways these more casual conversations were more helpful than official therapy.
‘Some young patients don’t want to “talk about it”,’ says Professor Bernadka Dubicka, a consultant
psychiatrist at Hull York Medical School. ‘It’s not right to refuse these children antidepressants. Equally, I see many young people who absolutely do not want to take medication and would rather talk.’
If CBT doesn’t work, NICE suggests trying another type of psychological intervention, such as psychodynamic or family therapy.
But experts say patients often wait even longer for these specialist treatments. In many regions, the average waiting time for an initial appointment was at least two months, and in some cases it can be up to three years.
Much of the concern about giving antidepressants to children relates to side effects. A review in May linked SSRIs to a 38 per cent increased risk of suicidal thoughts and suicide attempts in young people. But researchers also say it is difficult to tease apart the effects of the medication from the mental disorder itself.
In 2013, University College London published findings from a study of more than 5,000 young people with a high risk history of mental illness and suicidal behaviour, followed over a period of 14 years. Of the 81 who died by suicide, 11 were taking antidepressants, including SSRIs, around the time of their death. The majority – 75 per cent – hadn’t taken the medication for at least a year beforehand, meaning the greater risk by far comes from not having treatment.
‘Studies show these psychiatric side effects tend to occur in the first eight weeks because the brain’s receptors are sensitive, but then they disappear,’ says Prof Goodyer. ‘It is often clear which patients are at risk of suicidal behaviours and they need to be monitored especially closely.’
IN RECENT years, campaigners have drawn attention to withdrawal symptoms related to SSRIs. Patients have reported being stuck on the drugs for years, because coming off them proves unbearable, triggering increased mental distress and brain fog. In 2019, NICE updated its guidance to acknowledge this. But these problems can usually be avoided if the medication is stopped gradually.
Professor Argyris Stringaris, an expert in child and adolescent psychiatry at University College London, adds: ‘When studies have looked at the risks and benefits of prescribing versus not prescribing, the balance is always in favour of prescribing.’
Thankfully, I didn’t get hooked on
SSRIs aged 16. But I have taken them twice more since then. Once, when I suffered anorexia in my early 20s, to help calm food anxiety. That time I stayed on them for a year. And I started taking them again in August – there had been a series of stressful life events and my anxiety returned.
I’ve never experienced withdrawal symptoms, but I have endured side effects.
This time round, aged 31, it was pretty bad. Shortly after I started, I went from feeling constantly nervous and distracted to barely being able to function and permanently panicky.
I called my GP, who told me to try to stick with it, assuring me that patients often feel worse before they feel better. He was right. Within a week, I felt myself again – a better version, without the endless, all-consuming worries.
A few days of misery was a small price to pay for a clear head.
Experts are calling on NICE to rewrite the guidelines, empowering GPs to prescribe antidepressants to teens with confidence.
Prof Goodyer says: ‘GPs are overwhelmed with mentally ill children and there are no specialist services or guidelines to help them. Many feel they are simply flying by the seat of their pants.’