Children under 10 among those given strong antidepressants in UKRita Dune
Children under 10 among those given strong antidepressants in UK.
Guidance warns against prescribing paroxetine and venlafaxine due to risk of suicide
Seroxat, a brand of paroxetine. Thirty-eight children aged 10 and under were prescribed paroxetine and venlafaxine last year. Photograph: Jack Sullivan/Alamy
Children aged 10 and under are among hundreds of young people being given strong antidepressant drugs – in breach of official guidance – that increase the risk of suicide, the Guardian can reveal.
Figures show 597 children and teenagers were given paroxetine and venlafaxine last year. Government guidance cautions against their use due to increased suicidal thoughts and behaviour in younger people, but some experts argue they can be used as a last resort when all other treatments have failed.
Data shows 38 children aged 10 and under were prescribed paroxetine and venlafaxine last year.
According to guidance from the National Institute for Health and Care Excellence (Nice), antidepressants should be a last resort for under-18s, and in those instances only fluoxetine (Prozac) is recommended. Nice says paroxetine and venlafaxine should not be used.
Experts have said the disclosure of their use needs further examination, and expressed concern about the use of medication that may harm developing brains.
“Paroxetine and venlafaxine should not be prescribed as first-line treatment, that is for sure – there is no data to support this and special cautions should be taken as we don’t know the impact of these drugs on the developing brain,” said Andrea Cipriani, a psychiatrist at Oxford University.
“We should not give antidepressants to all kids but only use them if they are clinically appropriate and agreed with the patient first, and even then the best option is fluoxetine.”
Cipriani said the only instance where these drugs could be considered was if nothing else had worked, but he noted that there was no evidence these substances were effective in young people.
“We need to look at the clinical data and at the moment … [these drugs] should not be used unless as a last resort or to treat a specific issue, but they should not be routinely prescribed.”
The psychiatrist said one of the main reasons the drugs should be considered cautiously was because of their short half-life – meaning the time it takes for the concentration of the drug in the body to halve.
“There are drugs which are quickly metabolised and have a short half-life … This is why some drugs need to be taken every six to eight hours. Paroxetine and venlafaxine have a very short half-life, which means people tend to feel the symptoms of when the effects stop much more strongly.”
Cipriani carried out an overview of 34 trials two years ago and found that no antidepressant apart from Prozac was any better than a placebo in treating children and teenagers.
Guardian analysis of data from 2017 and 18 found that the most frequently prescribed drug in under-18s was fluoxetine, given to 34,371 young people, followed by sertraline (29,589 patients) and citalopram (12,656).
The guidance says sertraline or citalopram can be prescribed to under-18s but only in very severe cases and where there is clear evidence that fluoxetine and psychological therapy have not been effective.
Another expert said the figures related to paroxetine and venlafaxine needed further examination. “If it is happening [being prescribed] under specialist supervision and it is very closely monitored then that is very different to these drugs being prescribed by non-specialist doctors,” said Dr Ann John, a clinical academic at Swansea University who has conducted a study about antidepressant prescribing in children.
“We need to be very aware of the difficulty that GPs are struggling with in terms of accessing appropriate therapies and support. What we need to be doing is looking more broadly at the education and social connections of young people to prevent problems … GPs are the ones who are left looking after that young person and what they have available to them is the use of antidepressants.”
Dr Louise Theodosiou, a member of the child and adolescent psychiatry faculty at the Royal College of Psychiatrists, said some instances of the drugs being prescribed could be for problems other than depression. She said that in other cases a child may not be able to take other drugs such as fluoxetine because of an allergy.
Theodosiou said: “If a child had an allergic reaction to selective serotonin re-uptake inhibitors (SSRI), it’s not worth running the risk of trying another SSRI, so you may say let’s then try venlafaxine instead. But you would need to know that it may increase thoughts of suicide and in that situation would make sure medication was locked away … give prescriptions on a weekly basis and increase reviews.”
Data shows that 71,365 people under 18 were given antidepressants last year, a slight rise from 69,210 in the 2015-16 financial year.
Theodosiou said she did not think there was overprescribing of antidepressants. “The debate about the use of antidepressants is good but … it’s really important that people are not frightened of the prospect of medication. What we wouldn’t want is a situation where people thought these medications were inherently dangerous.”
Cipriani offered more caution, saying there was a risk of “over-medicalisation”. “Medications are not a quick fix for depression. They should be discussed and agreed with parents/patients – they are not magic pills,” he said. “We need to find a balance. It’s true medication can be overprescribed and we need an evidence-based approach but we should not give the message we are simply giving pills to people as the risk is under-treatment of depression, which can be fatal.”
Tom Madders, the campaigns director at YoungMinds, said the charity would like to see greater training for GPs relating to children’s mental health so that they felt confident about how best to provide support. “But ultimately there also needs to be far better and more consistent access to psychological treatments across the country,” he said.
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