From The Oregonian

By Katy Muldoon of The Oregonian staff

SHOOTING SPURS DEBATE ON PROZAC’S USE BY KIDS

• Although some experts say the medication is the best hope for depressed children, others think this use is inadequately studied

A boy walks into a school and opens fire. The news stories that follow reveal a thousand facts. One fact raises a thousand questions: Prozac.

Kipland P. Kinkel, suspected of gunning down his parents and then his schoolmates at Thurston High in Springfield, had reportedly taken the antidepressant medication fluoxetine, commonly known as Prozac. According to a family friend, the boy’s parents took him off the medicine last fall because it had worked so well for him.

But include the word "Prozac" in the same sentence with "children" or "violence," and the result is a prescription for controversy and misunderstanding.

Parents ask, is it safe to treat children with medicine approved only for adult use?

Psychiatrists ask, why don’t more parents come to them for help?

Schoolteachers ask, how many students take antidepressants?

And despite evidence to the contrary, one human rights group contends that the medicine makes patients more angry and violent than they already are.

Answers to questions about Prozac and other antidepressants are not simple.

The medications alternately are painted as the best possible hope for the estimated 4 million U.S. children who suffer some form of depression or as a potentially dangerous experiment that has not been studied enough to ensure children’s safety.

Prozac and other medications in its class—known as selective serotonin re uptake inhibitors, or SSRIs—have not been fully tested in children. But because the U.S. Food and Drug Administration has approved them for adult use, doctors can prescribe them for children and adolescents.

They do, in burgeoning numbers.

Last year, doctors prescribed these medications to 207,000 children ages 6 to 12, and to 702,000 patients ages 13 to 18, according to IMS America, a health information company in Pennsylvania.

Eli Lilly, the Indiana company that manufactures Prozac, reports that in the 11 years since the medicine hit pharmacy shelves, 31 million people worldwide -- 22 million in the United States—have taken the drug.

Most studies show it to be effective and safe for adults, which has boosted physicians’ confidence in prescribing it for children. The American Medical Association says antidepressants can help nine of 10 patients for whom they are appropriate.

Still, many think more research is needed.

Prozac is thought to work by increasing serotonin in the brain; serotonin, a chemical naturally present in the body, is associated with mood changes.

Some wonder what the long-term effects of antidepressants are on children and adolescents, whose brains are still developing. And some have suggested that use of fluoxetine might be related to increased thoughts about suicide in a small number of patients.

One often-quoted study, paid for by the National Institute of Mental Health, showed Prozac works as well for children and teen-agers as it does for adults. Another, published last December in the Archives of General Psychiatry, concluded that study subjects who took fluoxetine were less aggressive and irritable than those taking a placebo.

No fast fixes

But psychiatrists are quick to warn that antidepressants should not be considered an easy fix for a sad, angry or listless child.

They should be prescribed only as part of a comprehensive evaluation and treatment plan that includes individual psychotherapy and family counseling, said Dr. David G. Fassler.

"Medication can be extremely helpful," he said. "But medication alone is never the appropriate treatment."

Fassler, chairman of the American Psychiatric Association’s Council on Children, Adolescents and Their Families, is a child and adolescent psychiatrist who practices in Burlington, Vt. He is co-author with Lynne Dumas of "Help Me, I’m Sad: Recognizing, Treating and Preventing Childhood and Adolescent Depression" (Viking, 1997).

The book is timely. Depression in young people is either at an all-time high or is simply diagnosed more often as parents and physicians learn about the complex disorder, and as the stigma traditionally attached to seeking treatment for mental illnesses eases.

Until the early 1980s, depression was not recognized as a diagnosable illness in children and teen-agers; many mental health professionals thought children lacked the emotional maturity to become depressed.

Now it’s considered a common and serious childhood illness, affecting as many as one in four youngsters by the time they finish high school.

Left untreated, depression’s effects can be devastating: Children and teens might hurt themselves or others in the worst cases. Others fall behind socially and academically. And those who have depressive episodes early on are more likely to have recurring episodes later in life.

"The experience of depression is extremely painful for a child," Fassler said.

The sooner depression is discovered and treated, the sooner a child can return to feeling like a kid again.

But Fassler said depression, which he considers highly treatable, still is often missed or misdiagnosed.

Some depressed children look a lot like depressed adults: They appear sad, withdrawn or tearful. They have insomnia or trouble with appetite.

Others, though, are hyperactive or aggressive. They get into fights at school, act out sexually or steal things.

"Some kids act in and other kids act out, so it’s sometimes hard to sort out," he said. "Is this depression, or is this the normal moodiness of adolescence?"

Correctly diagnosing depression in children is critical—and no small task. It requires a thorough physical examination, a detailed history of the child’s development, school history, family history, and individual interviews with the child, parents and often the entire family.

"It’s not something you can do in a typical six-minute office visit" with a child’s pediatrician, Fassler said.

Paying close attention

Alert parents, teachers, school nurses, counselors and doctors can help spot the signs early and get children treatment.

In order to do that, school nurses in the Multnomah Education Service District took part in three training sessions in the past year to boost their knowledge about mental health issues.

Dee Kathryn Bauer, a registered nurse who is director of the department of school health services for the district, said school nurses are "seeing an increase in children who present with mental health problems—and they’re not all under medical care." In particular, she said, they’re seeing more children who are angry and afraid.

No one knows how many Oregon schoolchildren take antidepressants, though the picture might grow clearer in the next school year. By July 1, schools have to adopt a policy to keep better track of antidepressants and other prescription drugs that affect children’s cognitive abilities.

The change emerged from the 1997 legislative session, in which lawmakers updated a 1973 law outlining schools’ responsibilities with regard to students’ medications.

Fassler said more study is needed to determine which children are most likely to respond well to antidepressants. In his experience, they have worked best for children who have a family history of depression, or if the symptoms seem more biologically than psychologically based.

He said doctors certainly should consider antidepressant treatment for children who have not responded to other types of treatment, or if a child’s safety is at risk.

Children and adolescents who take the medications often are on them for six to 12 months; doses might be similar to doses given adults, depending on how patients react to the medicine.

But in the early 1990s, the FDA debunked those allegations, saying violent actions and suicidal thoughts are common among depressed people; it found no link among the medication, violence or suicidal thoughts.

From Fassler’s perspective, Prozac and similar medications have gone a long way toward helping children and teens with mental and emotional problems. He agrees it’s appropriate to keep an eye on the rate at which they’re being prescribed, and to make sure those prescribing antidepressants are trained in the appropriate and safe use of the medicines, as well as their potential side effects.

"But I don’t agree with the sense that we’re rushing to put all kids on medication as the answer to all kinds of society’s problems," he said. "I see the opposite problem: There are still millions of kids with clinical depression who are not getting the treatment they need.

"There’s no question in my mind that these medications are saving lives," he said. "I actually believe that in many instances, they are probably preventing or helping to prevent violent episodes."

Contact staff writer Katy Muldoon at 221-8526; by mail at The Oregonian, 1320 S.W. Broadway, Portland, Ore. 97201; or by e-mail at