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Treating children with depression: how will history judge us?

An investigative report by the BBC recently found that the number of antidepressants prescribed to children in England, Scotland and Northern Ireland has risen 24% over the past three years.

Drugs may not be the most effective way to treat depression (more of which later), but pity the children who were treated for depression before antidepressants were invented.

Bloodletting was the standard treatment for “melancholia” in ancient Greece. This was followed by burning in medieval Europe and locking people up during the so-called “age of enlightenment” in Europe.

Last century, Sigmund Freud improved things a bit when he introduced psychoanalysis as a treatment for depression. The problem was that he thought cocaine was a good way to treat his own depression.

Freud – a fan of some unusual treatments. Max Halberstadt/Wikimedia Commons

Then things got worse again. In the 1950s and 60s depression was sometimes treated by lobotomy (removing part of the brain) and electroconvulsive therapy (an electric shock so strong it induces a seizure in the patient). The latter technique is still used today for some cases of treatment-resistant depression, where the patient is at imminent risk of harm.

Looking back at these bonkers therapies, you might feel a little shocked yourself. Today things seem more scientific. Now we have psychological therapies, such as cognitive behavioural therapy and antidepressant drugs. These are much better than lobotomies and beatings.

Typical drugs for treating depression are selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Zoloft and Sertraline. These drugs are quite effective for people who are severely depressed. But not everyone who gets the drugs has severe depression.

The drugs are prescribed for one in ten adults in most developed nations, and prescription rates for young depressed people are climbing in the US and UK. Many people getting the drugs don’t have severe depression, and the drugs barely work better than placebo for mild or moderate depression. On a standard depression scale, which rates depression from zero (not depressed) to 52 (most severely depressed), the drugs improve things by an average of about two points, compared with placebo in adults.

So, if you were a bit worried about work and were a bit fidgety, then (compared with placebo) after the drugs you would be worried a bit less and you’d be a bit less fidgety – hardly earth shattering. And the effects are even smaller in children and teens.

Worryingly, the drugs are often not being prescribed in an evidence-based way for young people. Whereas guidelines in the UK state that antidepressants should only be prescribed within child and adolescent mental health services (CAMHS), many GPs prescribe them. This means that children are unlikely to be getting the supervision needed to avoid unnecessary harm. And the harms can be serious.

Significant side effects

Trials show that antidepressant drugs increase the risk of suicide, compared with placebo in young people. Other side effects include nausea, sexual dysfunction and sleepiness.

Given the limited benefits and serious side effects, why have antidepressant prescriptions for young people risen so much? We don’t yet have a good answer to this question. It could be that increased loneliness, caused by young people spending too much time staring at screens, is causing more depression that needs to be treated.

Another possibility is that funding is being cut to mental health services, which leaves GPs with the difficult task of having to help young depressed people, but not having the option of sending them to mental health services.

A gentler approach

Until we find out why antidepressant prescriptions have skyrocketed, why don’t we use safer options? Trials show that exercise seems to be as good as drugs for most depression. And the side effects of exercise are good things, such as reduced cardiovascular disease and higher sex drive in men and women.

Another safer option is face-to-face socialising. Studies with hundreds of thousands of people show that contact with friends, family and social groups is associated with less depression. (This doesn’t include contact via social media, which seems to increase the risk of depression.) And a side effect of maintaining close relationship is that you’ll live an average of five years longer.

So it’s common sense: the right treatment for staring at a screen too much isn’t a pill that increases the risk of suicide, it’s to get some exercise, preferably with friends.

Fifty years from now, are we going to look back at the widespread prescription of antidepressants for mildly depressed young people the same way we look at beatings, lobotomies and cocaine? My guess is “yes”. But I doubt that exercising and hanging out with friends will ever be viewed in a negative light, so next time you’re feeling low, why not give it a try.

The original version of this article stated: “Trials show that exercise seems to be as good or better than drugs for most depression.” This has been changed to: “Trials show that exercise seems to be as good as drugs for most depression.”

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