By Martin Whitely
Last month, well before today's easing of Melbourne's lockdown, a group of ten GPs co-signed an open letter to Victorian Premier Daniel Andrews, pleading with him to review his Government’s approach to Covid-19 and ‘look at what we can reopen safely’.[1] Their letter was driven by their experience of vast increases in the number of severely depressed (sometimes suicidal) children they were seeing.
The principal author of the letter, Dr Stacey Harris, wrote:
I am doing 15-20 mental health care consultations daily, in comparison to 3-5 this time last year. I have many 12-15 year olds so depressed that I have no other option but to put them on antidepressants… Seeing children as young as 12 years describe their darkest thoughts, some suicidal, is very disturbing. They cry how much they are missing school and friends.
There is no doubt that the issues they raised were real. Restrictions were impacting on the wellbeing of young people. There is also no doubt that Dr Harris and her fellow signatories were motivated by a genuine concern for the wellbeing of their patients, particularly suicidal children and adolescents. However, there are good reasons to question the treatment practices they promote.
Dr Harris’s statement that she has no other option but to put depressed 12-15 year olds on antidepressants is extremely disturbing. She and the other signatories should know that:
No antidepressant is approved by the TGA for paediatric (under 18) use to treat depression in Australia.[2]
The US FDA (Food and Drug Administration) and the Australian TGA (Therapeutic Goods Administration) have issued repeated warnings that antidepressant use roughly doubles the risk of suicidal thoughts and behaviours in people aged under 25 diagnosed with depression and other psychiatric disorders.[3]
Even if a GP lacks the skills or time to offer adequate counselling and the waiting lists for psychiatrists and psychologists are impossibly long, Dr Harris’s claim that there is no other option but to put children and adolescents on antidepressants is simply not true. Yes, doctors are obliged to try and help; but if they can’t help, they are obliged not to hurt.
One option is watchful waiting, where parents and doctors closely monitor the young person and avoid exposing them to the extra risk of suicidality associated with using antidepressants.[4]
Throwing petrol on an already out of control fire is rarely a good idea. Nonetheless, between July 2017 and June 2018, over 100,000 (1.8%) Australians aged under 18 were prescribed an antidepressant. Some received these drugs for anxiety, but many were prescribed them off-label for depression.
Perhaps this is understandable. Parents and doctors are often desperate to help; but prescribing antidepressants to isolated, distressed children and adolescents is desperation-based medicine, not cautious evidence-based medicine. It is based on the erroneous assumption that doing something is always superior to doing nothing.
In defence of Dr Harris and her co-signatories, they are not outliers. Many other Australian doctors – including prominent Australian suicide prevention experts – have either minimised, dismissed, ignored, or been ignorant of the suicidality warnings.[5] [6] Too often they have simply assumed that any treatment (including prescribing antidepressants) is necessarily safer than waiting and watching.
As detailed in recently published research – led by the PsychWatch Australia team – over the last decade a spike in the rates of antidepressant use by young Australians has coincided with a large increase in the rate of youth suicide and self-harm.[7] This real-world experience is consistent with the FDA and TGA warnings that were based on the results of randomised controlled trials. However, as demonstrated in the letter to Premier Andrews, this compelling evidence is either unknown or not accepted by many Australian medical practitioners.
To their great credit, two Australian federal politicians, Labor MP Julian Hill, and the Morrison Government Minister for Health, Greg Hunt, are taking the issue of antidepressant use and suicide seriously. At Hill’s urging, Minister Hunt has instructed the TGA to review issues raised in our research and promised to take appropriate action.[8] Minister Hunt and the TGA are expected to announce their response late this year.
In the meantime, medical practitioners should practice and promote cautious prescribing. While many are understandably frustrated at their lack of treatment options, and their contribution to the debate about Melbourne’s lockdown is valuable, this does not exempt them from their Hippocratic obligation to ‘first do no harm’.
References
[1] A copy of the letter is included in Charlie Coe, 'Crying out for help': Doctor blasts Dan Andrews for not 'fully' easing restrictions NOW - saying lockdown is sparking suicidal thoughts among children as young as 12, Daly Mail Australia, 30 September 2020. Available at https://www.dailymail.co.uk/news/article-8785701/Doctor-blasts-Dan-Andrews-not-fully-easing-Melbournes-draconian-COVID-19-restrictions-NOW.html [2] Whitely M. Raven M. Jureidini J, Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends. Frontiers in Psychiatry. Vol.11 2020 478 [3] Whitely M. Raven M. Jureidini J, Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends. Frontiers in Psychiatry. Vol.11 2020 478 [4] Jureidini J. (2011) You can work it out: shrinks aren't always the best option http://theconversation.edu.au/articles/you-can-work-it-out-shrinks-arent-always-the-best-option-1778 [5] Jill Margo, Suicide prevention experts may have got it 'horribly wrong'. Australian Financial Review, 9 June 2020. https://www.afr.com/policy/health-and-education/suicide-prevention-experts-may-have-got-it-horribly-wrong-20200606-p5506d [6] Whitely M. Raven M. Jureidini J, Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends. Frontiers in Psychiatry. Vol.11 2020 478 [7] Whitely M. Raven M. Jureidini J, Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends. Frontiers in Psychiatry. Vol.11 2020 478 [8] Dana McCauley, Health Minister orders review after study links antidepressants and youth suicide, Sydney Morning Herald, June 14, 2020 https://www.smh.com.au/politics/federal/health-minister-orders-review-after-study-links-antidepressants-and-youth-suicide-20200609-p550yr.html