Antidepressant Ban for Kids Puts Pressure On U.S. / Canada
Mon, 15 Dec 2003
The British government ban for use of all but one SSRI antidepressant drug in children and teens (Dec 10, 2003) is reverberating wherever these drugs are widely prescribed. The action was taken after an independent committee of experts examined the raw data from controlled clinical trials that had been conducted by these drugs' manufacturers. The evidence shows that contrary to the claims made by their promoters, SSRIs are neither effective against depression in children, nor safe. The hazards posed by SSRIs--of which the most serious is self-harm and aggression toward others--had been detected during company controlled clinical trials, but the hazards were concealed--even in published reports in academic journals. Thus, doctors who prescribed the drugs and patients and families for whom they have been prescribed were kept in the dark.
The revelation about the hidden hazards posed by SSRIs raised serious concerns about how drugs are tested, how the findings are reported, and how the regulatory agencies meet their public responsibility. * How is it that the prominent expert psychiatrists worldwide failed to notice the significant finding of emergent suicidal behavior in adolescents testing Paxil?
In a published paroxetine study, one in 10 (10.5 per cent) of the patients taking Paxil had a "serious" adverse effect compared to just one in 100 of the placebo patients and nearly eight of 100 (7.5 per cent) taking paroxetine required hospitalization. See: Keller, MD, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B, et al. Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial. Journal of the Academy of Child and Adolescent Psychiatry (2001), 40:762-772.
Neither the leading experts in psychiatry nor officials of the FDA (or equivalents in the UK) noticed these suicide findings. A British journalist not trained in science readily detected the problem and brought it to public attention.
* How do officials in the UK and US regulatory agencies explain their failure to protect children from hazardous drugs that are no more effective than placebo? * How do regulators explain their role in helping drug companies conceal the evidence by not even examining the efficacy and safety data from clinical trials submitted to them 7 years ago? * How do regulators explain their failure to read the published reports and to inform the public about findings of potential hazards? * How do regulators explain their failure to request long-term studies to ensure that these problematic drugs don't pose irreversible damage?
The regulatory agencies failed to examine the data even as a body of evidence accumulated from case reports of drug-induced adverse reactions. Only after the manufacturers sought to obtain a marketing license for depressed children did the British authority convene an expert panel to examine the raw data from previous pediatric trials. On Dec. 11, Health Canada announced it will review the data as well. See: www.cbc.ca/cgi-bin/templates/print.cgi?/2003/12/12/Consumers/ssri031212
A two part article in the Canadian Sterling News Service reports that warnings by the British authority in June, prompted Canadian doctors to ask serious questions and to re-examine the wisdom of prescribing antidepressant drugs for children, inasmuch as the evidence from clinical trials clearly shows that children may be helped equally by the placebo effect without the drug-related risks.
For example, Dr. Jane Garland, director of the mood disorders clinic at British Columbia Children's Hospital, and one of the investigators who tested SSRIs in clinical trials, put it this way: "As physicians, we want to be helpful, but we often suffer individually and collectively from a pharmacological imperative: If we have a drug, we feel compelled to prescribe it." Dr. Garland acknowledges, "We suffer from excessive therapeutic optimism."
But a re-examination of the data led her to conclude: "If it were ethical, placebo treatment would be the recommended first step. Alternatively, supplements such as omega-3 fatty acids could be plausible and inexpensive 'active' placebos."
US psychiatrists, by contrast, have consistently rallied in defense of psychotropic drugs even as the evidence shows that the risks to outweigh any benefits. Reporters rarely inform readers that the psychiatrists they quote are paid consultants to the drug manufacturers.
See: THE NEW YORK TIMES December 11, 2003, British Warning on Antidepressant Use for Youth http://www.nytimes.com/2003/12/11/international/europe/11DRUG.html?pagewanted=print&position= See: WASHINGTON POST. December 11, 2003, Britain Warns Against Giving Newer Antidepressants to Kids Only Prozac's Benefits Outweigh Risks, Health Officials Say http://www.washingtonpost.com/ac2/wp-dyn/A54446-2003Dec10?language=printer
Statements by FDA officials have sent confusing contradictory messages: In June, after the British issued warnings about Paxil's potential to induce suicidal behavior in children, FDA followed suit. But on October 28, Dr. Thomas Laughren, the FDA's team leader for psychiatric drug products, told The New York Times: "I think probably that we have backed off a little bit from the advisory issued in June, which recommended against using Paxil. I believe our position now is that we just don't know." When in doubt about the risk of inducing suicide, shouldn't regulators err on the side of children's safety?
Of equal concern is FDA's announced method for examining the data: "FDA plans to re-examine many of the clinical conclusions made during studies of the drugs." (See: NY Times, 10/28/2003.) Inasmuch as the physicians who tested the drugs in children had first-hand contact with those children, their professional judgment and written description about the nature of the emerging severe adverse effects--such as suicidal behavior--cannot be set aside by distant second-guessing. Furthermore, inasmuch as these physicians were paid by the drugs' manufacturers, they are not eager to find hazards. Thus, FDA's attempt to raise doubts about their professional judgment is an obvious effort to explain away the higher suicide rate among children given the drugs compared with those on placebo.
Why are FDA officials trying to avoid a scientifically legitimate examination of the safety and efficacy data--such as was done by the British? There is growing concern that FDA's planned advisory committee meeting on Feb. 2, 2004 will be a re-play of the much criticized 1991 rigged meeting at which experts who had documented evidence of drug-induced suicide attempts, were not given an opportunity to present testimony. In 1991, Dr. Martin Teicher, the doctor who had first discovered a suicide effect in a minority of patients prescribed Prozac, was denied an opportunity to testify at the FDA committee hearing. In 2003, FDA officials have indicated once again, their disinclination to provide Dr. David Healy an opportunity to present his analysis of the clinical trial data. Dr. Healy is a uniquely qualified world expert psychopharmacologist whose testimony led the British medicines authority to examine the raw data, prompting the agency to take action accordingly.
Sterling News Service
Depressed Kids: The Drug Debate
Are the young used as guinea pigs for untested antidepressants?
Thursday, December 11, 2003
FIRST OF TWO PARTS
Every year more and more kids -- some still in preschool -- are popping pills for anxiety, depression, even shyness. What they're mostly taking are selective seratonin reuptake inhibitors, or SSRIs.
Paxil, or paroxetine, is the most commonly prescribed SSRI and experts estimate that five per cent of those prescriptions are written for patients 18 and younger, including some preschoolers. With 3.57 million prescriptions written for Paxil in the 12 months from September 2002 to September 2003 in Canada, that means about 178,500 of those were for kids. That's a 58 per cent increase over just five years ago.
In B.C., an estimated 20,700 Paxil prescriptions were written for kids between Oct. 1, 2002, and the end of October this year. That's a 68.8-per-cent increase over five years ago.
Yet with the exception of Prozac, or fluoxetine, Paxil and its SSRI cousins have never been fully tested on kids. They've never been approved for pediatric use and because drug companies have never sought pediatric approval, they have never had to show regulators the results of clinical trials.
And, by the way, nobody has ever done a study to determine what effect SSRIs will have on their developing brains and bodies. Doctors know how little real information there is about the effects of these drugs on little kids and teens. Parents should.
Yet that hasn't slowed sales at all. Billions of dollars' worth are sold globally each year. In Canada, nearly 14 million prescriptions for SSRIs were filled in 2002 at a cost of $869 million. In B.C. alone, doctors wrote 1.69 million prescriptions for the drugs at a cost of $116.3 million.
There have always been questions about them -- their efficacy and their effects. But again, it hasn't in any way dissuaded doctors from prescribing them by the millions.
Until this spring. Evidence was presented to the British drug regulatory agency in late May that wasn't new, it was only new to the regulators. It was raw data from seven-year-old clinical trials that had never before been available. There was no reason for the drug company GlaxoSmithKline to release it because until 2003, it was not applying for pediatric use of paroxetine.
The data showed that kids on paroxetine (sold as Seroxat in Britain and Paxil in North America) were 1.5 to 3.2 times more likely to be suicidal than kids taking placebos. Ironically, the trials found that kids taking placebos were almost as likely to get well as kids on the real pills.
In June, Britain advised doctors to quit prescribing the most popular of the SSRIs -- paroxetine -- to anyone under 18. The British regulatory agency said that paroxetine not only appears to be harmful to kids, it may be no more effective in treating anxiety and depression than sugar pills.
It was stunning news for families and physicians and it pushed other regulatory agencies into action. Within a few weeks, the U.S. food and drug administration warned physicians about the new evidence, but stopped short of recommending against pediatric use of paroxetine. Instead it urged physicians to watch their patients more carefully for suicide. A few weeks later, it issued an advisory that another SSRI, venlafaxine (which is marketed as Effexor) is "ineffective" in treating childhood depression.
Canada followed the Americans' lead in both cases. By October 2003, the clamour of parents, patients and physicians demanding more information grew so loud that the FDA announced it will hold a special meeting Feb. 2 to discuss all of the published data, the new data and, if required, recommend further studies on eight different SSRIs. The list includes paroxetine (Paxil), venlafaxine (Effexor), fluvoxamine (Luvox), citalopram (Celexa), sertraline (Zoloft), nefazadone (Serzone) and mirtazapine (Remeron).
The doctors -- mostly family physicians and pediatricians -- started calling experts like Dr. Jane Garland, a psychiatrist and clinical head of the mood disorders clinic at B.C.'s Children's Hospital, and Dr. Marshall Korenblum, chief psychiatrist at Toronto's Hincks-Dellcrest Centre for Children and training director in psychiatry at Toronto's Sick Children's Hospital. "We were caught with our pants down," says Garland.
But after spending the summer digging out everything she could find on SSRIs, Garland says she and her colleagues shouldn't have been. "The evidence was before us. We just weren't paying attention." In the fall, Garland circulated a couple of papers to her colleagues here and internationally, summarizing the information that is available.
Here is a sampling of some of the information she has provided to B.C. doctors. - Prior to 1997, more than a dozen controlled studies demonstrated that SSRIs were no more efficacious than placebos in treating childhood depression. - In a published paroxetine study, one in 10 (10.5 per cent) of the patients taking Paxil had a "serious" adverse effect compared to just one in 100 of the placebo patients and nearly eight of 100 (7.5 per cent) taking paroxetine required hospitalization. - Seven of 10 young patients treated with Zoloft (or sertraline) for a major depressive episode would improve, but only one of those improvements could be directly attributed to the medication.
Despite the evidence, Garland said Wednesday, "I don't think that it was necessarily the right solution to go to a full ban [in Britain]. Their point is that people are not looking at the data objectively, but it leaves people with very few treatment options. ... It seems that they [the British committee members] were reacting to the profession not dealing with this issue rationally."
The reassurance Garland offers physicians is this: Even though there has been a consistently observed doubling of the rate of suicidal thinking in patients treated with several different SSRIs, the incidence is only between two and five per cent and "no completed suicides have been reported."
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In a perfect world, there would be obvious heroes and villains in a story of how kids as little as three came to be taking drugs that not only may not work, but might actually hurt them. But at the confluence of drugs, big money and politics, it is far from a perfect world.
To unravel this, let's start with some stark truths. - There is not a single study that shows that an abnormality in a person's ability to metabolize seratonin causes depression, according to Dr. David Healy, who has written three books and more than 1,200 articles about SSRIs. In fact, he says there's not a single psychiatrist, pharmacologist, pharmacist or pharmaceutical executive who can explain exactly how a selective seratonin reuptake inhibitor work or even how seratonin works.
- Most drugs given to children have never, ever been approved for pediatric or adolescent use, whether they are drugs for liver disease, cancer or depression, because drug companies ask for adult approval, not pediatric approval.
Yet doctors routinely prescribe them as a so-called "off-label use" on the assumption that the drugs are safe for adults, they'll be safe for kids too.
Off-label prescribing is such an accepted practice that even though SSRIs have never been approved for pediatric use -- Prozac being the exception -- they are recommended as first-line treatment by the American Academy of Children and Adolescent Psychiatry.
Dosages are determined by extrapolating from the recommended adult dose based on considerations such as weight and height. One of the reasons drugs aren't tested on kids is simple economics. Drug companies almost always apply to have a drug licensed for adult use and because of that there is no need for them to prove to the regulators that the drugs are safe for children or teens. But once approved, doctors aren't limited to adult-only uses. So why would pharmaceutical companies go to the substantial expense of repeating drug trials on kids when doctors will be able to prescribe them off-label anyway?
This is changing, albeit slowly. Two years ago, the United States passed legislation extending patent protection to individual drugs for five years, if pharmaceutical companies agreed to do pediatric trials on the drug. But getting that legislation passed was difficult. Ethicists and parents raised a troubling question: Should kids be guinea pigs? It was answered with another even more troubling question: Is it ethical to put kids on drugs that have never been tested on kids?
- There have never been any studies of the long-term effects of SSRIs on adults or children. Again it comes back to economics. Long-term studies cost tens of millions of dollars. Pharmaceutical companies have no reasons to do them once their drugs have regulatory approval and, so far, except in rare cases, countries and research institutions have had little interest or money for doing them.
It's why nefazadone (Serozone) was sold for nearly a decade before it was pulled off Canadian shelves in November. It took that long to establish the link between its use and severe liver damage. But even with that link, Canada waited nearly a year longer than European countries to ban its sale.
- No major studies involving adults or children have been done comparing the long-term effectiveness of SSRIs versus extensive therapy that includes exercise as well as talk and teaching patients skills to cope with anxiety- and depression-inducing situations. xxx cut xxx
Part Two: Drugs for kids need scrutiny: Canada slow to warn about pediatric use of antidepressants at: http://www.canada.com/vancouver/vancouversun/columnists/story.asp?id=6daa9398-c381-4950-8b2f-1372dd1daf65