A preliminary position paper in response to NICE scope for clinical guideline on depression in children
In developing guidelines at least three areas need to be thoroughly examined, else we run the risk of developing guidelines based on faulty assumptions which could lead to the encouragement of practice that may be worse than useless.
Firstly: Does the concept of ‘depression’ have cross culturally validity?
Secondly: Is the concept of ‘childhood depression’ a valid and useful one?
Thirdly: How useful is the concept of childhood depression when making treatment decisions (Particularly with regards the use of anti-depressants)?
Does the concept of ‘depression’ have cross-cultural validity?
Reference to cross-cultural psychiatric and to anthropological literature throws serious doubt on the cross-cultural validity of the concept of depression as it has been developed and used in Western psychiatry. The concept of depression has been developed with reference to a particular cultural group and when applied to other cultural groups the psychiatric concept of depression lacks coherence and credibility (Kleinman, 1977,1987; Kleinman and Good, 1985). Many of the key psychiatric symptoms in depression refer to conceptual constructs influenced by Western philosophical ideas. These symptoms may be absent, nonsensical or have entirely different meanings in cultures where different philosophical traditions have been influential, particularly those not governed by notions of a mind/body split (Krause, 1989; Jackson, 1985; Currer, 1986; Obeyesekere, 1985). In order to be able to practice in a non-discriminatory manner in a multi-cultural society, the discrimination inherent in concepts with little cross-cultural validity must be acknowledged and practice must reflect this (Fernando, 1988). Unless we are able to understand the different systems of meaning that exist we will be faced with a deep seated problem where the clinician’s and the client’s paradigms are so incongruent that harmful outcomes result (Smith, 2003)
Is the concept of childhood depression a valid and useful one?
Examining cross-cultural, anthropological, psychological and sociological literature throws up even more question marks over concept of depression in children. Western psychiatry developed within a medical culture with an individualist (as opposed to collectivist) and technological orientation where context (cultural, political, spiritual etc.) has been marginalized (Bracken and Thomas, 2001). Use of such context-depleted paradigms is even more problematic in child psychiatry (Timimi, 2002) given the dependence children have on adults to make decisions on their behalf (even in the Western world!).
Whilst the immaturity of children is a biological fact, the ways in which this immaturity is understood and made meaningful is a fact of culture (Prout and James, 1997). Sociologists have argued that childhood in the West is being eroded, lost or indeed has suffered a strange death (Jenhs, 1996). For example Neil Postman (1983) has claimed that childhood is disappearing as children have gained access to the world of adult information resulting in a blurring of boundaries between what is considered adulthood and what is considered childhood, leading to children coming to be viewed as in effect miniature adults. This concern with regards the dramatic nature in which the way we view childhood is changing, is reflected in a huge number of books such as Children Without Childhood, (Winn, 1984), Stolen childhood, (Vittachi, 1989), The Rise and Fall of Childhood (Sommerville, 1982), Children in Danger (Garbarino, et al, 1992) and of course The Disappearance of Childhood (Postman, 1983), all of which suggest that with the invasion of the adult world into the space of childhood, a sense of the uniqueness and innocence of the experience of childhood is being lost. Furthermore globalisation and the cultural power of Western society has meant these newer Western notions of childhood are being exported and imposed on cultures who may well have much more nurturing and benign notions regarding childhood (Stephens, 1995, Comaroff and Comaroff, 1991).
Childhood depression reflects this individualized notion of little adults falling prey to internal mental diseases that resemble those that effect adults (despite no convincing evidence that depression in children is a state associated with biological correlates anymore than the less pathological notion of unhappiness or sadness, or that there is a reliable way to distinguish between depression and sadness in children). The language we use is of great importance to the message we give, as talking about a state in a child as an illness produces a very different attitude, set of expectations and therapeutic approach than talking about a state as a natural and normal human reaction (even if it is an undesirable one).
The above should raise concern at the way the concept of childhood depression has evolved, reflecting the tendency to ascribe in a poorly thought out way, notions of adult pathology directly onto children. This is despite the widely acknowledged fact that should childhood depression exist, it presents in a substantially different way than depression in adults. For example symptoms considered core symptoms in making the diagnosis in adults such as sleep disturbance, poor appetite, weight loss and suicidal ideation are believed to rarely be present in childhood depression, instead more non-specific symptoms such as irritability, running away from home, decline in school work and headaches are described (Hill, 1997). As there are no biological or psychological markers, nor any evidence of continuity with depression in later life, childhood depression appears to be a ragbag of garments borrowed from individualist adult psychiatry with no clear epistemological reason why, other than a vague idea that if it occurs in adults then it should in children. In other words the birth and increasing popularity of the diagnosis of childhood depression reflects a wider socio-cultural process occurring in Western society (of a diminishing boundary between the way we conceive childhood and adulthood), rather than being the result of any medical breakthrough.
How useful is the concept of childhood depression when it comes to making treatment decisions?
A context-deprived notion of childhood problems (such as childhood depression) leads to context-deprived, often medicalized solutions. This has resulted in a dramatic increase in the inappropriate use of anti-depressants in children and adolescents. In the USA a sharp rise during the nineties in use of anti-depressants in this age group is well documented (Olfson et al, 2002) and includes prescribing of antidepressants to pre-school children as young as two (Zito et al, 2001). In the UK there has also been a dramatic increase in the use of anti-depressants in the under-18 age group and there are currently around 50,000 children and adolescents taking them in the UK (Boseley, 2003).
Is this appropriate? It should be noted that there remains considerable doubt with regards the efficacy of anti-depressants in adults. There is considerable evidence to suggest that in adults anti-depressant drug effects are not much greater than placebo, particularly when compared to an active placebo (Greenberg and Fisher, 1997; Healy, 1999; Moncrieff, 2002), that psychological treatments are at least as effective as pharmacotherapy, even in severe depression and especially if patient rated and long term measures are used (Antonuuccio et al, 1995, 1997; De Rubeis et al, 1999), and that pharmacotherapy alone increases vulnerability to relapse (Hollon et al, 1991; Segal et al, 1999). The current state of evidence with regards the efficacy of anti-depressants in children and adolescents is much clearer. There is no convincing evidence that anti-depressants show any benefit over placebo in children or adolescents (Ambrosini et al, 1993; Hazell et al, 1995; 2002). There are only two studies that claim to have demonstrated a small benefit over placebo, however these where on clinician measures only, patient and carer measures did not demonstrate any improved outcome over placebo (Emslie et al, 1997; Avci et al, 1999). When we couple this evidence (or lack of it) with the deep concerns that exist about potentially fatal side effects (whether through cardio-toxicity or provoking suicidal impulses) and our lack of knowledge concerning the possible effects antidepressants have on the developing brain, the implications are clear. Indeed, due to concerns about the increased sensitivity to side effects of the under-18 age group, the government recently recommended that Seroxat and Venlafaxine should never be used in children and adolescents.
Interventions need to take a broader more context rich perspective that will allow access to multi-perspectives in a way that takes full account of the lived situation of a child (Timimi, 2002). Indeed in my clinical practice as a consultant child and adolescent psychiatrist it has been a long time (years) since I needed to use an anti-depressant.
The NICE guidelines offer an opportunity to reduce the serious, dangerous and escalating use of antidepressants in children and adolescents through the sort of thorough engagement with perspectives from other disciplines (sociology, anthropology, psychology, psychotherapy, philosophy etc.) that inevitably pose serious question marks with regards the validity and usefulness of the concept of ‘childhood depression’. The guidelines should caution against use of the diagnosis particularly when dealing with a catchment area with a high ethnic minority population. The guidelines should recommend that anti-depressants are not indicated for use in the under-18 age group.
Ambrosini PJ, Bianchi MD, Rabinovich H, Elia J (1993), Antidepressant treatments in children and adolescents. I. Affective disorders. Journal of the American Academy of Child and Adolescent Psychiatry 32: 1-6.
Antonuccio DO, Thomas M, Danton WG (1997), A cost-effectiveness analysis of cognitive behavior therapy and fluoxetine (Prozac) in the treatment of depression. Behavior Therapy 28: 187-210.
Antonuccio DO, Danton WG, DeNelsky GY (1995), Psychotherapy versus medication for depression: challenging the conventional wisdom with data. Professional Psychology: Research and Practice 26: 574-585.
Avci A, Diler RS, Kibar M, Sezgin F (1999), Comparison of moclobemide and placebo in young adolescents with major depressive disorder. Annals of Medical Science 8: 31-40.
Boseley S (2003), 50,000 children taking antidepressants. The Guardian: 20th September.
Bracken P, Thomas P (2001), Post psychiatry: a new direction for mental health. BMJ 322: 724-727.
Comaroff J, Comaroff J (1991), Africa observed: Discourses of the imperial imagination. In J Comaroff, J Comaroff (eds.) Of Revelation and revolution: Christianity, colonialism and consciousness in South Africa, Vol. 1. Chicago: University of Chicago Press.
Currer C (1986), Concepts of mental and ill being: The case of Pathan mothers in Britain. In C Currer, M Stacey (eds.) Concepts of health, illness and disease: A comparative perspective. Lemington Spa: Berg.
DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD (1999), Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. American Journal of Psychiatry 156: 1007-1013.
Emslie GJ, Rush AJ, Weinberg WA et al. (1997), A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry 54: 1031-1037.
Fernando S (1988), Race and culture in psychiatry. London: Croom Helm.
Garbarino J, Dubrow N, Kostelny K, Pardo C (1992), Children in danger: Coping with the consequences of community violence. San Francisco: Jossey-Bass Publishers.
Greenberg RP, Fisher S (1997), Mood-mending medicines: probing drug, psychotherapy, and placebo solutions. In S Fisher, RP Greenberg (eds.) From Placebo to Panacea: Putting Psychiatric Drugs to the Test. New York: John Wiley.
Hazell P, O'Connell D, Heathcote D (1995), Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis. BMJ 310: 897-901.
Hazell P, O'Connell D, Heathcote D, Henry D. (2002) Tricyclic drugs for depression in children and adolescents. Cochrane Database Systematic Revue: CD002317.
Healy D (1999), The Antidepressant Era. Cambridge, MA: Harvard University Press.
Hill P (1997), Child and adolescent psychiatry. In R Murray, P Hill, P McGuffin (eds.) The essentials of postgraduate psychiatry: Third Edition. Cambridge: Cambridge University Press.
Hollon SD, Shelton RC, Loosen PT (1991), Cognitive therapy and pharmacotherapy for depression. Journal of Consultative Clinical Psychology 59:88-99.
Jackson S (1985), Acedia, the sins and its relationship to sorrow and melancholia. In A Kleinman, B. Good (eds.) Culture and Depression. Berkley: University of California Press.
Jenhs C (1996), Childhood. London: Routledge.
Kleinman A (1977), Depression, somatization and the new cross-cultural psychiatry. Social Science and Medicine 11: 3-10.
Kleinman A (1987), Anthropology and Psychiatry. The role of culture in cross cultural research on illness. British Journal of Psychiatry 151: 447-454.
Kleinman A, Good B (1985), Introduction: Culture and depression. In A Kleinman, B Good (eds.) Culture and Depression. Berkley: University of California Press.
Krause I (1989), Sinking heart: A Punjabi communication of distress. Social Science and Medicine 29: 563-575.
Moncrieff J (2002), The antidepressant debate. British Journal of Psychiatry 180: 193-194
Obeyesekere G (1985), Depression, Buddhism and the work of culture in Sri Lanka. In A Kleinman, B Good (eds.), Culture and depression. Berkley: University of California Press.
Olfson M, Marcus SC, Weissman MM, Jensen PS (2002), National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry 41: 514-21.
Postman N (1983), The Disappearance of Childhood. London: W.H. Allen.
Prout A, James A (1997), A new Paradigm for the sociology of childhood? Provenance, promise and problems. In A James, A Prout (eds.), Constructing and re-constructing childhood: Contemporary issues in the sociological study of childhood. London: Falmer Press.
Segal ZV, Gemar M, Williams S (1999), Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression. Journal of Abnormal Psychology 108: 3-10.
Smith R (2003), An extreme failure of concordance. BMJ 327: 818.
Sommerville J (1982), The Rise and Fall of Childhood. London: Sage.
Stephens S (1995), Children and the politics of culture in "Late Capitalism". In S Stephens (ed.), Children and the politics of culture. Princeton: Princeton University Press.
Timimi S (2002), Pathological child psychiatry and the medicalization of childhood. London: Brunner-Routledge.
Vittachi A (1989), Stolen childhood: In search of the rights of the child. Cambridge: Polity Press.
Winn M (1984), Children without childhood. Harmondsworth: Penguin.
Zito JM, Safer DJ, Dosreis S, Gardner JF, Boles J, Lynch F (2000), Trends in prescribing of psychotropic medication in pre-schoolers. Journal of the American Medical Association 283: 1025-30.