Debate grows over antidepressant use among preschoolers

Like many mothers across the country, Chris Battaglini has been closely watching her son's high energy since he was a toddler. "He was excitable," the stay-at-home mom in Lakeville, Mass., says of those anxious, early days. "He wasn't bouncing off the walls, but he wasn't able to focus."

By the time he started school, her son's restlessness became more problematic, and Mrs. Battaglini took him to a doctor. The 6-year-old was put on medication, something his mother is still adjusting to. "I'm not thrilled," she says. "But if it's something that's going to help him be able to focus ... then I'm willing to do it."

Battaglini's experience is part of a growing trend in America: preschoolers being medicated to control behavior.

While antidepressants and other mood-altering drugs have long been prescribed to adolescents, the fastest-growing group using such medication is children under age 5.

Indeed, by one estimate, twice as many preschoolers are being prescribed antidepressants today than just five years ago. The development is touching off a new controversy over whether doctors should be prescribing mood-altering drugs to toddlers at all, let alone much more frequently.

Critics, including many in the medical community, question whether youngsters really are more depressed today or simply more medicated. Many would like to see greater federal oversight of the process - particularly at a time when there is little consensus on the impact of Ritilin and other drugs on children. "Depression in a 3- or 4-year-old?" says Lawrence Diller, a pediatrician and the author of "Running on Ritalin." "What is that? I can't see any reason for it. Every doctor who's ever prescribed a psychiatric drug to any kid is doing a balancing act between the needs of the kid and the needs of the system."

The latest evidence of the growing use of antidepressants among the very young comes from a report by Express Scripts, a healthcare management firm in St. Louis. It studied 2 million children in the US between 1998 and 2002. It found that the number of children younger than five prescribed antidepressants doubled during that time.

In 2002, 0.16 percent of girls and 0.23 percent of boys in this age group were on antidepressants, representing some 40,000 kids. For children of all ages, use was highest among girls age 15 to 18, at 6.8 percent. Overall, antidepressant use among patients 18 and younger increased from 1.6 percent in '98 to 2.4 percent in 2002. "It was surprising it doubled," says Thomas Delate, director of research at Express Scripts, of the growth among preschoolers. But he's not sure the prescription-drug culture shouldn't filter down to that age group. "One of the biggest reasons [for the jump] is the growing awareness of depression in this age group," he says.

That, in fact, is a key point of debate. Doctors such as Diller doubt the very notion of depression among toddlers - let alone something that's detectable. He calls it a "pseudo-science."

But others believe it definitely exists and needs to be dealt with. Graham Emslie, a psychiatry professor in Dallas, Texas, and author of several studies on antidepressants, estimates that as many five percent of all adolescents, which includes toddlers, suffer from severe depression.

"It's not very often that we have to treat preschoolers," he says. "I don't think a depressed preschooler should get medicine until a lot of other things are exhausted first." Nonetheless, he agrees that it should be done in some cases.

Others argue that the real reason behind the rise in preschooler prescriptions is simple profits. "The drug representatives ... have access to every doctor, to every clinic, wherever they can they push their wares," says Vera Sharav, president of the Alliance for Human Research Protection, an advocacy group in New York. "They're interested in pushing sales. It's turned medicine inside out."

Regardless of root causes, however, no one disputes that the longterm effects of these drugs remain uncertain. "This is like two blind persons touching the same elephant," says Thomas Moore, a health policy analyst at George Washington University, whose own research shows far more prescriptions among the very young than the numbers cited by Express Scripts.

Dozens of conflicting studies, in fact, are vying for the attention of the Food and Drug Administration (FDA) - among them a report released by Jane Garland, a Canadian expert, in February finding that antidepressants prescribed to adolescents are largely ineffective. Great Britain banned the prescription of Paxil to adolescents last summer due to suicidal behavior possibly resulting from the drug. The FDA has agreed to investigate the effects of about a dozen mood-altering drugs on adolescents.

The drug industry, for its part, says that antidepressants are safe and greatly benefit many troubled adolescents. But company officials do caution against overuse of the pills, especially among preschoolers. "We believe medication should be prescribed only after a careful diagnosis is made, and medication would be continued only if it clearly benefits the child," says Jennifer Yoder, spokeswoman for Eli Lilly & Co., the maker of Prozac.

Because medication is often more affordable than psychotherapy, some critics say there may be a greater incentive for doctors to prescribe a pill than hours with a therapist - and easier for parents to afford. Ms. Sharav, for one, worries that access to antidepressants, coupled with heavy advertising and a lack of label warnings, leads many parents to medicate their children.

"Because they are misled by the ads and societal pressure, parents think it's OK to use these drugs to control the behavior of their children," she says. "But bad behavior may come from a lot of reasons, including that no one is there to pay attention to these young children. It's not pleasant for women to reassess that, but it does need to be reassessed."

Battaglini, however, has reassessed. She resisted drugs for months, but in the end trusts her doctor: "You know what? I'm not exactly sure if it is an antidepressant. But between the school psychologist, myself, and the doctor, we decided to give it a try."