SHOOTING SPURS DEBATE ON PROZAC'S USE BY KIDS

* Although some experts say the medication is the best hope for
depressed children, others think this use is inadequately studied

A boy walks into a school and opens fire. The news stories that follow
reveal a thousand facts. One fact raises a thousand questions: Prozac.

Kipland P. Kinkel, suspected of gunning down his parents and then his
schoolmates at Thurston High in Springfield, had reportedly taken the
antidepressant medication fluoxetine, commonly known as Prozac.
According to a family friend, the boy's parents took him off the
medicine last fall because it had worked so well for him.

But include the word "Prozac" in the same sentence with "children" or
"violence," and the result is a prescription for controversy and
misunderstanding.

Parents ask, is it safe to treat children with medicine approved only
for adult use?

Psychiatrists ask, why don't more parents come to them for
help?

Schoolteachers ask, how many students take antidepressants?

And despite evidence to the contrary, one human rights group contends
that the medicine makes patients more angry and violent than they
already are.

Answers to questions about Prozac and other antidepressants are not
simple.

The medications alternately are painted as the best possible hope for
the estimated 4 million U.S. children who suffer some form of
depression or as a potentially dangerous experiment that has not been
studied enough to ensure children's safety.

Prozac and other medications in its class -- known as selective
serotonin re uptake inhibitors, or SSRIs -- have not been fully tested
in children. But because the U.S. Food and Drug Administration has
approved them for adult use, doctors can prescribe them for children
and adolescents.

They do, in burgeoning numbers.

Last year, doctors prescribed these medications to 207,000 children
ages 6 to 12, and to 702,000 patients ages 13 to 18, according to IMS
America, a health information company in Pennsylvania.

Eli Lilly, the Indiana company that manufactures Prozac, reports that
in the 11 years since the medicine hit pharmacy shelves, 31 million
people worldwide -- 22 million in the United States -- have taken the
drug.

Most studies show it to be effective and safe for adults, which has
boosted physicians' confidence in prescribing it for children. The
American Medical Association says antidepressants can help nine of 10
patients for whom they are appropriate.

Still, many think more research is needed.

Prozac is thought to work by increasing serotonin in the brain;
serotonin, a chemical naturally present in the body, is associated
with mood changes.

Some wonder what the long-term effects of antidepressants are on
children and adolescents, whose brains are still developing. And some
have suggested that use of fluoxetine might be related to increased
thoughts about suicide in a small number of patients.

One often-quoted study, paid for by the National Institute of Mental
Health, showed Prozac works as well for children and teen-agers as it
does for adults. Another, published last December in the Archives of
General Psychiatry, concluded that study subjects who took fluoxetine
were less aggressive and irritable than those taking a placebo.

No fast fixes

But psychiatrists are quick to warn that antidepressants should not be
considered an easy fix for a sad, angry or listless child.

They should be prescribed only as part of a comprehensive evaluation
and treatment plan that includes individual psychotherapy and family
counseling, said Dr. David G. Fassler.

"Medication can be extremely helpful," he said. "But medication alone
is never the appropriate treatment."

Fassler, chairman of the American Psychiatric Association's Council on
Children, Adolescents and Their Families, is a child and adolescent
psychiatrist who practices in Burlington, Vt. He is co-author with Lynne
Dumas of "Help Me, I'm Sad: Recognizing, Treating and Preventing Childhood
and Adolescent Depression" (Viking, 1997).

The book is timely. Depression in young people is either at an
all-time high or is simply diagnosed more often as parents and
physicians learn about the complex disorder, and as the stigma
traditionally attached to seeking treatment for mental illnesses eases.

Until the early 1980s, depression was not recognized as a diagnosable
illness in children and teen-agers; many mental health professionals
thought children lacked the emotional maturity to become depressed.

Now it's considered a common and serious childhood illness, affecting
as many as one in four youngsters by the time they finish high school.

Left untreated, depression's effects can be devastating: Children and
teens might hurt themselves or others in the worst cases. Others fall
behind socially and academically. And those who have depressive
episodes early on are more likely to have recurring episodes later in
life.

"The experience of depression is extremely painful for a child,"
Fassler said.

The sooner depression is discovered and treated, the sooner a child
can return to feeling like a kid again.

But Fassler said depression, which he considers highly treatable,
still is often missed or misdiagnosed.

Some depressed children look a lot like depressed adults: They appear
sad, withdrawn or tearful. They have insomnia or trouble with appetite.

Others, though, are hyperactive or aggressive. They get into fights at
school, act out sexually or steal things.

"Some kids act in and other kids act out, so it's sometimes hard to
sort out," he said. "Is this depression, or is this the normal
moodiness of adolescence?"

Correctly diagnosing depression in children is critical -- and no
small task. It requires a thorough physical examination, a detailed
history of the child's development, school history, family history,
and individual interviews with the child, parents and often the entire
family.

"It's not something you can do in a typical six-minute office visit"
with a child's pediatrician, Fassler said.

Paying close attention

Alert parents, teachers, school nurses, counselors and doctors can
help spot the signs early and get children treatment.

In order to do that, school nurses in the Multnomah Education Service
District took part in three training sessions in the past year to
boost their knowledge about mental health issues.

Dee Kathryn Bauer, a registered nurse who is director of the
department of school health services for the district, said school
nurses are "seeing an increase in children who present with mental
health problems -- and they're not all under medical care." In
particular, she said, they're seeing more children who are angry and
afraid.

No one knows how many Oregon schoolchildren take antidepressants,
though the picture might grow clearer in the next school year. By July
1, schools have to adopt a policy to keep better track of
antidepressants and other prescription drugs that affect children's
cognitive abilities.

The change emerged from the 1997 legislative session, in which
lawmakers updated a 1973 law outlining schools' responsibilities with
regard to students' medications.

Fassler said more study is needed to determine which children are most
likely to respond well to antidepressants. In his experience, they
have worked best for children who have a family history of depression,
or if the symptoms seem more biologically than psychologically based.

He said doctors certainly should consider antidepressant treatment for
children who have not responded to other types of treatment, or if a
child's safety is at risk.

Children and adolescents who take the medications often are on them
for six to 12 months; doses might be similar to doses given adults,
depending on how patients react to the medicine.

The Citizens Commission on Human Rights, a group financed by the
Church of Scientology, is a vocal critic of psychiatric drugs such as
Prozac and says the medicines are too dangerous to use on children.
The group says the drugs are linked to violent and suicidal episodes.

But in the early 1990s, the FDA debunked those allegations, saying
violent actions and suicidal thoughts are common among depressed
people; it found no link among the medication, violence or suicidal
thoughts.

From Fassler's perspective, Prozac and similar medications have gone a
long way toward helping children and teens with mental and emotional
problems. He agrees it's appropriate to keep an eye on the rate at
which they're being prescribed, and to make sure those prescribing
antidepressants are trained in the appropriate and safe use of the
medicines, as well as their potential side effects.

"But I don't agree with the sense that we're rushing to put all kids
on medication as the answer to all kinds of society's problems," he
said. "I see the opposite problem: There are still millions of kids
with clinical depression who are not getting the treatment they need.

"There's no question in my mind that these medications are saving
lives," he said. "I actually believe that in many instances, they are
probably preventing or helping to prevent violent episodes."

Contact staff writer Katy Muldoon at 221-8526; by mail at The
Oregonian, 1320 S.W. Broadway, Portland, Ore. 97201; or by e-mail at
katymuldoon@news.oregonian.com

Checked-by: (trikydik)