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Tuesday, 25 November 2014

Professor Peter Kinderman -Why We Need to Abandon the Disease-Model of Mental Health Care By Peter Kinderman


Why We Need to Abandon the Disease-Model of Mental Health Care
By Peter Kinderman | November 17, 2014 
The views expressed are those of the author and are not necessarily those of Scientific American.




The original English version of the DSM-5 as well as the French version of the DSM-IV-TR. (Credit: F.RdeC via Wikimedia Commons)
The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But in my view it is also a myth, and a harmful one. Our present approach to helping vulnerable people in acute emotional distress is severely hampered by old-fashioned, inhumane and fundamentally unscientific ideas about the nature and origins of mental health problems. We need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services.
Clarity without diagnosis
Even mainstream medical authorities have begun to question the creeping medicalization of normal life and criticize the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis. It is important that we are able to define, identify and measure the phenomena we are attempting to study and the problems for which people seek help. But we obfuscate rather than help when we use the language of medical disease to describe the understandable, human and indeed normal response of people to traumatic or distressing circumstances. So there are ethical and humanitarian reasons to be skeptical of traditional psychiatric diagnosis. But there are scientific reasons too. It’s odd but hugely significant that the reliability statistics for the American Psychiatric Association’s influential DSM franchise have been falling steadily over time. It is difficult reliably to distinguish different “disorders”, but also difficult to identify specific biological etiological risk factors. Indeed, Thomas Insel, director of the National Institute of Mental Health, recently suggested that traditional psychiatric diagnoses had outlived their usefulness.
A Prescription for Psychiatry, book cover.
Understanding rather than etiology
It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional disease-model way of thinking, those assumptions start to crumble.
Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signalers. But this logic applies to all human behavior and every human emotion and it doesn’t differentiate between distress — explained as a product of chemical “imbalances” — and “normal” emotions. Moreover, while it is clear that medication (like many other substances, including drugs and alcohol) has an effect on our neurotransmitters, and therefore on our emotions and behavior, this is a long way from supporting the idea that distressing experiences are caused by imbalances in those neurotransmitters.
Many people continue to assume that serious problems such as hallucinations and delusional beliefs are quintessentially biological in origin, but we now have considerable evidence that traumatic childhood experiences (poverty, abuse, etc.) are associated with later psychotic experiences. There is an almost knee-jerk assumption that suicide, for instance, is a consequence of an underlying illness, explicable only in biological terms. But this contrasts with the observation that the recent economic recession has had a direct impact on suicide rates, a rather dramatic (and sad) example of how social factors impact on our mental health.
Neural activity and chemical processes in the brain lie behind all human experiences, and it’s undoubtedly helpful to understand more about how the human brain works. However, this is very different from assuming that some of those experiences (psychosis, low mood, anxiety, etc) should be classified as illnesses. The human brain is not only a complex biological structure; it is also a fantastically elegant learning engine. We learn as a result of the events that happen to us, and there is increasing evidence that even severe mental health problems are not merely the result simply of faulty genes or brain chemicals. They are also a result of experience — a natural and normal response to the terrible things that can happen to us and that shape our view of the world.
Stigma & empathy
Traditionally, the idea that mental health problems are illnesses like any other and that therefore people should not be blamed or held responsible for their difficulties has been seen as a powerful tool to reduce stigma and discrimination.
Unfortunately, the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a more genuinely empathic approach would be to understand how we all respond emotionally to life’s challenges.
But things are changing. Over the past 20 years or so, we’ve seen a very positive and welcome growth of the user and survivor movements, where people who have experienced psychiatric care actively campaign for reform, and signs of more responsible media coverage. We are just starting to see the beginnings of transparency and democracy in mental health care. This has led to calls for radical alternatives to traditional models of care, but I would argue that we do not need to develop new alternatives.We already have robust and effective alternatives. We just need to use them.
Therapy
Clinicians have raised concerns about the relative benefits of psychiatric medication and there is increasing evidence for the effectiveness of psychological therapies such as cognitive behavioral therapy. Indeed, even for people with very serious mental health problems, such as those leading to a diagnosis of schizophrenia, and even for those choosing not to take medication, such therapies have great promise.
We need to place people and human psychology central in our thinking. Psychological science offers robust scientific models of mental health and well-being, which integrate biological findings with the substantial evidence of the social determinants of health and well-being, mediated by psychological processes.
We must move away from the disease model, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognizes our essential and shared humanity. Our mental health is largely dependent on our understanding of the world and our thoughts about ourselves, other people, the future and the world. Biological factors, social factors and circumstantial factors — our human experience — affect the key psychological processes that help us build up our sense of who we are and the way the world works.
A new approach
In my new book A Prescription for Psychiatry I offer a manifesto for mental health and well-being. I argue that services should be based on the premise that the origins of distress are largely social. The guiding idea underpinning mental health services needs to change; from an assumption that our role is to treat disease to an appreciation that our role is to help and support people who are distressed as a result of their life circumstances.
This also means we should replace traditional diagnoses with straightforward descriptions of problems. We must stop regarding people’s very real emotional distress as merely the symptom of diagnosable “illnesses”. A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and for the design and planning of services. This does not mean rejecting rigor or the scientific method — quite the opposite. While psychiatric diagnoses lack reliability, validity and utility, there is no barrier to the operational definition of specific psychological phenomena, and it is equally possible to develop coherent treatment plans from such a basis.
All this means that we should turn from the diagnosis of illness and the pursuit of etiology and instead identify and understand the causal mechanisms of operationally defined psychological phenomena. Our health services should sharply reduce our reliance on medication to address emotional distress. We should not look to medication to “cure” or even “manage” non-existent underlying “illnesses”.
We must offer services that help people to help themselves and each other rather than disempowering them — services that facilitate “personal agency” in psychological jargon. That means involving a wide range of community workers and psychologists in multidisciplinary teams, and promoting psychosocial rather than medical solutions. Where individual therapy is needed, effective, formulation-based (and therefore individually tailored) psychological therapies should be available to all. When people are in acute crisis, residential care may be needed, but this should not be seen as a medical issue. Since a disease model is inappropriate, it is also inappropriate to care for people in hospital wards. A different model of care is needed.
Adopting this approach would result in a fundamental shift from a medical to a psychosocial focus. It would mean a move from hospital to residential social care and a substantial reduction in the prescription of medication. And because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to address the underlying issues of abuse, discrimination and social inequity.
This is an unequivocal call for a revolution in the way we conceptualize mental health and in how we provide services for people in distress, but I believe it’s a revolution that’s already underway.
About the Author: Peter Kinderman is professor of Clinical Psychology at the University of Liverpool, and is a Chartered Clinical Psychologist. He is Head of the Institute of Psychology, Health and Society at the University of Liverpool. His research interests are in psychological processes underpinning well-being and mental health, and in particular psychotic phenomena such as delusions and hallucinations. In 2000, he received the British Psychological Society's Division of Clinical Psychology 'May Davidson Award', an annual award for outstanding contributions to the field of clinical psychology, in the first ten years after qualifying. He was twice elected Chair of the British Psychological Society Division of Clinical Psychology; from 2004 to 2005, and again from 2010-2011. In that role, he worked with the UK Department of Health, the BBC, the Health Professions Council, the European Union Fundamental Rights Agency and the UK Office for National Statistics, amongst others. He has recently launched a free, online, open-access course exploring our understanding of mental health and well-being. Follow on Twitter @peterkinderman.


The views expressed are those of the author and are not necessarily those of Scientific American.
By Peter Kinderman | November 17, 2014 |   30
The views expressed are those of the author and are not necessarily those of Scientific American.



The original English version of the DSM-5 as well as the French version of the DSM-IV-TR. (Credit: F.RdeC via Wikimedia Commons)
The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But in my view it is also a myth, and a harmful one. Our present approach to helping vulnerable people in acute emotional distress is severely hampered by old-fashioned, inhumane and fundamentally unscientific ideas about the nature and origins of mental health problems. We need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services.
Clarity without diagnosis
Even mainstream medical authorities have begun to question the creeping medicalization of normal life and criticize the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis. It is important that we are able to define, identify and measure the phenomena we are attempting to study and the problems for which people seek help. But we obfuscate rather than help when we use the language of medical disease to describe the understandable, human and indeed normal response of people to traumatic or distressing circumstances. So there are ethical and humanitarian reasons to be skeptical of traditional psychiatric diagnosis. But there are scientific reasons too. It’s odd but hugely significant that the reliability statistics for the American Psychiatric Association’s influential DSM franchise have been falling steadily over time. It is difficult reliably to distinguish different “disorders”, but also difficult to identify specific biological etiological risk factors. Indeed, Thomas Insel, director of the National Institute of Mental Health, recently suggested that traditional psychiatric diagnoses had outlived their usefulness.
A Prescription for Psychiatry, book cover.
Understanding rather than etiology
It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional disease-model way of thinking, those assumptions start to crumble.
Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signalers. But this logic applies to all human behavior and every human emotion and it doesn’t differentiate between distress — explained as a product of chemical “imbalances” — and “normal” emotions. Moreover, while it is clear that medication (like many other substances, including drugs and alcohol) has an effect on our neurotransmitters, and therefore on our emotions and behavior, this is a long way from supporting the idea that distressing experiences are caused by imbalances in those neurotransmitters.
Many people continue to assume that serious problems such as hallucinations and delusional beliefs are quintessentially biological in origin, but we now have considerable evidence that traumatic childhood experiences (poverty, abuse, etc.) are associated with later psychotic experiences. There is an almost knee-jerk assumption that suicide, for instance, is a consequence of an underlying illness, explicable only in biological terms. But this contrasts with the observation that the recent economic recession has had a direct impact on suicide rates, a rather dramatic (and sad) example of how social factors impact on our mental health.
Neural activity and chemical processes in the brain lie behind all human experiences, and it’s undoubtedly helpful to understand more about how the human brain works. However, this is very different from assuming that some of those experiences (psychosis, low mood, anxiety, etc) should be classified as illnesses. The human brain is not only a complex biological structure; it is also a fantastically elegant learning engine. We learn as a result of the events that happen to us, and there is increasing evidence that even severe mental health problems are not merely the result simply of faulty genes or brain chemicals. They are also a result of experience — a natural and normal response to the terrible things that can happen to us and that shape our view of the world.
Stigma & empathy
Traditionally, the idea that mental health problems are illnesses like any other and that therefore people should not be blamed or held responsible for their difficulties has been seen as a powerful tool to reduce stigma and discrimination.
Unfortunately, the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a more genuinely empathic approach would be to understand how we all respond emotionally to life’s challenges.
But things are changing. Over the past 20 years or so, we’ve seen a very positive and welcome growth of the user and survivor movements, where people who have experienced psychiatric care actively campaign for reform, and signs of more responsible media coverage. We are just starting to see the beginnings of transparency and democracy in mental health care. This has led to calls for radical alternatives to traditional models of care, but I would argue that we do not need to develop new alternatives.We already have robust and effective alternatives. We just need to use them.
Therapy
Clinicians have raised concerns about the relative benefits of psychiatric medication and there is increasing evidence for the effectiveness of psychological therapies such as cognitive behavioral therapy. Indeed, even for people with very serious mental health problems, such as those leading to a diagnosis of schizophrenia, and even for those choosing not to take medication, such therapies have great promise.
We need to place people and human psychology central in our thinking. Psychological science offers robust scientific models of mental health and well-being, which integrate biological findings with the substantial evidence of the social determinants of health and well-being, mediated by psychological processes.
We must move away from the disease model, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognizes our essential and shared humanity. Our mental health is largely dependent on our understanding of the world and our thoughts about ourselves, other people, the future and the world. Biological factors, social factors and circumstantial factors — our human experience — affect the key psychological processes that help us build up our sense of who we are and the way the world works.
A new approach
In my new book A Prescription for Psychiatry I offer a manifesto for mental health and well-being. I argue that services should be based on the premise that the origins of distress are largely social. The guiding idea underpinning mental health services needs to change; from an assumption that our role is to treat disease to an appreciation that our role is to help and support people who are distressed as a result of their life circumstances.
This also means we should replace traditional diagnoses with straightforward descriptions of problems. We must stop regarding people’s very real emotional distress as merely the symptom of diagnosable “illnesses”. A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and for the design and planning of services. This does not mean rejecting rigor or the scientific method — quite the opposite. While psychiatric diagnoses lack reliability, validity and utility, there is no barrier to the operational definition of specific psychological phenomena, and it is equally possible to develop coherent treatment plans from such a basis.
All this means that we should turn from the diagnosis of illness and the pursuit of etiology and instead identify and understand the causal mechanisms of operationally defined psychological phenomena. Our health services should sharply reduce our reliance on medication to address emotional distress. We should not look to medication to “cure” or even “manage” non-existent underlying “illnesses”.
We must offer services that help people to help themselves and each other rather than disempowering them — services that facilitate “personal agency” in psychological jargon. That means involving a wide range of community workers and psychologists in multidisciplinary teams, and promoting psychosocial rather than medical solutions. Where individual therapy is needed, effective, formulation-based (and therefore individually tailored) psychological therapies should be available to all. When people are in acute crisis, residential care may be needed, but this should not be seen as a medical issue. Since a disease model is inappropriate, it is also inappropriate to care for people in hospital wards. A different model of care is needed.
Adopting this approach would result in a fundamental shift from a medical to a psychosocial focus. It would mean a move from hospital to residential social care and a substantial reduction in the prescription of medication. And because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to address the underlying issues of abuse, discrimination and social inequity.
This is an unequivocal call for a revolution in the way we conceptualize mental health and in how we provide services for people in distress, but I believe it’s a revolution that’s already underway.
About the Author: Peter Kinderman is professor of Clinical Psychology at the University of Liverpool, and is a Chartered Clinical Psychologist. He is Head of the Institute of Psychology, Health and Society at the University of Liverpool. His research interests are in psychological processes underpinning well-being and mental health, and in particular psychotic phenomena such as delusions and hallucinations. In 2000, he received the British Psychological Society's Division of Clinical Psychology 'May Davidson Award', an annual award for outstanding contributions to the field of clinical psychology, in the first ten years after qualifying. He was twice elected Chair of the British Psychological Society Division of Clinical Psychology; from 2004 to 2005, and again from 2010-2011. In that role, he worked with the UK Department of Health, the BBC, the Health Professions Council, the European Union Fundamental Rights Agency and the UK Office for National Statistics, amongst others. He has recently launched a free, online, open-access course exploring our understanding of mental health and well-being. Follow on Twitter @peterkinderman.




Thursday, 20 November 2014

PRN.FM RADIO - The Dr. Peter Breggin Hour – 19th November 2014 - BIG RESPONSE TO - Dave Traxson who Challenges the 'Medical Model' Dominance of Using Psychotropic Drugs to Treat Behavioural Issues in Young Children



The Dr. Peter Breggin Hour – 11/19/14

Posted on: November 19th, 2014 by Archivist   Categories: Dr. Peter Breggin Hour




British Chartered Psychologist Dave Traxson describes the “Psycho-economic colonization” of childhood by the pharmaceutical and medical industries and what stressed children really need instead. Interested in Safeguarding our children?  Listen to this show, please.

Wednesday, 5 November 2014

Antidepressants can increase rate of suicide in yung people = USFDA study


A study has found that young adults under the age of 25 have an increased risk of suicide or suicidal thoughts when they take antidepressants, The Independent reported. The newspaper continued, “the risk is greatest after they take the drugs for anxiety and other mental problems not connected with depression”.

One of the scientists behind the US Food and Drug Administration (FDA) study said, "It doesn't mean that these drugs shouldn't be given to young adults but you have to think about the risks and the benefits. The findings tell you to watch people carefully. If someone on antidepressants talks of being suicidal, it may actually be due to the drugs."

This extensive research by the FDA examined reports of suicidal thoughts or behaviour in 372 placebo-controlled trials of antidepressants in all ages for various reasons. It found that under-25s on the drugs tended to have an increased risk of suicidal thoughts or behaviour (preparatory actions for suicide or attempted or completed suicide).

There are several important limitations to these findings, but they are likely to lead to further research and may lead to changes in drug regulatory information. The results highlight the need for warnings on medications and prescribing guides to alert practitioners to the potential for increased suicide risk in this age group.

 

Where did the story come from?

The research was carried out by Dr Marc Stone and colleagues from the Center for Drug Evaluation and Research at the US Food and Drug Administration (FDA). The study received no specific grants from any external agencies other than the FDA. The study was published in the (peer-reviewed) British Medical Journal.

 

What kind of scientific study was this?

This review examined the risk of suicidal behaviour in adults taking part in clinical trials of antidepressants. It involved a systematic review of placebo-controlled trials with meta-analysis. The researchers aimed to test the theory that suicidal ideation (suicidal thoughts) or preparatory actions for suicide or worse (attempted or completed suicide), would be increased among adults using antidepressants compared to placebo.

The FDA commissioned the review in 2005-06, when it asked the industry sponsors (such as pharmaceutical companies) of 12 marketed antidepressant drugs to submit data on trials of antidepressants in adults for any indication. Information was requested for all completed double blind, randomised placebo controlled trials. If the sponsors had excluded any trials, they were asked to provide reasons for this.

The sponsors were asked to search their databases for adverse events reported during clinical trials. The various search terms that were used related to suicidality, and may have included examples such as ‘attempt’, ‘burn’, ‘cut’ and ‘jump’. False positives, where these terms had been used but did not relate to suicidality, were also identified.

Sponsors prepared a narrative report of all adverse events, which were classified by a board of expert reviewers into one of several categories:

  • completed suicide,
  • suicide attempt,
  • preparatory acts towards imminent suicidal behaviour,
  • suicidal ideation,
  • self-harm, intent unknown,
  • not enough information (fatal), and
  • not enough information (non-fatal).

For participants who had multiple events, only the most severe event was coded.

The researchers did not include trials that had fewer than 20 participants in each treatment arm, those without sufficient patient data and those that had used active comparison drugs rather than placebo.

The primary outcome was defined as definite suicidal ideation or behaviour, while the secondary outcome was preparatory actions or worse (also called suicidal behaviour).

 

What were the results of the study?

Following exclusions, 372 trials were included in the review, with a total of 99,231 participants. Of these, 295 trials had used antidepressants for psychiatric indications, while the other 77 trials had looked at their use for non-psychiatric reasons. Most of the studies were unpublished and had not been included in previous reviews of antidepressant trials.

The average (mean) age of participants was 43.1 years, 63.1% were female and 86.9% were white. The trials investigated selective serotonin reuptake inhibitors (SSRIs, eight different drugs), tricyclics (five different drugs) and other antidepressants (five different drugs).

Across the trials there were reportedly eight completed suicides, 134 suicide attempts, 10 reports of preparations without attempted suicide and 378 reported suicidal ideation alone, without action.

The researchers first carried out an analysis by medical indication. This showed that suicidality rates were higher in those treated for major depression (341 reports of suicidality) compared to other depressive disorders (22 reports), psychiatric disorders (148 reports) and non-psychiatric behavioural disorders (nine reports).

When the researchers carried out an analysis of suicidality by age group they found a non-significant increased risk of suicidality (either ideation or actual behaviour) in those under the age of 25 (OR 1.62, 95% CI 0.97 to 2.71). However, when they looked at the subcategory of suicidal behaviour alone, the increase in risk for those under 25 became significant (OR 2.30, 95% CI 1.04 to 5.09).

There was a trend for a decreased risk of suicidality in all age groups above the age of 25, but the association was non-significant for the majority of age brackets. When age brackets were combined (25 to 64 year olds), antidepressants had a decreased risk of ideation (OR 0.79, 95% CI 0.64 to 0.98) but had no effect on actual suicidal behaviour. For those aged 65 years and over, antidepressants reduced both ideation (OR 0.37, 95% CI 0.18 to 0.76) and behaviour (0.06, 95% CI 0.01 to 0.58).

When the researchers looked at individual antidepressant drugs, most associations with suicidality were not significant (neither increased nor decreased risk). Across all age groups, the only significant observations were a decreased risk of suicidality with the SSRIs fluoxetine and sertraline.

Combining all age groups, active treatment for psychiatric disorders with any antidepressant drug decreased suicidality with only borderline significance (OR 0.83, 95% CI 0.69 to 1.00). This result was calculated from a total of 314 suicidal events in 50,043 people treated with an active drug compared to 197 suicidal events in 27,164 treated with placebo (rate 0.63% versus 0.73%). However, in the under-25 group there were 64 events in 4,780 people treated with an active drug compared to 21 events in 2,621 treated with placebo (1.3% versus 0.80%).

When the researchers modelled age as a continuous variable, they observed that the risk of suicidality associated with taking antidepressants decreased at a rate of 2.6% per year of age, and actual suicidal behaviour by 4.6% per year of age.

 

What interpretations did the researchers draw from these results?

The researchers conclude that risk of suicidality associated with antidepressants is strongly age dependent. There is an increased risk for suicidality and suicidal behaviour in adults under 25 treated with active treatment compared to placebo.

They say that antidepressants seem to protect against suicidal ideation in adults aged between 25 and 64, but have no effect on suicidal behaviour, and they reduce the risk of both suicidality and suicidal behaviour in those aged 65 or over.

 

What does the NHS Knowledge Service make of this study?

This reliable and extensive research found an overall trend for any antidepressant treatment to reduce the risk of suicidality in people aged 25 years or above.

In the under 25s, however, there was a non-significant increased risk of suicidal thoughts or behaviour (preparatory actions for suicide or attempted or completed suicide) with antidepressant treatment. When limited to suicidal behaviour alone this increased risk became significant.

These findings are likely to lead to further research and may lead to changes in drug regulatory information. The research highlights the need for warnings on medications and prescribing guides to alert practitioners to the potential for increased suicidality risk among this young age group.

As the authors say, the possibility of separate therapeutic and adverse effects from antidepressant drugs on suicidal thoughts or behaviour requires further investigation, particularly in terms of possible mechanisms for age-related differences.

A few points to note:

  • The review included any suicidal events that were reported during the treatment phase of trials. However, it is difficult to determine whether this behaviour represented a change in condition or reflected the pre-treatment condition. Suicidal thoughts may have been present before the person commenced treatment and persisted unchanged with treatment, rather than being new onset suicidal thoughts in a person who did not have any prior to treatment.
  • The data were obtained from drug development programmes by drug sponsors. Most of the trials were unpublished. These unpublished trials are valuable as they are unlikely to have been included in previous reviews; however, their methods are not available for critique and as such it is not possible to comment on the quality of these trials.
  • The trial setting may also only provide information from a select population group. As the researchers say, people with severe depression which clearly warranted treatment are unlikely to have been entered into a randomised trial where they could have been allocated to inactive placebo.
  • In general, the trials were relatively short and treatment was given for weeks rather than months or years. Longer term trials may have given different results.
  • Individual trials may have reported adverse events differently. In particular, the reported rate of suicidality may be an underestimate of the true number of suicidal thoughts, as the rate at which people reported these thoughts to researchers may have varied between trials.

Links to the headlines




Links to the science


 

Further reading

Hetrick SE, Merry SN, McKenzie J, Sindahl P, Proctor M. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 2007, Issue 3

Hazell P, O'Connell D, Heathcote D, Henry DA. Tricyclic drugs for depression in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 2

Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, Kerse N, MacGillivray S. Antidepressants versus placebo for depression in primary care. Cochrane Database of Systematic Reviews 2009, Issue 3