Help your teenager

There’s a learning curve to antidepressants

There’s a learning curve to managing antidepressants in your teenager’s life. Things I hadn’t considered until I was faced with them.

And almost as soon as I got my head around it, I found a brand new suitcase of emotional baggage to unpack, along with some unexpected practical challenges.

For what it’s worth, here are some of the potholes I encountered on the road to success with antidepressants.

The Hilarious World of Depression Pill Box, free with a donation to The Hilarious World of Depression
I received this handy pill box when I donated to The Hilarious World of Depression. My daughter loved it and uses it for overnights.

The anxiety of conflicting information

Google “antidepressants for teenagers” and you’ll find articles and studies that say that antidepressants like Fluoxetine (Prozac) or Paroxetine (Paxil) can help in treating depression and anxiety in teenagers.

You’ll also find the exact opposite. There are studies that show these selective serotonin re-uptake inhibitors (SSRIs) are not only ineffective, but that they have been associated with the worsening of depression and increased risk of suicidal behaviour and ideation in kids and teens.

According to this article on Medscape (note: signup required to read, but it’s free), Paroxetine was not the only antidepressant to show such effects. The authors write:

“Although some studies demonstrated efficacy of Sertraline (Zoloft) and Citalopram (Celexa) for the treatment of depression in young people, the majority showed no benefit over placebo. Furthermore, elevated risk of suicidal ideation and other potentially related adverse effects (e.g., mania, hypomania, agitation and aggression) have been reported in pediatric trials involving Sertraline, Citalopram and Fluvoxamine (Luvox).”

Antidepressant use in Canada

To make matters worse, I learned that Canadians have a penchant for antidepressants. We are among the world’s top users, according to the OECD.

In this Walrus Magazine article, I learned that antidepressant use amongst children under the age of 18 in Canada jumped 63% between 2010 and 2013.

Most frightening was this statement made by Dr. Allen Francis at Duke University in the National Post: “Having saturated the adult market, Pharma has turned its attention to aggressively marketing pills for children, who are, in some ways, their perfect customers—because once pill solutions become the norm, the kid may become a customer for life.”

With our first prescription in hand (for Zoloft), I found myself right back where I’d started: unsure if my daughter should take antidepressants, doubtful they would help, and scared to death of the long-term effects and the short-term risks.

To manage my guilt and fear, and to break my paralysis, the only solution I could see was to focus my thoughts on supporting the person versus the treatment. My daughter was suffering and she wanted medication. I could oppose her or support her. The choice, in those terms, was simple.

It can take weeks or months or years for antidepressants to work

Doctors say antidepressants should start working in 4-6 weeks, but that it could take 8-12 weeks before the patient realizes the full benefits.

Because of the risks of antidepressants in teenagers, this process often takes even longer. Doctors will prescribe a small dose—too small to produce any positive results—and monitor side effects before upping the dose.

Still, at the outside, I thought that with medication and continued therapy, we’d been in the clear after three to four months of treatment. I was wrong.

My daughter, it turned out, is treatment resistant, meaning she didn’t have an “adequate response” to two or more treatment options. She’s not unusual. Apparently thirty percent of patients are treatment resistant.

The medical response, at least in my personal experience, is to try again. Different drugs, different dosages, different combinations.

Each new pill or dose requires adjustment

We quickly learned that every new pill required an adjustment period.

Some made her dizzy, enough that she couldn’t go to school. Others sleepy. One still makes her sick to her stomach in the middle of the night if she doesn’t eat dinner–a problem easily remedied in normal circumstances, but challenging when your teenager is clinically depressed. Another, we discovered only after she admitted to not taking it, didn’t fit with her routine.

Most frustrating, some worked for a while and then suddenly stopped working. And while all of them helped take the edge off her illness, none helped her shake the feeling that she wanted to die. Our psychiatrist was confident we could do better.

We don’t know a lot about how antidepressants work

I wasn’t so sure, because when I asked her why one drug could work for a few months and then suddenly stop working, she just shrugged. They don’t know, she said. It happens.

When I asked if a teenager’s developing brain might have an impact, she didn’t know that either. Studies haven’t been conclusive.

When I asked if there was a brain scan we could take or a blood test that might help us better target her physiology, she said tests were still in development and not readily available for teenagers.

But don’t lose hope, she said. There are plenty of other drugs we could try.

Dr. Madhukar Trivedi, a lead researcher at UT Southwestern Medical Centre for Depression Research and Clinical Care, summed up the trial and error approach this statement: “Our selection of depression medications is no more superior than flipping a coin.”

He also said one third of patients don’t improve during their first round of medication. Forty percent of patients stop taking medication within the first three months of treatment because they give up. They lose hope it will work.

I get that. It wasn’t hope that kept my daughter trying one pill after another, it was a will of steel. An unusual character trait in depressed people, I think.

And three months into a new combo, a full three years after we started the trial and error process, we hit the jackpot.

Her symptoms dissipated. She’s been symptom-free for five months now and says she’s “happy”. And she is. She’s like a new person. And I’m cautiously optimistic.

The end of trial and error?

I’m also hugely encouraged by the fact that researchers like Trivedi are moving beyond trial and error. 

In 2017, Science Daily reported Trivedi and his research team had a breakthrough. They were able to prescribe a medication that was more likely to work based on the results of a finger-prick blood test.

The key was the level of the c-reactive protein (CRP), a marker of inflammation. Less than 1 milligram CRP per litre: try Escitolopram (Cipralex). More, try Escitolopram and Bupropion (Wellbutrin)

A genetic test called GeneSight, which analyses an individual’s genes and recommends medication and dosage levels, is also looking promising.

From a simple cheek swap, the test can identify genetic variants that influence how that patient will respond to 33 different types of medication. Green indicates medications most likely to work. Yellow suggests use with caution, and red says use with more caution and more frequent monitoring.

In an IMPACT (Individualized Medicine: Pharmacogenetic Assement and Clinical Treatment) study at CAMH in Toronto, Dr. James Kennedy reports he’s tried the test on more than 11,000 patients and the results have been encouraging. His findings: “it gets the patient better faster.”

Provincial health care plans do not yet cover the $1500 test. In Ontario, Health Quality Ontario, the provincial advisor on health care quality, concluded that patients who had the test responded better to treatment and their mood improved, but “GeneSight care did not lead to better rates of complete relief of depressive symptoms.”

I can’t help but think who the hell cares when the alternative is a guessing game?

Perhaps corporate Canada will move faster than governments. In August 2017, Sun Life Canada Financial stepped up to partner with IMPACT. People on a mental health-related disability claim, who are taking medication and covered by Sun Life, could participate in the study.

Sun Life, it should also be noted, in 2016, raised their coverage for psychology benefits from $1200 to $12,000 per person annually. Go Sun Life!

Label fear

I’ve read that a mental health diagnosis often brings relief. In giving the problem a name, we can begin to make sense of it, and give abstract feelings that are hard to describe a vocabulary. 

I think the opposite can be said for antidepressants. Unless you’re professionally trained, antidepressants are a mystery and labels are just plain scary.

Take this definition of Quetiapine (Seroquel) from RXList, for instance:

“Quetiapine is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). It is also used with other medications to treat depression. Quetiapine is known as an anti-psychotic drug (atypical type).”

If by naming a disease we can begin to pinpoint potential treatment options, can the opposite be said? If a particular drug at a particular dosage seems to work, is the problem something else altogether?

In addition, there are the reported side effects to contend with: nausea, weight gain, loss of sexual desire, fatigue, insomnia, dry mouth, constipation, and blurred vision.

The added worry of side effects

As a parent, these side effects create a whole set of new worries. Will the drugs cause additional complications for kids who may also be having problems at school, social problems, a difficult relationship with food, or self-esteem issues? Depression, after all, rarely travels alone.

Add to that, the Health Canada and Food and Drug Administration (FDA) advisories that warn about a risk of increased suicidal thinking and behavior in some individuals under the age of 25.

Parents are advised to watch for talk of suicide or dying, attempts to commit suicide, self-injury, agitation, new or worsening panic attacks, aggression and more.

If your teenager is already exhibiting many of these signs, it’s hard to tell if the medication is making things better or worse.

It’s a lot to take on. My advice? Focus on separating facts from fears. Deal with each problem as it comes up and try not to jump ahead into the what ifs.

Remind yourself that the warnings are there as a precaution, but don’t be afraid to speak up or sound the alarm if your gut tells you something’s off. Remember, the doctors are running blind here, too. You know your child better than they do. Your observations are valid and important.

Also, keep a journal to track of time and events and take it with you to appointments. I didn’t know to do this. I wish I had.

Incorporating antidepressants in daily life

I have no idea why, but it never occurred to me to ask our doctor what to do with the bottle of pills when we got home.

Similarly, while the pharmacist walked me through the risks, he, too, failed to give us any advice beyond “one pill every evening on a full stomach, and watch for side effects.”

If my child were a child, it would have been obvious. But my daughter was a teenager, fiercely independent and exceedingly responsible. She was also severely depressed. Giving her a bottle of pills didn’t seem prudent.

We decided to keep the medication in our room. This meant my daughter had to ask us for her pill before she went to sleep each night. It was a horrible way to end the day.

My husband and I, eager for the medication to start working and on high alert for an adverse reaction, couldn’t seem to help ourselves from asking how she was feeling.

She, thirteen years old and furious we didn’t trust her, would snap, “Depressed!” and storm out. Some nights we just got a withering look.

After several weeks, we gave in and handed over the bottle. It wasn’t enough medication to cause a fatal overdose—I Googled—and it wasn’t worth the strain it was putting on our relationship.

Was it the right decision? I have no idea. All I can say is that it seemed right for us at the time.

Tips for managing daily life with antidepressants

Since then, I’ve learned these tips from other, smarter parents to avoid some of the stress we experienced in handling medication:

  • Consider your teen’s health–are they well enough to manage medication on their own? Will they remember to take it? Do they want to take it? If you have any doubts, consider taking a more active role
  • Use a seven day pill box and refill weekly if you’re concerned about misuse, but not about their ability to remember their medication
  • Set an alert in your own phone every time you pick up a new prescription to remind you of the next refill
  • Alternatively, set aside a week’s worth of meds so that you have backup when your teen runs out and forgets to tell you they’re running low—believe me, it will happen
  • If your teen has a second home they visit often, keep a stash there in case they forget to bring their medication

Beyond the daily management, until you find a medicatiton that works, you might also want to plan ahead for special events like exams or summer holidays.

After the initial ramp up, my daughter typically needed a couple weeks to adjust to new medication. To minimize risks and the impact on her life and school work, we tried to make any changes before big events.

Our other big challenge was summer holidays. My daughter spends her summers at camp on lengthy canoe trips in remote areas. She feels happiest there, and for several years she’d say it was the only thing in life that kept her alive.

However, it meant sending her off with a stockpile of medication and hopes they didn’t get abused or left behind at a camp site. It also meant sharing with the camp what was until then was a family secret, and trusting kids, not much older than herself, to support her if necessary.

The good news, if you can call it that, is that the camp had experience dealing with kids with depression and on antidepressants. It was routine for them. Same for her schools.

Antidepressants and drugs and alcohol

Willfully supplying your child with mood-altering pharmaceuticals, I also learned, complicates parent-child discussions about drugs and alcohol. Legalized pot in Canada just adds to the fire.

Thankfully, substance abuse hasn’t been a huge issue with my daughter. I realize how lucky I am.

According to Addiction Centre in the U.S, drug abuse and depression and anxiety are commonly found together in teens. They report, dual diagnosis occurs in more than half of all teens who abuse drugs.

The Canadian Centre on Substance Abuse reports that young people ages 15-24 were more likely to report mental health and substance use or abuse more than any other age group. Further, it reports between 20 and 30% of young people who abused drugs have been diagnosed with clinical depression.

It’s not hard to see why teens develop what they call concurrent disorders, mental health problems and substance abuse. Depression or anxiety may lead to self-medication to obscure bad feelings. Substance abuse may lead to distress, which contributes to the onset of mental health patients. 

Still, I wasn’t prepared for my daughter’s argument that if weed or alcohol allows her to have a rare moment of fun in her life, wasn’t that better than feeling like she wanted to die all the time?

It was a tough question to answer. Particularly as both my husband and I drink. More than the recommended amount. We were also teenagers once and not very well behaved.

What’s riskier–staying in or going out?

Like most teenagers, drugs and alcohol are very much a part of her social scene. Canadian Drug Crisis reports 42% of Ontario students surveyed have used an illicit substance in the last year. Forty-nine percent of grade twelve students report binge drinking. The average age drug use begins is 15.7 years old.

My daughter’s amazing in a thousand different ways, but she’s not immune to these influences. As depression wants her to stay in bed in a dark room contemplating death, I also think it’s good for her to go out and be a teenager.

As a result, I’ve picked her up from parties, more than once, trying not to laugh or cry as she drunkenly hung her head out the window and apologized profusely for being a disappointment.

While I warn her frequently about the complications of consuming drugs and alcohol with her illness and medication, I’m acutely aware that I’m not in control of the situation. And that my daughter, because she has a mental illness, is at increased risk.

Right now, I’m focused on two things: keeping the lines of communication open and curbing my own bad habits.

To mitigate risks, we have a standing rule—she can call us at any time, under any circumstances, if she needs help. We’ll pick her up, no questions asked and no judgements. I’ll even put aspirin and a big bottle of water on her bedside table.

We will, however, have a discussion the next morning. Which, I must admit is incredibly satisfying as my daughter, hungover and contrite, feels like she at the very least owes it to me to listen.

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