Medicalization of Childhood Depression ?
Q.Increasing numbers of children are being treated for depression. At the end of 2003, over 50 000 children were prescribed antidepressants, and over 170 000 prescriptions a year for antidepressants were issued to people under 18 years old in the United Kingdom.1 Recent evidence has suggested that selective serotonin reuptake inhibitors are largely ineffective and may be dangerous in this age group.2 3 Older antidepressants have already been shown to have no beneficial effect in people under 18.4 So how did we get into this mess? Undoubtedly part of the problem is with pharmaceutical industry tactics, designed to enable greater consumption of their products.3 However, the gateway diagnosis to prescribing antidepressants to under 18s is that of childhood depression. In this article I discuss the notion of childhood depression and suggest that the medicalisation of children's unhappiness is hindering our ability to respond effectively to this problem.
A.The new child centred permissive culture was a godsend to consumer capitalism. Childhood could now be commercialised, and an industry of consumer goods for children developed.8 As a result, children have gained access to the world of adult information and entertainment. The boundaries between what is considered adulthood and what is considered childhood have become blurred, and this has led to children coming to be viewed as, in effect, miniature adults.9 One effect of these changing expectations of childhood and parenting is that more childhood behaviours previously considered normal are now seen as problematic, and problematic behaviours are more likely to be medicalised.10 Just as our concepts of childhood have changed, so have our concepts of childhood problems. It was only in the late 1980s that our understanding of childhood depression began a far reaching transformation. Before this, childhood depression was viewed as very rare, different from adult depression, and not amenable to treatment with antidepressants.11 A shift in theory, and consequently practice, then took place as influential academics claimed that childhood depression was more common than previously thought (8-20% of children and adolescents), resembled adult depression, and was amenable to treatment with antidepressants (often resulting in antidepressants becoming a first line treatment3).4 12 Childhood depression has become a popular notion, reflecting the broader cultural changes that have taken place in our view of childhood and its problems. These days we are as likely to use medicalised terminology to describe children's feelings (such as depressed) as we are less pathological descriptions (such as unhappy). According to the current criteria, psychiatric comorbidity in childhood depression is so high that nearly every child can be diagnosed with at least one other psychiatric condition.4 This raises doubts over the specificity of the construct. Despite awareness of the continuity between normal sadness and clinical depression, the diagnosis assumes that clinical depression exists as a category (rather than on a continuum). It is unclear, however, who decides where the cut-off mark is, and on what basis. Furthermore, the categorical diagnosis bears only a tenuous relation with levels of psychosocial impairment. Many children below the threshold of diagnosis show higher levels of impairment than those above the threshold.13 Similarly, a diagnosis of childhood depression is only weakly associated with suicide (stronger predictors include history of aggression and use of drugs or alcohol).14 The biological markers (such as cortisol hypersecretion) that are sometimes found in adults diagnosed with depression do not work with children and adolescents diagnosed as depressed.4 With regard to genetics, separating environmental from biological factors in the familial clustering has been virtually impossible, particularly as children whose parents have depression are at risk of developing a wide range of psychiatric disorders.14 Childhood depression has been argued to be a precursor of adulthood depression.15 However, follow up studies of children deemed to have had "major depressive disorders" have used dubious standards for diagnosing childhood and adult psychiatric disorders, have discovered high rates of comorbidity (in childhood and adulthood), have been unable to differentiate biological factors from continuing social adversity,15 16 and have not taken into account the possible effects of any treatment received (such as continuing morbidity as a result of toxic side effects of drug treatment and the experience of psychosocial adversity and decreased self worth arising from becoming a psychiatric patient).
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