“Old and new antidepressants must not be administered to patients less than 18 years of age because of the potential risk of suicide”.
—New Zealand Medicines Adverse Reactions Committee, 2004
Over the last few days of 2021, I spent time reflecting personally on the past year. I reflected on the fact that I had finally completed and had published the book Running on Empty: Antidepressants and Youth Suicide – A New Zealand Review. The book had been a ‘work in progress’ since 2014. I also reflected on key points of the book that looked at the impact antidepressants had on young people over the past two decades.
In New Zealand, the prescribing of psychotropic medication to adults, adolescents, and children has increased significantly since the start of the new millennium, and by 2018 over 800,000 people (one in five people) were prescribed a psychotropic medication.
This represents a 87.35% increase in the prescription of psychotropic medication over the past five years, up from 427,900 people in June 2013, which was up 20% from 2008 when 348,000 people were prescribed a psychotropic medication.
Furthermore, when it comes to antidepressant prescriptions to children and adolescents, five out of the six most commonly prescribed antidepressants have not been recommended for use in young people under 18 years of age by Medsafe (the New Zealand Medicines and Medical Devices Safety Authority).
The prescribing of off-label drugs involves prescribing medications for an indication or using a dosage from that has not been approved by regulating authorities. While the practice is now quite common, off-label prescribing is outside what the drugs were designed for, is unregulated and outside the safety parameters established.
In his book Over-Prescribing Madness: What’s Driving Australia’s Mental Illness Epidemic, Dr Martin Whitely refers to a 2019 Lancet editorial on the now common practice of GPs prescribing off-label medications to children.
“Children are not small adults and evidence-based treatments are arguably more important in children. Both the potential for adverse events with lifelong consequences and the danger of ineffective drugs with poor outcomes have far-reaching consequences,” the Lancet editors write.
Therefore, the question that needs to be asked is: How effective has the prescription of these medications been in reducing the incidence of suicidal ideation, anxiety, and depression in children and adolescents?
A Snapshot of the Prescription of Antidepressant Medication to NZ Children and Youth (2000-2020)
In 2002, young New Zealanders had a higher crime and suicide rate than their peers in America, declining achievement in school through an increase in learning and anxiety disorders, and significant increases in the prescription of antidepressant drugs.
- Between 2007 and 2016, prescriptions of antidepressants to young people under 25 increased by around 44% and rates of suicide increased by 266% for those 9-14 years old and by 34% for those 15-24 years old.
- In 2017 there were approximately 15,000 young New Zealanders under the age of 18 taking antidepressants, a 98% increase in the past decade.
- Between 2013 and 2018/19, there was a 24.2% increase in the number of children (2-14 years old) diagnosed with some psychological disorder. Within this group there was a 35.7% increase in emotional and behavioural problems. The largest increase (94.7%) had occurred in children being diagnosed with anxiety.
- The Youth 19 Rangitahi Smart Survey released in August 2020 interviewed 7891 secondary school students in Auckland Northland and the Waikato.
Key findings of the survey revealed that:
- 6% of the participants revealed that they had attempted suicide in the past twelve months.
- The proportion of young people with depression has increased markedly from 12% in 2012 to 23% in 2019.
To put this data into some sort of context: Over the past two decades all the key indicators that measure optimal health and wellbeing in young people were trending downwards and, furthermore, research indicated that antidepressants, to some degree, were a recurring factor in this downward spiral.
Key points from the accumulated data revealed:
- The increase in the prescription of antidepressants to youth (2007-2016), ran parallel to an increase in the incidence of suicide within this cohort.
- A gradual decline in academic achievement in core school subjects such as English, maths and science.
- An increase in violence and bullying in school settings amongst school children and increasing number of attacks by students on teaching staff.
- An increase in anxiety, depression and a surge in teen self-harm.
- An increase in child obesity.
There well maybe a number of factors that need to be taken into account regarding the decline in academic achievement and increases in suicide, self-harm, violence and obesity amongst children and adolescents.
However, it appears that the FDA Black Box suicidality warning is justified. Studies have identified a correlation between the incidence of suicide and suicide ideation and the prescription of antidepressants, particularly in children and adolescents. Two recent studies have shown that antidepressants may alter brain structure and can cause neurotoxic effects on the developing brain which could result in the increase in learning difficulties in children and adolescents. Furthermore, a Swedish Study in 2015 identified that antidepressants are a factor in the incidence of anti-social behaviour in youth. Studies in 2014 and 2018 clearly show a correlation between antidepressants and weight gain.
Furthermore, there appears to be limited evidence relating to the benefits of prescribing psychotropic medication to children and adolescents diagnosed with depression and anxiety. Prior to advent of the selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressant medications did not outperform placebo in nine small RCTs for youth depression. In more recent times, studies of antidepressants used on children and adolescents have shown that little has changed regarding the efficacy and benefits of these medications.
It appears, therefore, that the prescription of antidepressants to young people is a well-worn track which has provided little evidence of any long-term benefits and significant evidence of life-threatening adverse events (suicidal ideation) and anti-social behaviours. Metaphorically, the practice can be summed up as ‘playing leapfrog with a unicorn’. The practice is very risky, and the consequences are painful and have long term implications for a country’s society and economic outlook.
For example, the cost of mental health in New Zealand youth (0-25 years) via lost GDP, service provision, and loss of life through suicide is very high. In 2010 this cost had been estimated to be around $1.5 billion, and that figure is likely to have blown out to over $3 billion currently. In 2018, the annual cost of serious mental illness including addiction in New Zealand (which continues to escalate year in year out) amounted to an estimated $12 billion or 5% of the gross domestic product.
So, What Can Be Done?
While the wheels of government turn slowly, in the past few years there has been an acknowledgement from government that change is needed, and in 2018 the Labour Coalition Government released a report called the Report of Government Inquiry into Mental Health and Addiction.
Two of the key points of this report were:
“If our treatments work, shouldn’t we have fewer people presenting in crisis, [fewer] people on a disability benefit due to mental illness, a reduction in community measures of psychological distress and a decrease in the suicide rate? Despite access to costly biomedical treatment, something central to recovery appears to be missing in the social fabric of developed countries.”
“New Zealand needs to stop talking about the needs for a continuum of services to address people in need and make action a priority – furthermore people want a choice of therapies with a range of practitioners.”
The Labour-led Coalition’s response to the report was a new Suicide Prevention Strategy (2019-2029) and Suicide Prevention Action Plan (2019-2024) called Every Life Matters – He Tapu te Oranga o ia tangata, which was released on September 10th 2019.
In addition, in the 2019 budget the government allocated NZ$1.1 billion for operational spending on mental health initiatives over the next five years and, over the past 18 months, has established a Suicide Prevention Office and a Health and Wellbeing Commission.
While these actions showed a commitment by the Labour Government to bring about change, in more recent times there have been concerns over the pace of change at a grassroots level.
In an investigative probe, it was reported that a routine report on the Government’s mental health services was delayed for over a year as officials battled behind the scenes over plans to dramatically reduce the amount of data in it.
In summary, the report that was released in early April 2021, still showed a very distressing picture of the New Zealand’s mental health system with a spike in seclusion which is generally accepted as a very distressing practice for patients, and to which the Health Quality and Safety Commission launched a project to the end the practice in 2017, after a scathing condemnation of New Zealand from the United Nations Committee Against Torture.
Furthermore, it was revealed after an Official Information Act Request, many indicators such as – wait time lists, suicide statistics and data on people using mental health service – had been removed from the Ministry of Health report.
While the Ministry of Health said it was just upgrading the formatting of the report and had nothing to hide, Shaun Robertson, CEO of the Mental Health Foundation said it was “gob smacking “and “not acceptable” that so much information had been removed from the “scathing” report.
The Way Forward – An Optimistic Outlook
New Zealand has a tradition and reputation for punching above its weight in a number of fields – sport and technology are two areas that immediately come to mind.
At a grass roots level throughout the country, there are innovative programmes that have existed for some time or are emerging to meet the needs of young people who are experiencing levels of depression and anxiety.
The NZ Children’s Art House Foundation has been offering art therapy to a diverse range of children to help them overcome a number of social barriers since the early ‘90s.) More recently programmes designed by Māori to meet the needs of Māori youth have been established.
In 2017, there were a total of 17 (youth based) Rangatahi Suicide Prevention Programmes throughout the country, which had increased to over 25 programmes by 2021. The innovative content of these programmes are based around creative arts, such as the use of music and spoken poetry (to encourage creative expression and cultural identity), outdoor recreational activities such as camping, snorkelling, and surfing, physical exercise (to encourage confidence and connectedness, leadership and teamwork, communication and decision making), and emotional literacy training (to enable young people to understand their emotions). One of the key learnings from these programmes is that the best outcomes are obtained when young people are facilitating the personal development being offered.
These are strategies that all young people, regardless of race and culture, could benefit from.
The 4 M’s: Micronutrients – Mentoring – Meditation – Massage
When reviewing a choice of therapies, evidence-based research clearly shows that holistic alternative treatments/practices that incorporate the use of nutrition in mental health, mentoring, mindfulness-in-the-curriculum and massage therapy could be implemented quite seamlessly into health and wellbeing services as safe and effective ways of treating anxiety and depression in New Zealand youth. These services would incorporate new roles in their human resources such as nutritionists, naturopaths, and massage therapists to maintain optimal health and wellbeing; arts and music therapists to encourage creativity, and mentors/coaches to support young people deal with challenges in their everyday lives.
While there is reason for optimism, there is also cause for concern.
In 2019, the United Nations Agency UNICEF stated that there was an urgent need to review aspects of New Zealand’s health and wellbeing practices for children and young people.
UNICEF was scathing in its report card, New Zealand is failing its children, which reviewed indicators of health and wellbeing for young people. The agency called for significant investment and policy change to address ‘deeply embedded and terrifying childhood trends’ around suicide, obesity, and declining proficiency in reading and maths.
The report card gave New Zealand an F for failure when it came to wellbeing outcomes for children.
“This is a woeful result for a country that prides itself on the great outdoors, academic achievement and the international success of our sports teams. It is time to be alarmed and activated about the inequality of opportunity, health and wellbeing in NZ,” the UNICEF NZ Executive Director Vivien Maidaborn said.
To wrap up: The findings outlined emphasise the need for health professionals to continually educate themselves about the treatments and medications they offer, taking time to assess the risks and benefits, in order to make informed decisions that provide the best possible care and outcomes for their patients. As a society we should expect nothing less from our health system and be quick to question medical authorities when this is not happening.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.