As a family physician, I have come to find that helping people with anxiety and depression is as important as anything else we do. If you’re not feeling well physically, you often will not feel well emotionally. Conversely, if you’re not feeling well emotionally, you are less likely to feel well physically. To be a good primary care provider, I feel it is pertinent and prudent to gain as much experience in the field of psychiatry as possible.
However, this is not just true with regard to taking care of adults, but is also relevant to the care of children and adolescents. Unfortunately, the limited access to psychiatry for adults and children is a barrier to care. This is more so the case for child psychiatry. Given the limitation of access to child and adolescent psychiatrists, family physicians and pediatricians have found themselves prescribing and monitoring psychiatric medication when they might not have been as comfortable doing so in the past. However, 10 years ago, the FDA initiated a black box warning on antidepressants for use in children, adolescents, and young adults. This was due to a statistically significant increase in suicidal ideation in patients treated for depression, particularly in the first few weeks of initiating treatment. However, the studies did not show an increase in actual suicide attempts. Standards of care for prescribing changed in response to this finding, including the recommendation for more frequent visits in the first month for patients initiating medical treatment.
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Whereas the black box warning was initiated to help reduce the risk of suicide, the rate of adolescent suicide has actually increased over the last 10 years since the warning was published. This may correlate with the decrease in prescribing of antidepressants as well as patient and family reluctance to initiate medications for anxiety and depression. It appears that since the black box warning was published, child psychiatrists have not necessarily been more reluctant to prescribe antidepressants; however, there does seem to be a decrease in prescribing by pediatricians and family physicians for children.
The data seem to indicate that the stigma of the black box, as it is perceived by physicians and parents, has impaired the effective treatment of childhood depression and has possibly led to an increased incidence of suicide. This raises the question of whether it may be time to revisit and possibly even lift the black box warning 10 years after its initiation. Certainly, improved education for primary care providers in the use of antidepressants is warranted, as well as careful education of patients and their families regarding the benefits and potential risks of taking psychiatric medication. They should know what to expect in terms of side effects, how long they may wait until symptom reduction is experienced, what support will be helpful in the interim, and when to contact their providers. Depression itself increases the risk of morbidity and mortality, but it is a treatable condition, and it needs to be treated properly.
