Correspondence
Fluvoxamine for the Treatment of Anxiety Disorders in Children and Adolescents
N Engl J Med 2001; 345:466-467August 9, 2001
- Article
To the Editor:
It is with concern that I read the article by the Research Unit on Pediatric Psychopharmacology Anxiety Study Group (April 26 issue)1 promoting the treatment of young children with potent psychotropic drugs, adding to the several million American children who are already taking such medications. The Surgeon General's 1999 report on mental health, which states that “approximately one in five children and adolescents experiences the signs and symptoms of a DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised] disorder during the course of a year,”2 emphasizes that we have increasingly relabeled troublesome behavior and emotional distress in children as mental illness, which can and should be treated with drugs. The large number of researchers making these claims cannot offer any evidence that psychopharmacologic treatments do not affect the developing brains of young children, over the short or long term.
What is more troubling about this study, however, is that it originates from departments of child psychiatry that attribute the difficulties of childhood to the defective genes or neurologic systems of the children themselves and that do not deal with questions of poor schools, stress on families, or other environmental factors. Although small numbers of severely disturbed children may need drug treatment, we are pacifying millions of our children to avoid dealing with larger social issues.
2 ReferencesEileen Isaacs, M.D.
385 Palisade Ave., Yonkers, NY 10703
eisaacs@pol.net 1
The Research Unit on Pediatric Psychopharmacology Anxiety Study Group
Full Text | Web of Science | Medline2
Mental health: a report of the Surgeon General. Rockville, Md.: Public Health Service, 1999.
Author/Editor Response
The authors reply:
To the Editor: Dr. Isaacs suggests that our study promotes the use of psychotropic drugs, psychiatrists inappropriately label some forms of behavior as mental disorders to be treated with drugs, these drugs might harm the developing brain, and our departments misattribute children's difficulties to genetic or neurologic factors and neglect social and environmental factors.
First, our study was designed to test the safety and efficacy of a potentially useful treatment, not to promote the treatment. Second, it is essential to differentiate normal behavior from symptoms of mental disorders. Anxiety is a normal part of childhood; anxiety disorders are not. Anxiety disorders involve persistent irrational fears that cause marked distress and limitations in functioning, and they impair children's well-being, often to the same degree as other serious conditions such as asthma.1,2 Moreover, children with anxiety disorders have a high risk of long-term impairment.3 The children in our study had severe anxiety, which had resulted in social isolation and absence from school. It is crucial to recognize the pain experienced by children with anxiety disorders, given that in the past the impact of major mental disorders has been trivialized. Our study demonstrated that drugs represent one efficacious treatment for these children. Discouraging such studies limits our ability to provide children with effective treatment.
Third, no harmful neurologic effects of selective serotonin-reuptake inhibitors have emerged in research on their use in children, but studies examining this issue have just begun. Although studies in animals suggest that these drugs may affect brain development, other studies suggest that the developing brain may have increased sensitivity to stress, which accompanies anxiety disorders.4 By not considering the potential effect of anxiety disorders on brain development, Dr. Isaacs ignores the possibility that withholding appropriate treatment may carry its own risks.
Finally, Dr. Isaacs misrepresents our views concerning the causes of anxiety disorders. Anxiety disorders in children have many causes and cannot be attributed to purely genetic, neurobiologic, social, or other environmental factors. Although the ultimate causes remain incompletely understood, consensus has emerged that social and emotional factors and neurobiologic factors have key roles in the pathogenesis of these disorders.1,5
5 ReferencesDaniel S. Pine, M.D.
National Institute of Mental Health, Bethesda, MD 20892
daniel.pine@nih. gov John T. Walkup, M.D.
Johns Hopkins University, Baltimore, MD 21287Laurence Greenhill, M.D.
Columbia University, New York, NY 10032for the Research Unit on Pediatric Psychopharmacology Anxiety Study Group
1
Klein RG, Pine DS. Anxiety disorders. In: Rutter M, Taylor E, Hersov L, eds. Child and adolescent psychiatry: modern approaches. 4th ed. London: Blackwell Scientific (in press).
2
Ialongo N ,Edelsohn G ,Werthamer-Larsson L ,Crockett L ,Kellam S . The significance of self-reported anxious symptoms in first grade children: prediction to anxious symptoms and adaptive functioning in fifth grade. J Child Psychol Psychiatry 1995;36:427-437
CrossRef | Web of Science | Medline3
Pine DS ,Cohen P ,Gurley D ,Brook J ,Ma Y . The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998;55:56-64
CrossRef | Web of Science | Medline4
Francis DD ,Caldji C ,Champagne F ,Plotsky PM ,Meaney MJ . The role of corticotropin-releasing factor-norepinephrine systems in mediating the effects of early experience on the development of behavioral and endocrine responses to stress. Biol Psychiatry 1999;46:1153-1166
CrossRef | Web of Science | Medline5
Merikangas KR ,Avenevoli S ,Dierker L ,Grillon C . Vulnerability factors among children at risk for anxiety disorders. Biol Psychiatry 1999;46:1523-1535
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Michael P. Milham, Allison C. Nugent, Wayne C. Drevets, Daniel S. Dickstein, Ellen Leibenluft, Monique Ernst, Dennis Charney, Daniel S. Pine. (2005) Selective reduction in amygdala volume in pediatric anxiety disorders: A voxel-based morphometry investigation. Biological Psychiatry 57:9, 961-966
CrossRef
