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Press releases Saturday 6 October2007

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(1) Should young people be given antidepressants?
(2) Women should make their own decision about breast screening
(3) Expert welcomes withdrawing of funding for complementary medicine

(1) Should young people be given antidepressants?
(Head to Head: Should young people be given antidepressants?)
Yes: http://www.bmj.com/cgi/content/full/335/7623/750
No: http://www.bmj.com/cgi/content/full/335/7623/751

Depression is disabling a growing proportion of children, but evidence on treatment is disputed. In this week's BMJ, two experts debate whether young people should be given antidepressants.

To deny these vulnerable groups the possibility of receiving antidepressants would be to withhold one of the few evidence based treatments available to them, argues Andrew Cotgrove, Clinical Director and Consultant in Adolescent Psychiatry at Pine Lodge Young People's Centre in Chester.

It is the use of selective serotonin reuptake inhibitors (SSRIs) in children that has been most controversial. However, objective analysis of the studies shows a significant benefit over placebo for some SSRIs and guidelines recommend that they can be used for the treatment of depression and obsessive-compulsive disorder in young people.

Research shows that there is an increase in suicide related events, but the risk is small and can be reduced further by careful monitoring, he says. There is also some evidence that psychological treatments (cognitive behavioural therapy, interpersonal therapy, and family therapy) are effective for depression in young people, but the effects are small.

Worrying methodological errors, publication bias, and omissions of evidence in the conduct and reporting of some SSRI trials have rightly alarmed the medical profession and the public, he writes. However, careful and objective review of the evidence shows that antidepressants have a place in treating young people with depression or obsessive-compulsive disorder.

Parents and young people need to be told the risks and benefits, given advice, and be supported in choosing an evidence based treatment.

Removing antidepressants from this choice would take away one of the few potentially effective interventions for these disabling conditions, he concludes.

Continuing to use SSRIs in young people is not good value for money, dangerous, and ethically unsound, argues Sami Timimi, Consultant Child and Adolescent Psychiatrist in Lincolnshire.

None of the studies on SSRIs for childhood depression have showed significant advantage over placebo. Despite this, national guidelines have concluded that fluoxetine has a favourable balance of benefit over risk.

But the profile for fluoxetine is similar to that of all other SSRIs, says Timimi - it has little efficacy and is potentially dangerous. However, he acknowledges that the high placebo response can make it difficult for doctors faced with a distressed young person to accept that SSRIs may be ineffective.

Distorted reporting hasn't helped this situation, he adds, and marketing spin has taken precedence over scientific accuracy. One reason for doing the studies in the first place was to justify well established prescribing patterns. It created a trend which has been difficult to reverse despite the evidence. But reverse it we must, as it is neither value for money nor clinically useful, may have resulted in a small but tragic number of avoidable suicides, and contributed to a trend of inappropriately medicalising common emotional states and experiences.

Most states of childhood distress are self limiting and do not require extensive intervention but, when intervention is necessary, psychotherapy has a well established record of effectiveness, he concludes.

Contacts:
Andrew Cotgrove, Clinical Director and Consultant in Adolescent Psychiatry, Pine Lodge Young People's Centre, Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
Email: andy.cotgrove@cwpnt.nhs.uk 
Sami Timimi, Consultant Child and Adolescent Psychiatrist, Lincolnshire Partnership NHS Trust, Sleaford, Lincolnshire, UK
Email: stimimi@talk21.com 

(2) Women should make their own decision about breast screening
(Editorial: Participation in mammography screening)
www.bmj.com/cgi/content/full/355/7623/731

Women in their 40s should be encouraged to decide whether breast screening is right for them, rather than being told what to do, argue two US experts in this week's BMJ.

In April 2007, the American College of Physicians issued new guidelines on screening mammography for women aged 40-49. Rather than calling for universal screening, they recommend that women make an informed decision after learning about the benefits and harms of mammography.

Reaction to these guidelines was muted, write authors Lisa Schwartz and Steven Woloshin, suggesting that the public and profession increasingly accept that cancer screening has both benefits and harms.

Perhaps we are finally moving beyond the debate about what women should do and are ready to focus on how to help women make the best decision for themselves, they say.

But no right choice exists, they explain, because screening has mixed effects - some women will benefit (by avoiding death from breast cancer) but others will be harmed by unnecessary treatment. So the next step is to ensure that women understand what is likely to happen if they do or do not undergo screening.

The data shows that in the US, for every 1000 women screened over the next 10 years less than one life will be "saved" for younger women and about three lives will be saved for older women.

But screening has several harms, say the authors. False positives - abnormalities detected at mammography that often cause women to undergo repeat testing (or perhaps biopsy) to rule out cancer - are the most familiar and can cause short term anxiety, inconvenience, and sometimes unnecessary biopsies. But they think that overdiagnosis is the most important harm of screening.

Overdiagnosis is the detection of lesions that meet the pathological criteria for cancer but would not progress to cause symptoms or death, they explain. Women who are overdiagnosed can only be harmed by treatment - they cannot benefit because no treatment was needed. Harms include disfiguring surgery, side effects of chemotherapy or hormonal therapy (such as nausea, fatigue, and hair loss), and injury from radiation.

Calculating the chance of overdiagnosis is challenging, but the authors estimate that, for every 1000 women screened over the next 10 years, up to five aged 40-49 and up to nine aged 50 and over may be affected.

Once informed about the possibility of overdiagnosis, most women say they would factor it into their decision about screening.

The new guideline is an improvement because it integrates informed decision making into policy recommendations, say the authors. Rather than telling women what they should do, policy makers should encourage women to make a decision that is right for them, they conclude.

Contact:
Lisa Schwartz, Associate Professor of Medicine, Department of Veterans Affairs Medical Center, White River Junction, VT, USA
Email: Lisa.Schwartz@dartmouth.edu 

(3) Expert welcomes withdrawing of funding for complementary medicine
(Letter: What to do about CAM?)
http://www.bmj.com/cgi/content/full/335/7623/736

The withdrawing of funding from homoeopathy in the NHS is welcomed in a letter to this week's BMJ.

In the UK National Health Service, primary care trusts are, quite rightly, withdrawing funding from homoeopathy, writes David Colquhoun, Professor of Pharmacology at University College London.

"Something has been done, at last," he says, following news that Tunbridge Wells Homoeopathic Hospital will close and the Royal London Homoeopathic Hospital is in great danger.

He also supports the view that the US Congress should stop funding the National Center for Complementary and Alternative Medicine (NCCAM).

He points to an article about NCCAM1, which states: "After ten years of existence and over $200 million in expenditures, it has not proved effectiveness for any 'alternative' method. It has added evidence of ineffectiveness of some methods that we knew did not work before NCCAM was formed."

That is something that could be done, he says. The total funding so far for NCCAM approaches $1 billion.

Contact:
David Colquhoun, Professor of Pharmacology, University College London, UK
Email: d.colquhoun@ucl.ac.uk 

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