Psychiatric Times.
No. 10
CLINICAL
Antidepressant Use in Children With Cancer
What We Now Know (and Need to Know) About the Use of Antidepressants
By Maryland Pao, MD, Elizabeth D. Ballard, and Julie M. Zito, PhD |
October 10, 2009
Dr Pao is deputy clinical director at the NIMH, NIH in Bethesda, Md; Ms Ballard is a predoctoral fellow at the NIMH, NIH; Dr Zito is professor in the departments of pharmaceutical health services—research and psychiatry at the University of Maryland in Baltimore. The authors report no conflicts of interest concerning the subject matter of this article.
The estimated prevalence of antidepressant use in the Medicaid-insured youth with cancer was about 9% versus about 5.2% in those aged 2 through 17 years who did not have cancer.22 By comparison, in an HMO youth cohort, the prevalence of antidepressant use was 1.75% among 5- to 17-year-olds in 2000 and 2001.23 Thus, it appears that children with cancer are being treated with psychotropic medications, particularly antidepressants, at a higher rate than matched noncancer controls or community-treated populations. The data suggest that clinicians may be responding to high levels of symptoms and poor functioning.
Conclusions
Given the greater prevalence of antidepressant use and the higher prevalence of psychiatric symptoms in children with cancer than in the general pediatric population, further research is imperative. Prioritizing antidepressant research would help ensure a solid evidence base of efficacy, safety, and tolerability in youths undergoing cancer treatment.
To date, only youths with Medicaid insurance have been studied. This population probably includes many chronically ill youths, for whom cancer is a significant condition. The need to expand the research evidence on the role of antidepressants in youths with cancer is further heightened by the current controversy surrounding SSRI use in children. Well-designed studies with adequate assessment and follow-up are essential. Current studies are limited by sample size, few comparison groups, and failure to assess comprehensive treatment interventions. In addition, validated instruments to assess psychiatric symptoms in pediatric oncology populations are needed to best identify those patients in need of treatment.
The increased prevalence of antidepressant use among Medicaid-insured pediatric oncology patients suggests that clinicians may be responding to some form of distress in their patients that is possibly biologically triggered. Further research will elucidate the most effective and safe treatments for these patients.
It is also important to remember that medications are only one aspect of comprehensive psychosocial care of children with cancer. Nonpharmacological interventions such as cognitive-behavioral therapy, guided imagery, and hypnosis may help manage symptoms, and further research is needed to see the effect of these treatments on clinical outcomes. Collaborative efforts by pediatric oncologists, psychiatrists, and other mental health clinicians will no doubt enhance resilience in this population by ensuring that they receive comprehensive psychosocial care to maintain the best possible quality of life in the face of physical challenges.
References
1. American Cancer Society. Cancer Facts and Figures 2007. Atlanta: American Cancer Society.
http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf. Accessed March 4, 2009.
2. Heron MP, Smith BL. Deaths: Leading causes for 2003. National Vital Statistics Reports. Vol 55, No 10. Hyattsville, MD: National Center for Health Statistics; March 15, 2007.
http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_10.pdf. Accessed April 13, 2009.
3. Ries LAG, Melbert D, Krapcho M, et al, eds.
SEER Cancer Statistics Review, 1975-2005. Bethesda, MD: National Cancer Institute.
http://seer.cancer.gov/csr/ 1975_2005. Accessed March 4, 2009.
4. Shaw RJ, DeMaso DR.
Clinical Manual of Pediatric Psychosomatic Medicine. Washington, DC: American Psychiatric Publishing, Inc; 2006.
5. Shemesh E, Bartell A, Newcorn JH. Assessment and treatment of depression in medically ill children.
Curr Psychiatry Rep. 2002;4:88-92.
6. Hedström M, Kreuger A, Ljungman G, et al. Accuracy of assessment of distress, anxiety, and depression by physicians and nurses in adolescents recently diagnosed with cancer.
Pediatr Blood Cancer. 2006;46:773-779.
7. Kersun LS, Elia J. Depressive symptoms and SSRI use in pediatric oncology patients.
Pediatr Blood Cancer. 2007;49:881-887.
8. Canning EH, Hanser SB, Shade KA, Boyce WT. Mental disorders in chronically ill children: parent-child discrepancy and physician identification.
Pediatrics. 1992;90:692-696.
9. Bennett DS. Depression among children with chronic medical problems: a meta-analysis.
J Pediatr Psychol. 1994;19:149-169.
10. Hedström M, Ljungman G, von Essen L. Perceptions of distress among adolescents recently diagnosed with cancer.
J Pediatr Hematol Oncol. 2005;27: 15-22.
11. Schultz KA, Ness KK, Whitton J, et al. Behavioral and social outcomes in adolescent survivors of childhood cancer: a report from the childhood cancer survivor study.
J Clin Oncol. 2007;25:3649-3656.
12. Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer.
J Clin Oncol. 2006;24:3852-3857.
13. Stuber ML, Shemesh E, Saxe GN. Posttraumatic stress responses in children with life-threatening illnesses.
Child Adolesc Psychiatr Clin N Am. 2003;12: 195-209.
14. Pai AL, Drotar D, Zebracki K, et al. A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment.
J Pediatr Psychol. 2006;31: 978-998.
15. Gothelf D, Rubinstein M, Shemesh E, et al. Pilot study: fluvoxamine treatment for depression and anxiety disorders in children and adolescents with cancer.
J Am Acad Child Adolesc Psychiatry. 2005;44: 1258-1262.
16. DeJong M, Fombonne E. Citalopram to treat depression in pediatric oncology.
J Child Adolesc Psychopharmacol. 2007;17:371-377.
17. March J, Silva S, Petrycki S, et al; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.
JAMA. 2004;292:807-820.
18. Kersun LS, Kazak AE. Prescribing practices of selective serotonin reuptake inhibitors (SSRIs) among pediatric oncologists: a single institution experience.
Pediatr Blood Cancer. 2006;47:339-342.
19. Portteus A, Ahmad N, Tobey D, Leavey P. The prevalence and use of antidepressant medication in pediatric cancer patients.
J Child Adolesc Psychopharmacol. 2006;16:467-473.
20. Pao M, Ballard ED, Rosenstein DL, et al. Psychotropic medication use in pediatric patients with cancer.
Arch Pediatr Adolesc Med. 2006;160:818-822.
21. Zito JM, Valluri S, Ballard E, et al. Antidepressant treatment of Medicaid youth with a cancer diagnosis. Presented at: the Annual Conference of the American Psychiatric Association; May 2008; Washington, DC.
22. Zito JM, Safer DJ, Zuckerman IH, et al. Effect of Medicaid eligibility category on racial disparities in the use of psychotropic medications among youths.
Psychiatr Serv. 2005;56:157-163.
23. Hunkeler EM, Fireman B, Lee J, et al. Trends in the use of antidepressants, lithium and anticonvulsants in Kaiser Permanente–insured youths, 1994-2003.
J Child Adolesc Psychopharmacol. 2005;15:26-37.
Evidence-Based References
Hedström M, Ljungman G, von Essen L. Perceptions of distress among adolescents recently diagnosed with cancer.
J Pediatr Hematol Oncol. 2005;27:15-22.
Wiener LS, Pao M, Kazak AE, et al, eds.
Quick Reference for Pediatric Oncology Clinicians: The Psychiatric and Psychological Dimensions of Pediatric Cancer Symptom Management. Charlottesville, VA: IPOS Press; 2009.
