BLOG No. FORTY ONE

Welcome back to my blog on anxiety and depression. Today I want to discuss pediatric anxiety and depression. If there is ever an area where we need to improve psychiatric treatment, I believe it is here. Last year, in the United States alone, there were nearly 7000 suicides in patients aged 10 to 24. I want to explore some thoughts about pediatric anxiety and depression and why it so often leads to suicide.

I remember a pediatrician telling me in medical school that kids are not small adults. And no statement could be more true. The neurochemistry of children and teens are similar to that of adults, but is still very different. There is a black box warning on every SSRI and SNRI antidepressant for patients 18 and under that states this drug may cause suicidal ideation. But the same warning is not given to adults. Why is that?

Some psychiatrists say that it’s because certain neurological tracks in the brain that help us to foresee consequences just aren’t as developed in younger patients. And that is very true. I remember as a kid jumping my bike over a deep ditch, without thought to consequence. A bent handlebar and a bloody nose resulted. Do you think I considered that would happen? Nope, never crossed my mind. And kids that attempt suicide don’t completely connect with the fact that they will never come back forever.

But this does not explain why the kid wants to commit suicide in the first place! Let’s explore that!

Suicide is generally an impulsive act. We were so shocked when Bobby blah blah blah. But it’s true. People are shocked when young people take their own life. And they are right to be shocked, as a good number of young people committing suicide do not give much forewarning. So there is our first clue to teenage depression—when the patient become suicidal there is impulsivity, which we know is a D2 dopamine thing. And because of the extreme mood shifts that come at the beginning of suicide ideation, this seems to me to be even more D2 dopamine at work, don’t you think?

1) The Past, the Present, and the Future walk into a bar at the same time. Needless to say, it was very tense.

2) When I was a teenager, everyone said, “Live your dreams!” But I didn’t want to be naked in my high school classroom, taking a test that I didn’t study for.

About 10 years ago, the company that makes Abilify had a commercial that said, “If your antidepressant is not working completely, ask your doctor about Abilify”. As we have seen in previous blogs, Abilify lowers D2 dopamine. It was Big Pharma’s way of saying, “Is there a component of D2 dopamine chemistry to your depression?” It never caught on. Monoamine, monoamine, monoamine… it was the American Psychiatric Association’s mantra.

My belief is that the vast majority of pediatric depression has a strong D2 dopamine component.

We know that SSRI’s make D2 dopamine conditions worse. For example, bipolar patients prescribed SSRI’s without a mood stabilizer, usually go manic—and watch out, because the crash afterword is imminent. And when the bipolar patient leaves the high of mania or hypomania, it begins the plunge toward depression. And this is a common time for suicide. SSRI’s prescribed to bipolar patients without a mood stabilizer is like pulling your car out on the street, taking your hands off the wheel, and hitting the gas. It is instability on steroids!

When I lectured several years ago on recognizing bipolar disease, I told the providers in my audience that handing out an SSRI without screening for bipolar disorders was like handing out antibiotics without checking allergies. It was very dangerous. I told him that they had to rule out bipolar chemistry with 100% certainty before they wrote that prescription, especially in pediatric patients.

And it is because of the black box warnings on SSRI’s in pediatric patients, along with the impulsivity of pediatric suicide, that I believe most pediatric depression and anxiety has a strong D2 dopamine component. Treating pediatric depression and anxiety without the list of D2 dopamine questions being asked, is like playing Russian roulette.

Well, I am in my final leg of my trip back to Dayton from Wisconsin and a nice flight attendant just pushed the beverage cart passed me. Of course, I asked for a glass of Chardonnay. But my choices were water, water and wait for it…water! I wanted to tell her to stop calling it a beverage cart BECAUSE IT DIDN’T CONTAIN ANY BEVERAGES! JUST WATER! ARGGGG! So until next time when I share a true SSRI case, this is Dr. G saying keep the faith!