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The Role of SSRI's in Treating University Students: Assessment of Benefit and Risk

Recommendations for working with college students

Norman Hoffman, M.D., F.R.C.P.C.
Director, McGill Mental Health Service


Over the past ten years there has been an explosion in the development and the use of new anti-depressant drugs. Recently there have been warning’s of possible suicidal ideation caused by these medications. This has led to a ban on these medications being used on adolescents in Britain, warnings required by the FDA in the United States, and caution urged in Canada. Last year SSRI's were prescribed to 15% of the adult population in Canada. These medications are being marketed for an ever increasing list of indications. The efficacy of these drugs as the primary treatment for many of these disorders is still questionable. This is especially true in the use of anti-depressant medication in adolescents and young adults, where research has shown overall poor responses to this class of drugs. The following points are of crucial importance in evaluating the use of medication in the student population.

Diagnosis requires extended assessment. It is not possible to properly evaluate the problems and mental state of an adolescent in one session. Mood states in this population are variable, and it takes time to establish enough trust to be able to elicit crucial information.

Research on brain development have indicated that in the post-natal to adolescent period, an overabundance of receptor sites are produced in many brain pathways. These sites are pruned during the late adolescent and early adult period. This implies that artificially increasing neurotransmitter levels during this period could potentially lead to an overpruning of receptor sites. It is therefore possible that prescribing anti-depressant medication to people aged 18-24 could make them prone to depressions throughout their adult life. With our present state of knowledge, we have no assurance that the use of psychotropic medication in young people does not have adverse long term effects.

SSRI's do not just effect serotonin pathways. Most of these drugs affect noradrenaline and dopamine pathways, especially at higher doses.

Research on depression in adolescents has consistently shown that anti-depressant medication has little advantage over placebo. Some recent studies show some mild responses, but it is unclear how clinically significant are these responses. There has been no research done specifically on a young adult population. Clinical experience indicates that young adults are similar to adolescents in response to treatments.

One of the main clinical effects of the SSRI’s appears to be a mood containing effect, rather than a specific anti-depressant effect. This is probably a significant aspect as to why these medications can be helpful in various conditions. It is important for clinicians to recognize that this mood containing effect is not necessarily an indication of a biological disorder, but that it can be helpful to patients who are overwhelmed by the degree of their affect.

Suicidal ideation with SSRI’s can be a result of; agitation caused by side effect of medication; discomfort and sense of alienation caused by the mood containing effect; emotional alienation resulting from inappropriate use of medication and failure to address emotional issues; or the energizing effect of medication that may precede the anti-depressant effect. An understanding of the issues involved in any individual can help to both prevent and counter suicidal thoughts.

Research on treatment of depression by medication in adult populations have consistently shown that medications seem most effective primarily in severe Major Depression. Other depressive syndromes show only marginal responses to medication when compared to placebos, and show equally positive and sustained responses to various therapies.

Severe Major Depression is a rare diagnosis in young adults. Most depressions in young adults show a labile mood pattern. However this may not be evident on an initial interview.

Side effects experienced by a student population tend to be more pronounced then described in the literature. This is probably due to increased expectations and the active lifestyle of students.

Recommendations:

The use of anti-depressant medication in the student population needs to be very carefully considered. While these medications may be valuable in certain conditions, the possible ramifications of treatment, both physiological and psychological can be profound. Anti-depressant medication should almost never be prescribed on a first visit. It is impossible to make an accurate assessment of consistent symptoms in students without at least two in-depth interviews. Medication should not be considered to be a primary treatment modality in students. Most students respond well to therapy without the need for medication.

Indications for Anti-depressant Medication:
  • Severe unremitting Major Depression
  • Severe Panic Attacks. ( > 3 weekly)
  • Severe Bulimia. ( > 3 purges daily)
  • Severe, constant anxiety
  • Poor response to other treatment modalities with significant symptoms of depression or anxiety


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