A recently reported 10% decline in the percentage of children and adolescents taking antidepressants last year is alarming but not surprising, given all the controversy and publicity leading up to the Food and Drug Administration's black box requirement for these drugs, leading experts say.

What is surprising, they say, is the finding that psychiatrists as well as primary care physicians might be writing fewer prescriptions.

The data were released last month by the pharmacy benefit manager Medco Health Systems Inc. Medco reported that antidepressant prescriptions for patients younger than 18 years fell 10% in 2004 after rising by almost the same percentage in 2003.

The steepest declines occurred in the second half of 2004, Medco said. In the third quarter, prescription use fell more than 19% from a year earlier. In the fourth quarter, prescription use fell by 16% from a year earlier.

Medco did not break down use patterns among specific antidepressants or diagnoses, nor did it release data on use by prescribing physicians. However, “we looked at both primary care physicians and psychiatric specialists, and we saw no difference in the drop-off rate [in prescribing],” said Ann Smith, a spokesperson for the company, which manages drug benefits for about 60 million Americans. “We're looking more at that [trend].”

The drop in antidepressant use among patients of primary care physicians is likely a physician-driven trend, but the drop among patients of psychiatrists is more likely a result of parents' concern, sources said.

“If that's the case [that psychiatrists are prescribing less], then that indicates to me that there's greater concern among parents… It's a result of the scare that has gone through the community and the misinterpretation that there's an increase in suicide [with use of the drugs],” said Darrel Regier, M.D., director of research for the American Psychiatric Association.

Like Dr. Regier, David Fassler, M.D., an American Medical Association delegate to the American Academy of Child and Adolescent Psychiatry, said he was surprised by Medco's report of cross-specialty declines.

“It was my impression that most of the change is taking place among [family physicians] and [pediatricians], both from my experience locally and from talking with physicians anecdotally,” said Dr. Fassler, also with the University of Vermont, Burlington.

Indeed, said Lynn Wegner, M.D., who chairs the American Academy of Pediatrics' section on developmental and behavioral pediatrics, said, “I think we've tapped into a segment of doctors who were uncomfortable [with prescribing the drugs], anyway. I think the [physicians] who have stopped are those who were leery to begin with or in very litigious areas.”

When the FDA announced last October its requirement for antidepressant labels to carry a black box warning about the risks of suicidal behavior, the APA immediately issued a statement of concern that the warning would have “a chilling effect on appropriate prescribing” for patients.

As expected, “this is a very significant change in prescribing patterns over a relatively short period of time,” Dr. Fassler said.

Just as alarming as the data from Medco, sources said, are anecdotal reports that primary care doctors renewing their malpractice insurance policies are being asked whether they prescribe antidepressants and are being told that they face higher premiums if they answer yes.

The APA has received such reports, Dr. Regier said, and “we're afraid this will have an additional chilling effect” on prescribing these drugs.

Adelaide Robb, M.D., medical director of inpatient psychiatry at Children's National Medical Center in Washington, said she has also heard of prescribers being told that their malpractice insurance premiums will rise.

Add this problem to primary care physicians' “feeling that they're not trained to handle suicidal ideation,” as well as the difficulty in complying with FDA recommendations for monitoring patients on antidepressants, and “I'm afraid the suicide rates will rise,” Dr. Robb said.

“New patients are going without care. It's getting harder and harder to see someone,” she said. “In our area, many pediatricians are now reluctant to initiate antidepressant drug treatment, whether for depression or other disorders. They're also reluctant to take stable patients.”

Dr. Regier said health insurers and managed behavioral health companies in particular “are going to have to loosen some of their restrictions on psychiatric disorder management” so that physicians can follow the FDA's guidelines for patient monitoring.

The black box says, “patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

Dr. Regier said the APA hopes to learn more about “which groups of patients are most affected” by the declining prescriptions trend, and why.

In the next few months, the APA will also evaluate use of its Web site, www.ParentsMedGuide.org

Antidepressant Use Dropped 10% in Youth