The impact of parental psychiatric disorder on children
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7409.242 (Published 31 July 2003) Cite this as: BMJ 2003;327:242All rapid responses
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Dear Editor,
It was interesting to read the Editorial of Ramachandani &
Stein,The impact of parentral psychiatric disorder on children(1). I would
like to give my comment:
1.The authors mentioned that depressive, anxiety & eating disorders are
among the main psychiatric disorders which have a deleterious effect on
the psychological development of children, although they thought that
Health authorities tend to put more emphasis on serious psychiatric
disorders, schizophrenia & bipolar. But it is well known that
alcohol & substance misuse, attempted suicide have a great effect on
psychological wellbeing of the developing child.
2.To deal with that problem could be only through the
psychiatric community team & social services working together to
identify risk groups & put plans on how to deal with them.
Thank you.
Yours sincerely
AK.Al-Sheikhli
References
1.Ramachandani P & Stein A, The Impact of parentral psychiatric disorder
in children, BMJ;2003,327,242-243.
Competing interests:
None declared
Competing interests: No competing interests
The Impact of Poor Parental Psychiatric Treatment on Children
Ramchandani P and Stein A are critical of the insufficiency of help
and support, in terms of policy and interventions, for those children who
have a parent with a psychiatric disorder. They quote the Australian
Infant, Child and Family Mental Health Association report, which calls for
improved provision of help for problems that these children may have.
In their conclusion, Ramchandani & Stein state that research must
be done into finding "the most effective, efficient and equitable way of
providing treatment to this diverse group of children and families" (1).
What stands out in their editorial is that they do not expect the
psychiatric treatment for the parents to be improved. They do not call
for improvements in the psychiatric care of the parents, but rather for
"research...into...treatment to...this group of children..."
If the psychiatric care of the anxious and depressed parent is such
that they can improve their social and psychological functioning, so that
they are no longer experiencing difficulties in their family life and at
work, then policies and interventions, which Ramchandani & Stein call
for on behalf of these children, are no longer required.
This BMJ editorial has coincided with an article in the Brit J
Psychiatry entitled "Clinical trials of antidepressant medications are
producing meaningless results" (2).
A study by Kirsch et al concluded that "antidepressant medication
appears to have only a small effect on outcome over and above placebo".
They analysed 38 drug trials between 1987 and 1999 and found that the mean
drug-placebo difference was just TWO points on the Hamilton Rating Scale
for Depression. They concluded further that the effects of antidepressant
drugs were "very small and of questionable clinical significance" (3).
There is "a growing body of critical opinion proposing
that...antidepressants either do not work at all or have an effect that is
so small as to be clinically unimportant" (4,5).
The study comparing St John's Wort with Sertraline came to the
conclusions that the SSRI was no better than St John's Wort, and that
neither of them was significantly better than placebo in reducing
depression severity or disability nor in overall improvement (6).
The Brit J Psychiatry article says that, in using the metaphor of the
Emperor's New Clothes, the "drug trials are the fraudsters", that there is
a deception in regard to the clinical effectiveness of antidepressants,
and that this deception is now being revealed by critical opinion (2).
So, in the light of the clinical uselessness of the licensed and
heavily marketed antidepressants, what deductions can be made?
Firstly, clinicians must revisit the monoamine hypothesis of
neurotransmission, and recognise that the dopamine system could be as
important as the serotonin and noradrenaline systems in regard to
depression and anxiety. For example, dopamine neurotransmission is known
to be increased following ECT, which is used as a treatment of depression.
Secondly, clinicians must reconsider their unquestioning faith in the
double-blind, placebo-controlled trials conducted by the pharmaceutical
industry. There is a deception in progress, and this includes the
evidence that about half of the negative trials remain unpublished (7).
Thirdly, when clinicans are critical of the antidepressant
recommendations of the phramaceutical industry and when they revisit the
dopamine system, more adults ought to be treated with dopaminergic
medication when little benefit has been obtained using a serotonergic or a
noradrenergic. Alternatively, using a combination of low dose SSRI + low
dose DRI (Dopamine Reuptake Inhibitor) can be effective for treating
depression.
Fourthly, since these dopaminergics are not recommended by the
pharmaceutical industry on account of being unable to obtain marketing
authorisation, clinicians can free themselves from the intellectual strait
-jacket imposed by the industry. This would allow them to prescribe
Ritalin or Dexamphetamine for depression and anxiety under the protection
of the Medicines Act 1983.
Fifthly, Ritalin and Dexamphetamine are found by some clinicians to
be good antidepressants because they improve a range of skills in the
depressed person, thus lifting their self-esteem by the experience of
success and achievement. The marketed antidepressants, on the contrary,
only target mood and do not do that very well either.
In conclusion, it would seem that the call by Ramchandani & Stein
for improvements in the treatment, support and help for the children of
patients with depression and/or anxiety is misplaced. It is better to
call for the improved treatment of the psychiatric disorder in the
parents, and to suggest ways in which this can be effected, so that the
children can be benefitted indirectly through the normalisation of mental
health in the parent.
References:
1 Ramchandani P, Stein A. The impact of parental psychiatric
disorder on children. BMJ 2002;327:242-3.
2 Parker G, Anderson IM, Haddad P. Clinical trials of
antidepressant medications are producing meaningless results. Br J
Psychiatry 2003;183:102-4.
3 Kirsch I, Moore TJ, Scoboria A et al. The Emperor's new drugs: An
analysis of antidepressant medication data submitted to the US Food and
Drug Administration. Prevention & Treatment 2002;5 Article 23
http://www.journals.apa.org/prevention/volume5/pre0050023a.html
4 Andrews G. Placebo response in depression: bane of research, boon
to therapy. Br J Psychiatry 2001;178:192-4.
5. Moncrieff J. The antidepressant debate. Br J Psychiatry
2002;180:193-4.
6 Hypericum Depression Trial Study Group. Effect of Hypericum
perforatum (st John's Wort) in major depressive disorder: A randomised
control trial. J Am Med Assoc 2002;287:1807-14.
7 Thase M. How should efficacy be evaluated in randomised
controlled trials of treatments for depression? J Clin Psychiatry
1999;60(suppl 4):23-31.
Competing interests:
None declared
Competing interests: No competing interests