Antidepressant use among youth is skyrocketing across Canada. Prescribing doctors say they have little choice as teens ‘can’t wait nine months’ for therapy
WARNING: This story contains sensitive subject matter, including suicide and self-harm, that could be triggering for some readers.
Publicly funded antidepressant prescriptions for youth have more than doubled over the past decade in the country's six largest provinces, an ongoing investigation by the Toronto Star and the Investigative Journalism Bureau has found.
There was a 240-per-cent increase in antidepressant prescriptions for people under 18 paid for by public drug plans in B.C., Alberta, Manitoba, Saskatchewan and Quebec between 2009 and 2019.
In Ontario, the story is more complicated.
Publicly funded benefit claims for youth antidepressants rose by 224 per cent in the first eight years of the decade, in line with the overall national portrait. Then, in 2018 and 2019, the newly adopted OHIP+ covered all prescriptions for Ontarians under the age of 25, making it tougher to assess increases after this point.
Like many Canadian doctors, Toronto pediatrician Dr. Michael Peer said he is writing far more prescriptions today than he did 15 or 20 years ago - reluctantly.
I don't like to prescribe medication," he said. But in this area, you don't really have many things you can do. ... A lot of us are prescribing them because (patients) can't wait nine months to see a child psychologist."
Interviews with 10 Canadian researchers, pediatricians, psychiatrists and pharmacologists, along with a review of academic literature, reveals a vigorous debate over the meaning behind growing youth antidepressant use and a concern about whether the pharmaceutical response to young people's calls for help is appropriate.
Though pharmacoepidemiologist Mina Tadrous shares Peer's concern, he said it is possible that the rise in these prescriptions also shows our health-care system is doing more to meet an increase in demand for mental health help among youth. The data may also show the result of vulnerable youth feeling less stigma in their attempts to get well.
Antidepressants are most often recommended for children in conjunction with talk therapy. But counselling programs in much of the country are overwhelmed by demand and long wait lists.
It's way easier to give someone a pill than it is to support them with the non-pharmacological support that they need, such as therapy that's expensive," said Tadrous, a scientist at the Women's College Research Institute and assistant professor at the University of Toronto. We don't know if (youth) are getting the support around this or we're just using a very quick and easy Band-Aid."
Provincial data obtained by the investigation do not include youth mental health prescriptions paid for privately, except the data for Alberta, which include public and private dispensing. Data obtained for Newfoundland and Labrador show antidepressant prescriptions rose 342 per cent from 2009 to 2018.
The data include prescriptions for selective serotonin reuptake inhibitors (SSRI), a class of drug most commonly prescribed to treat anxiety and depression, as well as serotonin-norepinephrine reuptake inhibitors (SNRIs), used to treat conditions including anxiety, major depressive disorder and attention-deficit hyperactivity disorder.
The Ontario Student Drug Use and Health Survey found that in 2019, 7.2 per cent of high school students indicated they were prescribed medication for anxiety, depression or both.
Though a prescription with no other health care intervention is not considered the ideal treatment by health professionals, experts agree antidepressants themselves are not something to fear or avoid.
They are typically not used effectively. Many physicians prescribe inadequate dosages for inadequate lengths of time. It is an issue of quality of care. Overall, antidepressants cause more good than harm in teens and young adults. Still, some individuals will not benefit from them and will be hurt," said Dr. Benoit Mulsant, chair of psychiatry at the University of Toronto.
Antidepressants are proven to be life-saving medications and can help reduce suicide among teens, studies show.
But there is also strong data showing that antidepressants can acutely increase suicidality in a subset of teens and young adults," said Mulsant.
Dr. Paul Kurdyak, a psychiatrist at Toronto's Centre for Addiction and Mental Health (CAMH), said we have become over-reliant" on antidepressants for youth as the sole form of treatment as therapy has become more difficult to access.
CAMH estimates that three in four Canadian children and youth with mental illness do not have access to specialized treatment.
Psychotherapy is not as available as antidepressants by a long shot," said Kurdyak, who is also senior scientist at ICES (formerly called the Institute for Clinical Evaluative Sciences). It looks as though there's a lot of use of antidepressants that is likely occurring from people who may not meet the criteria for need of those antidepressants."
That imbalance in available treatments creates a serious equity issue, he said, since patients who should have a choice between antidepressants and therapy - especially those with moderate depression - can't choose unless they have insurance or are able to pay.
When choice is not available, and you over-rely on one modality, and over-rely on one modality where there is known to be side effects - adverse effects - it short-changes the public. ... You'd never see an evidence-based treatment not available for diabetes, for example, across the province."
The data relied on for this story, which mostly detail publicly funded prescriptions, capture a portion of the population, typically those of lower socioeconomic status, said Tadrous. We probably want to study this a bit better, and understand the number of people, what kind of drugs are being used and how they're being used in a more robust way," he said.
In 2018 and 2019, OHIP+ was adopted. For two years, that drug benefit plan covered all prescriptions for Ontarians under the age of 25. These years have been excluded from our analysis as they provide insight into a total amount of people on medications but not the trends exhibited in publicly funded medications from 2009 onward.
In April 2019, the province pulled back coverage on drugs for young people who already had private drug plans.
The use of antidepressants has long been debated among medical professionals.
A 2004 black box" warning in the U.S., prompted by data showing the possibility of increased suicidality, triggered a warning issued by Health Canada about the use of antidepressants by children and adolescents. The warning led to a decline in prescriptions in Canada and the U.S. for several years.
Since then, research has shown a steady increase in prescribing rates in the country's six largest provinces.
A 2019 study in the Journal of Child and Adolescent Psychiatry suggested a 36-per-cent jump from 2012 to 2016 and a 2016 study published in the Canadian Journal of Psychiatry found a 63-per-cent increase from 2010 to 2013.
There's probably some kids who are not getting enough treatment and probably some kids are getting too much treatment," said Dr. Michael Rieder, professor and former Chair of Paediatrics at the University of Western Ontario.
The question is finding the right balance."
The complexity of this issue is furthered by the fact that no antidepressant has been specifically approved for use in people under the age of 18 in Canada. Due to difficulty in recruiting children for research, among other issues, children are often left out of clinical trials of drugs that can end up being used in pediatric care.
The majority of pediatric prescribing in Canada is off label,' and this practice is considered standard, and completely appropriate, care," said Dr. Charlotte Moore Hepburn, a Toronto-based pediatrician and director of medical affairs with the Canadian Paediatric Society.
The European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) require drug makers to submit pediatric study data of medications to support the authorization of use of medication in children. This is the kind of evidence that Canadian doctors may rely on when prescribing to children. In Canada, there is no such requirement for drug makers.
It's shocking," said Moore Hepburn. I think that that's a regulatory oversight that urgently needs correcting."
In 2019, the Canadian Paediatric Society issued a call to action for improvements in pediatric prescription medications, including the formation of an advisory board to establish standards for pediatric medication use. Health Canada said it is currently developing regulations in response.
Health Canada said several antidepressants contain warnings and precautions for their use not just in children under 18 but also young adults aged 18 to 24.
Liam Gunnip was prescribed an antidepressant last year in response to the 19-year-old's struggles with focus, signs of depression and possible ADD.
The Gunnips' family doctor prescribed 20 mg of citalopram, an SSRI, during a telephone meeting on March 25, 2020, according to his medical file reviewed by the Star/IJB. Notes contained in the file say Gunnip was physically doing well, mentally not doing so well."
Gunnip's mood was a bit down" and he had occasional passive suicidal thoughts ... not active at all," the notes read.
It also notes that he needs therapy."
Therapy was more of a suggestion, (his doctor) didn't refer him to anyone," said his older sister Nicole.
Gunnip's family doctor could not be reached for comment and her office receptionist declined to comment.
Gunnip began the medication on March 30 and had a follow-up telephone appointment with his doctor on April 21. That was the extent of the care he received, his family alleges.
When you give a child an antidepressant over the telephone, you don't see their face. You're asking them a simple questionnaire," said Gunnip's mother, Gail. She said she assumed he would be asked to come into the office for the follow-up appointment.
The doctor's notes from that meeting say Gunnip noticed a difference already with the medications. He notices that his sleep is a lot easier, more interested in some activities ... energy improving."
His family observed otherwise. Gail recalls in his first couple weeks on the medication, Gunnip's sleep was greatly affected and he was staying up all night.
Throughout April, Gunnip's family was seeing unusual changes. He just wasn't himself," Gunnip's sister recalls. He was saying things that were introspective ... I was worried about him."
On May 3, 2020, she and her mother found him dead by suicide.
Gunnip's family believes the antidepressant he had been prescribed was a primary factor in his death. While his medical file shows he had been wrestling with low moods for at least a couple of years, he had never before shown any signs of active suicidality, his family said.
The medical notes written by Gunnip's physician the day after his death say he showed no prior history of depression until the phone visit on March 25th. Liam's main concern was his ADHD. Of concern though was the fact that his moods were down and he told me they had been for the last two years. ... This is devastating news!"
A subsequent toxicology report revealed he had taken the antidepressant at prescribed levels.
He was the toughest person I know, he didn't bother anyone with his problems, he was very responsible," said his younger brother Sean.
Liam was a selfless person, and above all he wanted to help others. He was a very private person. But I know he would give up his privacy if that meant saving even one person. And that's why I wanted to share his story," his sister Nicole said.
Gunnip's mother has filed a complaint against their family doctor with Ontario's college of physicians.
This story is part of a cross-border investigation into youth mental health involving the Toronto Star and the Investigative Journalism Bureau (University of Toronto's Dalla Lana School of Public Health), the National Observer and NBC News in partnership with journalism faculty and students from the following universities: Stanford University, Temple University, University of Missouri, Syracuse University, City University of New York, University of British Columbia, Ryerson University, Carleton University and the University of King's College.
Data Analysis by Andrew Bailey
Morgan Bocknek works on the Star's Digital Desk, based in Toronto. She is also a Star contributor. Follow her on Twitter: @mobocks
Robert Cribb is a Toronto-based investigative reporter for the Star. Reach him via email: rcribb@thestar.ca
Liam G. McCoy is a medical student at the University of Toronto and a researcher with the Investigative Journalism Bureau