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Letter

Rethinking childhood depression

Does childhood depression exist?

EDITOR—For the debate about rethinking childhood depression to degenerate into a semantic argument about its existence would be unfortunate.¹ Reification of biomedical diagnosis acts as a justification for so called evidence based treatments, which currently in the case of childhood depression are antidepressant drugs, cognitive behaviour therapy, and interpersonal therapy. The question is whether this process of reification is necessary for clinical practice, and I agree with Timimi that it is not.¹

The onus is on Spender and Wilkinson to define exactly what they mean when they use the term childhood depression, which they do not do in their commentaries.¹

In the same issue Wade and Halligan ask whether biomedical models of illness make for good healthcare systems.² The potential danger of the biomedical model is reductionism. By contrast, psychosocial diagnosis does not necessarily require a single word label, and that single word label may not add much to the understanding and meaning of emotional problems. Such an approach is consistent with patient centred medicine and means that the patient is not merely seen as a passive recipient of treatment for which he or she has no responsibility.³ A psychosocial perspective in clinical practice therefore has advantages.

I suspect that the issue in this debate boils down to the readiness to use antidepressant drugs in children. Both Spender and Wilkinson quote the treatment for adolescents with depression study (TADS) in favour of the use of fluoxetine,⁴ but they do not mention criticisms of it.⁵ Fluoxetine was not in fact statistically better than placebo in this study and only became so when added to cognitive behaviour therapy in an unblinded arm. Strictly speaking, Spender and Wilkinson have therefore not provided support for their position. I prefer Timimi's critical approach, which takes a sceptical stance on the evidence, more in keeping with the spirit of scientific inquiry.

D B Double, consultant psychiatrist

Norfolk and Waveney Mental Health Partnership, Hellesdon Hospital, Norwich NR6 5BE dbdouble{at}dbdouble.co.uk

References

1. Timimi S. Rethinking childhood depression [with commentaries by Q Spender, P Wilkinson]. BMJ 2004;329: 1394-7. (11 December.)[Free Full Text]
2. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ 2004;329: 1398-401. (11 December.)[Free Full Text]
3. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred medicine. Transforming the clinical method. 2nd ed. Abingdon: Radcliffe Medical Press, 2003.
4. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA 2004;292: 807-20.[Abstract/Free Full Text]
5. Jureidini J, Tonkin A, Mansfield PR. TADS study raises concerns. BMJ 2004;329: 1343-4. (4 December.)[Free Full Text]

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