Jess P. Shatkin, M.D., M.P.H., is the Director of Education and Training at the NYU Child Study Center and Assistant Professor of Psychiatry at the NYU School of Medicine. Dr. Shatkin directs the child and adolescent psychiatry residency training program at the NYU Child Study Center and the Bellevue Hospital Center. In addition, Dr. Shatkin is the Director of Undergraduate Studies for NYU's Child and Adolescent Mental Health Studies (CAMS) Minor (the first child and adolescent mental health college minor in the country) and course director for Transition to College and Young Adulthood (an innovative course for new undergraduate students designed to help them adjust to college life). Dr. Shatkin is board certified by the American Board of Psychiatry and Neurology in general and in child and adolescent psychiatry.
Dr. Shatkin received his M.D. from the State University of New York at Brooklyn (Downstate Medical Center) and completed his medical internship, general psychiatry residency, and child and adolescent psychiatry residency at the University of California at Los Angeles Neuropsychiatric Institute. Dr. Shatkin also holds an M.P.H. from the University of North Carolina at Chapel Hill.
Upon graduation from his child psychiatry fellowship, Dr. Shatkin worked for two years in rural Arkansas in a Health Professional Shortage Area (HPSA) with the National Health Service Corps. Prior to joining the NYU Child Study Center, he was Medical Director of Child and Adolescent Psychiatry and Associate Residency Director at the Western Psychiatric Institute and Clinic and an Assistant Professor at the University of Pittsburgh School of Medicine.
Dr. Shatkin is the recipient of numerous awards for health policy and education and was selected in 2004 as one of six nationwide American Academy of Child and Adolescent Psychiatry Teaching Scholars, whose mission is to develop innovative methods for recruiting and training the next generation of child and adolescent psychiatrists by working in conjunction with the Harvard Macy Institute for Physician Educators.
Dr. Shatkin has published in the areas of child mental health policy, complementary and alternative medications, and sleep medicine in journals such as the Journal of Child and Adolescent Psychopharmacology, Child and Adolescent Mental Health and the American Journal of Psychiatry. ( the above biographical information was taken from the NYU Child Study Center Faculty and Staff Directory on the Internet )
In this interview, he responds to questions about the diagnosis of depression in infants and children. He clarifies some issues that emanated from a poll put on line by ABC news and "sets the record straight" regarding his views on depression in infants and children. I appreciate Dr. Shatkin's time and his responding to my questions and clarifying various issues that emanated from his television appearance.
1) You recently appeared on television to discuss depression in children. First of all, how many children (and I hear operationally define children as kids 6- 12 ) are depressed. What do you see as the causes?
The epidemiological studies that have been done on childhood depression have generally been small and too few in number to be definitive about the precise prevalence of childhood depression.Furthermore, it is often not easy to diagnose depression in a child, and as a field we are relatively new at making this diagnosis ourselves.Having said that, those studies that have been done are fairly consistent and suggest that about 1% of preschool, 2% of school age, and 4-8% of adolescents will at some point be depressed.
We believe the causes to be multifaceted, but we don't really have a good answer to the question of etiology.We accept that depression, like many mental illnesses, tends to travel in families and therefore has some genetic basis.However, it does not run exclusively in families, and we expect that neurodevelopment, neurochemistry, and environment all play significant roles in the final common pathway of what appears to be depression.
2) Now, moving on to adolescence (ages 12-18) how many are depressed and what are the causes, and what should be the " treatment"?
As above, about 4-8% of adolescents are thought to experience depression during the ages of 12-17.However, toward the end of adolescence, the rates tend to approximate those found in adults, such that the "lifetime prevalence" of depression in adolescents is around 15%.
Treatments studies have shown mixed results.Case studies but not double-blind, randomized placebo controlled studies, have shown older antidepressant medications, the tricyclics, to be effective; but we don't typically use them for treatment of children and adolescents b/c of safety risks and the fact that our best studies (the randomized, etc.) did not show them to be effective.Data on psychotherapy, particularly Cognitive Behavior Therapy (CBT), has also shown some benefits, as has Interpersonal Therapy (IPT).These treatments are "manualized" or scripted treatments, which often work well.The problem with psychodynamic psychotherapy (e.g., open ended talk therapy) is that it is highly idiosyncratic, depending upon the therapist and the patient and many other variables.Thus, it's difficult to replicate and unclear how effective it can be; it's also terribly difficult to do good studies on this type of therapy.
The antidepressant studies with SSRIs (the serotonergic, newer antidepressant medications) have also been mixed.Some studies show benefit, and some don't.Most of the randomized, double-blind, placebo controlled studies of the SSRIs, however, show some significant benefit, even if only a few percentage points better than placebo.The FDA currently has approved of the use of Prozac for the treatment of depression in children ages 7 – 17.Other medications may also be effective, but our best data rests with Prozac for now.So, ideal treatment depends upon the patient, family, and their needs and desires.Most often, we would recommend therapy as a starting point if the depression is mild/moderate and combined treatment (therapy + meds) if the depression is moderate/severe.
3) Now specifically, with infants, (ages birth to age 2) what do you see as the causes? Poor parenting, lack of nurturing, lack of stimulation? Or are these kids born depressed?
Probably all of the above play some role.Much of what we have always called "failure to thrive" amongst infants may, in fact, be depression.It's very hard to say.We know, for example, that lack of stimulation at an early age can result in brain growth changes (e.g., lack of nerve growth and synaptic connection).It's not too hard to extrapolate these findings to mood and anxiety states.For example, we know that if you patch the eye of a newborn monkey for the first 3 months of its life, it will never see out of that eye again; although the other eye will develop normally.The brain demands stimulation in order to grow; we suspect, then, that all types of emotion (e.g., joy, happiness, love, frustration, anger, etc.) must also be necessary exposures in order to help a person to develop his/her emotional states.Think about Victor, the Wild Boy of Aveyron, who was found by Itard in France at the age of about 11-12 in the 1800's.He had been in the wild since about age 3 and was never really able to learn language and develop emotion in the way that we would have expected him to be able to; he had probably passed the critical time when these systems develop.It's the same reason that we think autistic children must have early intervention – if you let them sit and stew in their autistic state for too long, their brain will probably grow into a state from which it will be difficult or impossible to return to "normalcy."
4) Now, I have some concerns about any physician giving an anti-depressant to a child who cannot verbally report symptoms. Are you basing your diagnosis on behavioral observations only and parental input?
You should have reservations, and I do too.I cannot imagine placing an infant on an antidepressant as a first, second, or third measure.I would do everything in my power to determine what else might be happening (e.g., find a neurological or physical cause) to explain whatever symptoms I am seeing.I would work with the parents and help them to be more responsive and connected to the child.Only after exhausting all of these strategies and witnessing the continual decline of the child would the thought of an antidepressant be entertained.
Even then, I must tell you that I've never treated an infant with an antidepressant; and I suspect that I may never do so.Diagnoses are based upon both parent and collateral report and observation.
5) Obviously, you cannot give an infant a Beck's Depression Inventory. Are you making a gargantuan inferential leap diagnosing depression in children?
Depending upon the age of the child, we now have some pretty good instruments to help us with diagnosis, in addition to our clinical acumen.The Children's Depression Inventory and the Child Depression Rating Scale are readily accepted and well validated measures; and the Beck Inventory is often useful with adolescents.
But this is really where the "art" of medicine comes into play; or you may wish to call it "experience."The more time you spend with kids, the better you understand what you're looking for and how to talk to them about their moods.It's not perfect, but we have nothing better.And while there may certainly be some kids out there who are placed on psychotropic medications that they don't "absolutely need," I can tell you that the outcome of severe and even moderate depression is generally much worse than a bit of therapy and a few months on a medication; and not only in terms of suicide, which is still the 3rd most common cause of death in adolescents and kills about 1600 kids each year, but also in terms of lost school time, damage to relationships, and generally not meeting their proper developmental milestones.
6) As you know, there has been some concern about Bextra and Vioxx and their relationship to heart problems. While anti-depressants are not NSAIDS, are physicians not running a risk when they give infants, who cannot verbally report side effects, medication?
As I said, by and large physicians should not be treating infants with antidepressants.It would be an extremely rare case where this would be appropriate.
7) How much feedback have you gotten about your appearance on ABC regarding diagnosing infants and children with depression?
I've gotten a few nasty emails, suggesting that I'm now on Scientology's bad side or that I'm being "watched" by those who consider folks like me a "Nazi pawn of the pharmaceutical industry."It's terribly ironic too because I never said a thing about the use of medications in my piece on ABC.All I said was that infants can be depressed and that we should work with the parents to help them become more responsive and attentive to their kids.If you read the transcript of the interview, or watch it, you'll see that's all I said.Of course, ABC did me no favors by linking my transcript to a poll asking whether people think infants should be placed on Prozac!That's just foolish hype, I suppose, to sell the story, and it ought to warn me off of anything but live TV in the future where I can defend my statements in real time.But in the end, people hear what they want to hear.I said nothing about Prozac, but somehow somebody sees me as a Nazi pawn pushing medication on babies. Go figure.