Comments and Controversies
Clarification on melatonin
Although I was impressed by Drs. Scott R. Beach and Shamim H. Nejad’s Pearl (“Using melatonin to reset the clock of hospitalized older patients” Current Psychiatry, April 2012, p. 38; bit.ly/JoVwYh), their recommended melatonin dosage (3 to 9 mg) seems high. Zhdanova et al recommended a much lower dose that can decrease time it takes to fall asleep, and said higher doses may cause daytime sleepiness and confusion. "How to lower suicide risk in depressed children and adolescents,” (Current Psychiatry, May 2012, p. 21-31; bit.ly/LD77tK), the diagnosis of mood disorders is challenged by the need to discern the difference between fear and unhappiness and mood disorders such as anxiety and depression. Fear and unhappiness are part of life, whereas a mood disorder is an illness. Ambivalent outcomes from studies of antidepressants in children and adolescents come from the inability to know when a child’s unhappiness stems from environmental factors rather than biological mood problems.
As a child and adolescent psychiatrist, I feel it is important to not “medicalize” a child’s experience because doing so may discourage a thorough inventory of sources of stress and unhappiness. Sometimes it is difficult to know what is going on in a child’s life. All self-reports are distorted, especially from children.
An important source of childhood stress may be medically undertreated. Failure in school often plays a part and predates the onset of “depression.” School failure is not an incidental issue because school is the most important area of a child’s life outside of family; failing is painful and demoralizing. A child who is failing often is very unhappy. I have known children who have committed suicide after failing “again.” Often, a child fails his or her classes because of untreated attention-deficit/hyperactivity disorder (ADHD). Diagnosing and treating ADHD can make a real difference in a child’s life. The best antidepressant is success.
In my experience, the risk of suicide can be lessened by the positive mood response to success. When we “medicalize” a child’s unhappiness rather than address the causes, we might be worsening his or her sense of alienation, which may drive suicidality.
Rodney Vivian, MD