Antidepressant Medications for Children and Adolescents

By Jerry Kearney

          Depression is a serious disorder that can cause significant problems in mood, thinking, and behavior at home, in school, and with peers. It is estimated that major depressive disorder affects about 5 percent of adolescents, who have more frequent suicidal thinking and behavior and greater likelihood of substance abuse than youth in general.

          Research has shown that, as in adults, depression in children and adolescents can be treated.  Certain types of psychological therapies have been shown to be beneficial, and, in those with moderate to severe depression, therapy combined with medications called selective serotonin reuptake inhibitors (SSRIs) have proved very effective.

          Recently, however, concerns have been raised that the use of antidepressant medications themselves may induce suicidal behavior in youths.  In fact, following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the FDA has warned the public about an increased risk of suicidal thoughts or behavior in children and adolescents treated with SSRI antidepressant medications.

          The warning emphasizes that children and adolescents started on SSRI medications should be closely monitored for any worsening in depression, emergence of suicidal thinking or behavior, and in general for any unusual changes in behavior — such as sleeplessness, agitation, or withdrawal from normal social situations. This monitoring is especially important during the first four weeks of treatment.  SSRI medications usually have few side effects in most children and adolescents, but for unknown reasons, can trigger agitation and abnormal behavior in certain individuals.

          The SSRI medications include those commonly known as Prozac, Zoloft, Paxil, Celexa, Lexapro, and Luvox.   SSRI medications are considered an improvement over older antidepressant medications because they have fewer side effects and are safer if taken in an overdose (which is an issue for patients at risk for suicide). They have been extensively tested in adult populations and have been proven to be safe and effective for adults.

          Currently, there is no way of telling who may be sensitive to an SSRI's positive or adverse effects.  Results thus far are based on populations—some individuals may show marked improvement, some may see no change, and some may be vulnerable to adverse effects.  The response to medication of an individual patient cannot be predicted with certainty from the kind of studies that have been done so far.

          It is extremely difficult to determine whether SSRI medications do or do not increase the risk of completed suicide, especially since depression itself increases the risk for suicide and because completed suicide is a rare event.

          Major depression in children and adolescents is a serious condition that should be adequately treated.  Each child should be carefully and thoroughly evaluated by a physician to determine if medication is appropriate. Those who are prescribed an SSRI medication should receive ongoing medical monitoring, with particular care paid in the first four weeks of taking the drug.

          Psychotherapy is often used as an initial treatment for milder forms of depression.  Many times, psychotherapy accompanied by an early follow-up appointment may help to establish the persistence of depression before a decision is made to try antidepressant medications. Should suicidal thinking or behavior, nervousness, agitation, irritability, mood instability, or sleeplessness emerge or worsen during treatment with SSRI medications, parents should obtain a prompt evaluation by a physician with expertise in these medications.

          Children already on any of the SSRI medications should remain on the drug if it has been helpful, but they should also be carefully monitored by a physician for evidence of side effects. Once started, treatment with these medications should not be abruptly stopped, because of potential adverse reactions. Families should not discontinue treatment without consulting with their physician.

          All treatments can be associated with side effects.  Thus, a careful weighing of risks and benefits, with appropriate follow-up to help reduce risks, is the best that currently can be recommended.

Jerry Kearney

CEO, Abilene Psychiatric Center