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Prescribing SSRIs for Depressed Children and Adolescents

Current Understandings

  • Depression is a significant illness, and can affect all aspects of a young person’s life, including relationships, academic performance, and loss of enjoyment and pleasure in day to day life.
  • Depression by itself puts young people at risk for suicidal feelings, suicide attempts, and in some cases, completed suicide.
  • While there are risks to treating any illness, the benefits of treating depression outweigh the risks.
  • The Utah Youth Suicide Study showed the young people who commit suicide are not in treatment and are not taking medications. [Moskos: 2005]
  • When the use of SSRI’s in teenagers rose exponentially in the mid 1990’s, the teen suicide rate dropped for the first time in many decades.
    • Overall suicide rates for adults and teens have dropped in 14 industrialized nations when the use of SSRI’s increased.
  • The best treatment study available was recently published in the Journal of the American Medical Association. [March: 2004] The Treatment of Adolescent Depression Study (TADS) included 439 patients, and demonstrated:
    • There was a significant response to medication (fluoxetine); and
    • The group with the best response got therapy and medication.
  • Fluoxetine is the only FDA approved medication for children and teenagers with depression, although several SSRI’s are approved for anxiety disorders.
  • There are other SSRI’s that have the support of good research for depression in young people:
    • Sertraline and
    • Citalopram.
  • Still other SSRI’s for children/teenagers may be supported by some studies, but there are alternative studies which do not demonstrate effectiveness (despite being effective in adult populations).
  • Why is it harder to demonstrate effectiveness of these medications in young people? Children and teenagers have high “placebo” response rates---don’t confuse placebo with no treatment. Placebo effects are large in young populations.
  • With some SSRI’s, new onset of suicidal feelings or actions exceeded the rate for placebo (sugar pill). While this only occurred with about 2% of patients, it raised concerns for doctors and the FDA.
  • Like many medications, some patients have side effects, and a small percentage of patients will worsen clinically on a given medication. Why?
    • Some depressed patients may have Bipolar Disorder, and giving them an anti-depressant may worsen their condition. (They need mood stabilizers, a different category of medications.)
    • Some patients may not respond to the antidepressant, and the course of their illness will get worse.
    • It is believed that some suicidal patients won’t harm themselves because they lack energy. Antidepressants may give them energy before having any effect on their suicidal feelings.
    • A small number of patients can have peculiar reactions to a specific medication that are not seen with other patients, i.e. agitation or anger.
  • In any case, parents and/or teenagers should contact their doctor if there are any unwanted effects from medication, so good decisions can be made.
  • Most of the risk of a new medication is in the first week or two, and after that the risk goes down significantly.
    • Reducing stress the first few weeks is an important step.
    • Good supervision and support are essential.
    • Keeping the home as safe as possible is also important.
  • It is the parent’s responsibility to monitor the situation on a daily basis, to ask the child/teenager regarding their mood and any impulses to act out, and to call the doctor if there are concerns. For any crisis after hours and weekends when the primary provider can not be reached: see all Crisis Intervention Mental Health services providers (87) in our database.
  • Although they can still be used in young people, the relative benefit to risk ratio of paroxetine and venlafaxine are uncertain. There were more problems with new suicidal thoughts/behaviors compared with other SSRIs.
  • Consider the severity of the depression when choosing treatment options. If the depression is mild to moderate, you can start with therapy.
  • More severe depression, with moderate to severe symptoms, usually requires medications, or optimally---medicine plus therapy.
  • Child psychiatrists are unhappy with the quality and amount of research done so far with depressed young people. They are happy to have some research available, but the national organization is lobbying for kids, and asking for:
    • More research funding;
    • Better study designs;
    • A national registry for all pharmacology studies;
    • Publication of all results, both positive and negative.

Resources

Services

Crisis Intervention Mental Health

See all Crisis Intervention Mental Health services providers (87) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Compiler: Information compiled by Medical Home Portal authors and staff
Content Last Updated: 10/2009

Page Bibliography

March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.
JAMA. 2004;292(7):807-20. PubMed abstract

Moskos M, Olson L, Halbern S, Keller T, Gray D.
Utah youth suicide study: psychological autopsy.
Suicide Life Threat Behav. 2005;35(5):536-46. PubMed abstract