Commentary: Clinical perspective on pediatric depression
How the evidence tipped SSRIs’ risk-benefit balance
Recently, a panel of psychiatrists and primary care physicians discussed the FDA’s earlier advisory and its effect on depression treatment.15 Overall, the FDA findings seemed not to have convinced these clinicians of a link between suicide and SSRIs. They commented that:
- the FDA has not established a “firm causal connection” between suicide and SSRIs but uses the term “activation syndrome” (Box 2)15-18
- “activation” may give some depressed patients “the energy to carry out things they have been somewhat inhibited from doing”
- “antidepressant jitteriness syndrome” has been observed more frequently in patients diagnosed with panic disorder or somatizing anxiety than with major depressive disorder, and very little evidence exists to link this syndrome with suicide risk.
Recommendations. As this dialogue continues, how should clinicians care for pediatric patients with major depressive disorder? We suggest the following approach:
- For patients taking antidepressants, recommend that they not stop the medication abruptly, as this may result in severe withdrawal syndrome and increase the risk of depressive relapse. If you discontinue SSRI therapy, taper the dosage over 1 to 2 weeks while monitoring for risky and suicidal behavior.
- For patients newly diagnosed with severe depression, fluoxetine remains an option to use with caution. This includes making an accurate diagnosis, monitoring for suicidality, minimizing side effects, and preventing drug interactions.1
Children with depression often exhibit somatic symptoms such as abdominal pain, headaches, or irritability. Adolescents are more similar to adults, exhibiting sad mood, boredom, apathy, lack of energy, and vegetative signs. Girls and boys are equally at risk for depression until puberty, when prevalence rates for girls begin to rise above those for boys.
Up to 6% of teens meet criteria for major depressive disorder, and up to 25% are affected by it by late adolescence.19 Untreated pediatric depression is associated with substantial morbidity, reduced academic performance, substance abuse, interpersonal problems, social withdrawal, and a poor quality of life.20,21 Depression is a major risk factor for suicide, the third-leading cause of death among U.S. teenagers.
Because treating bipolar depression with antidepressants can cause switching to mania, rule out bipolar depression and mixed episodes before prescribing antidepressants. Bipolar illness may be characterized by marked irritability—also seen in depressed children and adolescents (Box 3).19,21
Informed consent. Inform the patient and parents of antidepressants’ labeling and side effects. Discuss the possibility of disinhibition and impulsivity during initial therapy, which may increase the risk of suicidal ideation or suicide attempts.
Dosing. Although SSRIs do not show a clear dose-response relationship, their side effects are considered dose-dependent.22 Therefore, start children on lower dosages than are used in adolescents and adults, and monitor very closely.
Nondrug intervention. CBT and other psychotherapies have shown short-term benefits for depressed children.23 Therefore, to improve SSRIs’ risk-benefit ratio, you may wish to reserve antidepressants for youths:
- with moderate to severe depression, recurrent depression, or a three-generation family history of depression
- who are unlikely to respond to psychotherapy alone, behavioral or environmental change, or general emotional support.
CONCLUSION
Deciding to start, continue, or discontinue SSRIs and other antidepressants in depressed children and adolescents is difficult for clinicians, patients, and their families. Despite data showing increased suicidal behavior in some pediatric patients, SSRIs—when used with caution—remain an important depression treatment in this population.
Related resources
Drug brand names
- Bupropion • Wellbutrin
- Citalopram • Celexa
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Mirtazapine • Remeron
- Nefazodone • Serzone
- Paroxetine • Paxil
- Sertraline • Zoloft
- Venlafaxine • Effexor
Disclosure
Dr. Elizabeth Weller receives research/grant support from Forest Pharmaceuticals, Organon, and Wyeth Pharmaceuticals and is a consultant to Johnson & Johnson, Novartis Pharmaceuticals Corp., AstraZeneca Pharmaceuticals, and Otsuka Pharmaceutical.
Joon Kang reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Ronald Weller receives research/grant support from Wyeth Pharmaceuticals, Organon, and Forest Pharmaceuticals.
