Use
of antidepressants in children and adolescents
Background
Several psychiatric disorders
in children have been shown to improve with the use of antidepressant
medication, especially selective serotonin reuptake inhibitors. These include major depression,
dysthymia, obsessive-compulsive disorder, generalized anxiety disorder,
and
social phobia.
Types of antidepressants used
in children and adolescents include:
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Bupropion
Venlafaxine
Nefazodone
Mirtazapine
Of these medications, the
only ones approved for use in children and adolescents are fluoxetine
for major
depression and fluoxetine and sertraline have for obsessive-compulsive
disorder.
Antidepressants and
suicide
In June of 2003, evidence of
an increase in suicidal ideation in pediatric patients treated with
paroxetine
was reported to the FDA. This was
followed by several studies and meta-analyses of existing data to
determine the
safety of antidepressants in children.
In a review of 24
placebo-controlled clinical trials of antidepressants in pediatric
patients,
there was an increased risk of suicidal ideation, with many studies
showing a
relative risk of 2 or more.
However, of the 4600 patients in the 24 trials, there were no
completed
suicides (Hammad et al, 2006).
A Cochrane review of 10
placebo controlled trials of SSRIs for depression had similar findings,
namely
that there was a response to the medication at 8-12 weeks, there was an
increase risk of suicidal ideation in the same time frame (but no
increased
risk of suicide completion.) This
review also found fluoxetine to be the only SSRI with consistent
evidence of
improvement in depressive symptoms across three trials in both children
and
adolescents (Hetrick et al, 2008).
It has been proposed that the
supposed increased rate of suicidality in patients treated with SSRIs
may in
fact represent a greater likelihood of reporting suicidality to health
care
professionals rather than an actual increase in suicidal ideation
itself. Verbalization and communication
are
known to improve with antidepressant treatment, which may lead to more
openess
concerning suicidality, which is often kept secret among pediatric
patients.
Risk of untreated
depression
There is evidence that higher
SSRI prescription rates are associated with lower suicide rates in
children and
adolescents. (Gibbons et al, 2006).
The absolute rate of adolescent suicide in the United States
deceased
between 1990 and 2000, during a time of increased prescriptions for
SSRIs (Olfson
et al, 2003).
In 2003, a black-box warning
of increased risk of suicidal ideation in pediatric patients treated
with
SSRIs. One study found that
between 2003 and 2005, SSRI prescriptions for children and adolescents
decreased
by 22% in the United States and the Netherlands. (Gibbons
et al, 2007)
This same study found that during 2003-2004, youth suicides
increased by
14% in the United States and 49% in the Netherlands.
This represented the largest year-to-year change in suicide
rates in this age group in the United States ever recorded. This suggests that despite
existing untreated depression are
greater than the risks of pharmacotherapy in this age group.
Monitoring
of pediatric patients on antidepressants
Given some grave side
effects of antidepressants, following the response and progression with
therapy is extremely important. Patient being treated with
antidepressants must be closely monitored for worsening depression and
suicidality after initiation of therapy or change in dose or
medication. Physicians should educate the patient and the family to
monitor for symptoms such as anxiety, agitation, panic attacks,
insomnia, irritability, hostility, impulsivity, akathisia (severe
restlessness), hypomania, and mania, in addition to depression and
suicidality.
FDA initially
recommended specific scheduled monitoring (i.e. weekly monitoring for
four weeks, then every other week for four weeks, etc.); However, this
seemed unrealistic for both patients and physicians, failing to achieve
expected level of care and delivery of health services (Katz et al.
2008). FDA now recommends ÒÉ should be monitored appropriately and
observed carefully by mental health providers and family members.Ó,
which is a case-by case, individualized approach, taking into account
patientÕs social situation, support system, disease severity,
comorbidities, other stressors, and presence of suicidality.
Communication in any mode (in-person, phone etc) including several
office visits should be done for appropriate care and management. This
is especially important when initiating new therapy or changing dosage,
and should be done within the first eight weeks.
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