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.
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