What are the risks of treating my teenager with an antidepressant?
Although various antidepressant medications are effective in treating adults with depression, these medications may not be as effective in treating children and adolescents. Monitoring of medication therapy must be done very closely.
Little scientific data are available regarding medication use in children and adolescents. In years past it was often presumed that medications worked in young people the same as in adults. Clinical trials rarely included persons under the age of 18 years. FDA approval for most psychotropic medications is strictly applicable to adult populations. The use of many anti-depressants in children and adolescents is therefore considered "off label." Before the development of SSRIs, children and adolescents were rarely treated with antidepressants. The TCAs and MAOIs that were available had potentially harmful side-effect profiles that outweighed the benefit of the treatment. This was in part because clinical studies in persons under 18 did not demonstrate antidepressants to be more effective than placebo. When SSRIs entered the market, however, because of their better safety profile, prescriptions for antidepressants in children and adolescents increased dramatically. There was clearly a need for safe, effective treatments, because untreated depression can have serious adverse outcomes. In recent years studies of SSRIs have been conducted in children and adolescent populations, with efficacy demonstrated in some. One observation from SSRI studies (that was also noted in the early studies using TCAs) was the presence of a relatively high placebo response rate. Adolescents may benefit from the supportive contact with the treatment provider and thus "respond" to the placebo. Talk therapy is clearly a necessary part of treating depression in children and adolescents, even if on medication. Currently, medications with FDA approval for treatment of depression in pediatric populations are fluoxetine and escitalopram. Sertraline, fluoxetine, and fluvoxamine have FDA approval for treatment of pediatric obsessive-compulsive disorder.
Antidepressant therapy for children and adolescents can be a difficult decision for many parents who are wary of starting a medication for emotional or behavioral problems. Many teens too are wary of taking medication for fear of being labeled as "crazy." As with adults, the risk of taking medication must be balanced against the risk of forgoing medication treatment. When it comes to children and adolescents, understanding the risks of medication can be more difficult, however, because of the scarcity of scientific studies, as well as the evidence for higher placebo responses than in adults. Certainly, the severity of the depression must be taken into account when weighing the risks. With more severe depression, the response to a talk therapy intervention alone will likely be slower. In addition, there have been recent concerns about the possibility of increased suicidal thinking in children and adolescents who are prescribed SSRIs. An analysis by the FDA of all the studies of newer antidepressants showed a rate of suicidal behaviors in 3% to 4% of children and adolescents with depression who took an antidepressant and a rate of 1% to 2% of those taking a placebo (inactive pill). Of note, there were no deaths by suicide in any of the studies. Also, there was no difference in the rate of suicidal behavior for those being treated with an anti-depressant for an anxiety disorder. The results of the analysis prompted the FDA to require a warning on all antidepressants regarding the risk of increased suicidal behavior (thoughts or actions) when used in children and adolescents. Although this can be disconcerting for any parent, it is important to keep in mind that the risk for suicide in untreated depression is approximately 15%. Reasons for the increased rate while on medication may be due to some of the factors described in Question 63, but it is not understood at this time. What is important to keep in mind is the necessity for close monitoring. As in adults, depression is a condition that is associated with suicidality. Whether on an antidepressant or not, patients need to be closely monitored for the onset of such symptoms or worsening of existing symptoms. Keeping the data in mind, in contrast to fears of increased suicidal tendencies, data from around the world actually document that the suicide rate among teenagers had dropped concordant with increased prescribing of SSRIs for depression. Recent data have also shown that in the year after the warnings were placed on antidepressants, the suicide rate among teenagers actually climbed.