Are antidepressants safe and effective for children and adolescents?
Cheung AH, Emslie GJ, Mayes TL
The Bottom Line:
Only one antidepressant, fluoxetine, has been found to be effective in clinical trials for children and adolescents with depression. The evidence for the effectiveness of all other antidepressants is inconclusive. Furthermore, the risk that suicidal thinking or actual suicide attempts are linked to antidepressants is not clear. The risk of suicide should be kept in mind by prescribing doctors, parents, teachers and friends, who should be alert to any changes in behaviour in the adolescent. Fluoxetine plus cognitive behavioural therapy (CBT) is the best treatment, but children and adolescents on medication should be closely monitored. |
What problem is being addressed?
Although antidepressants are used frequently for the treatment of depression in adults and children, there has been recent controversy about the efficacy and safety of these medications in children and adolescents.
What intervention is being tested?
Treatment for depression in young people under the age of 19 using selective serotonin reuptake inhibitors (SSRIs). SSRIs are a group of drugs that are used to treat depression, anxiety, and obsessive compulsive disorder. They work by affecting the chemical processes in the brain that are believed to cause depression. Although there is a large body of literature about their effectiveness and safety in adults, there have been only a small number of similar studies in children and adolescents.
What is the real scientific evidence?
This is a review of the literature about the safety and efficacy of SSRIs in children and adolescents diagnosed with major depressive disorder of at least moderate severity. It is important to note that efficacy refers to whether or not a treatment works during clinical trials, not whether it works in real-life situations.
The review authors searched medical databases to find randomized controlled trials in which children and adolescents were treated with SSRIs. They also searched conference presentations and used information collected by the U.S. Federal Drug Administration (FDA) to identify studies on the topic.
The reviewers found the evidence for the effectiveness of SSRIs in child and adolescent depression to be inconclusive. The exception was fluoxetine, for which there is good evidence of effectiveness, especially in combination with cognitive behavioural therapy (CBT).
Many of the studies done on different SSRIs had problems with the way they were conducted or reported, so the evidence is lacking as to whether or not the drugs are effective.
Some of the studies showed little or no effect of the medication on depression and showed high adverse reaction rates. Both of these findings could be due to the rating scales used, or to the small number of children and adolescents taking part in the studies, making the results unreliable.
Along with side effects, these studies suggest that antidepressants other than fluoxetine can worsen depression, increasing the risk of suicide attempts, or can make a child with undiagnosed bipolar disorder become manic.
The reviewers also pointed out that the evidence for increased suicide rates is unclear. Depressed adolescents are at high risk of making suicide attempts. Those on antidepressants may say they feel like killing themselves, but studies found that the children on antidepressants were actually less likely to make serious suicide attempts or to actually commit suicide if they were on antidepressants. It is also possible that their suicidal thoughts or attempts may be related to the lack of effectiveness of the antidepressant, not to being on an antidepressant. Doctors, parents, and teachers are urged to watch for changes in the behaviour of a child or adolescent who is taking antidepressants to ensure that symptoms that can signal the intention to commit suicide, or symptoms of deepening depression, are identified and appropriate action is taken to protect the child/adolescent.
The review authors also pointed out that these studies showed that adolescents tend to have a response to antidepressants similar to that of adults. However, it is not clear whether children respond to antidepressant drugs the same way teenagers or adults do, and they may have more side effects that cause them to stop taking the drugs. For this reason, separate studies should be done on children to determine, among other things, the best medications and doses for them.
The preceding is a summary of:
Cheung AH, Emslie GJ, Mayes TL. Review of the efficacy and safety of antidepressants in youth depression. Journal of Child Psychology and Psychiatry 2005, 46(7): 735-754.
