The FDA issued a public health advisory on March 22,2004 cautioning physicians, their patients and patients’ families about the need to monitor closely all people being treated with antidepressants. The FDA noted an association between the use of ten commonly prescribed antidepressants and an increase in the symptoms of anxiety, agitation, panic attacks, insomnia, irritability, impulsivity, akathisia, suicidality hypomania and mania. These antidepressants were buproprion, citalopram, fluoxetine, fluvoxamine, mirtazepine, nefazodone, paroxteine, sertraline, escitalopram and venlafaxine. This warning came after two recent British reviews concluded that there were risks and adverse events associated with the prescribing of antidepressants. It should be stressed that there were no completed suicides in any of the 4100 children and adolescents enrolled in the studies.
More recently, another study examined more than three million people prescribed fluoxetine or paroxetine, or an older antidepressant, amitriptyline. Using information about patients treated between 1993 and 1999, the researchers concluded that there were no substantial differences in the effect of the three drugs on people ages 10-to-19 years with respect to their suicidal behavior. For each of the drugs, both in adults and in children, suicidal behavior was more common within the first few days to a month of starting the antidepressant. The authors concluded that the most likely explanation is that the antidepressant is not immediately effective. The medication may be prescribed just when the patient’s symptoms and suicide risk are the greatest.
The lessons learned from these studies and from the FDA’s warnings are for patients, their families, and physicians: antidepressants are not trivial medicines, and their use needs to be carefully monitored by both the prescriber and the family. Generally, if a child’s psychiatric symptoms are severe enough to warrant medication, the child should also be followed with psychotherapy services as well. Any child who is prescribed these medications needs to be followed closely by the prescribing physician. New guidelines recommend that a patient be followed for three or more follow-up visits in the first twelve weeks after an antidepressant is started.
Also, parents should be aware that pediatric depression is a serious illness. It carries with it the risk of suicide, as well as risk for substance abuse, pregnancy, poor academic performance, and impaired social functioning. Despite the prevalence of depression, effecting up to six percent of children and adolescents, less than one percent of these children receive the mental health services they need. Suicide is the third leading cause of death among teenagers in the United States. A recent study showed that eight and one-half percent of high school students attempted suicide in the last twelve months.
With better awareness and monitoring children with depression, the recognition and treatment of these children and teens will lead to better acknowledgment and care.