SSRI Use
At the Tarnow Center, I have been answering questions and fielding concerns regarding SSRI use for months now. It began with the United Kingdom’s word of caution and concern regarding Paxil. It became a concern that different adverse effects labeled as “emotional lability” in the Glaxo Smith Kline studies with Paxil may have included suicidal ideations or increased thoughts of self-harm. No suicides occurred, however, in some of the studies, the risk of “possible suicide related behaviors” appears significantly increased. Paxil had been approved for children with anxiety, but not Major Depressive Disorder. In all the studies and case reports, the risk of suicidal thoughts increased only in children or adolescents that were depressed or agitated. No increased risk occurred in patients who had been treated for anxiety disorders.
Since those initial reports, the other SSRI’s, including Zoloft (sertraline), Lexapro (citalopram), Effexor (venlafaxine), Wellbutrin (bupropion), Luvox (luvoxamine), and Prozac (Fluoxetine) have also come under scrutiny by the FDA, and thousands of concerned parents. At this time, Prozac is the only SSRI approved by the FDA for Major Depression in children and adolescents. Prozac has been used the longest and subsequently has the most data collected on it. It should be noted that in all of this data, there is absolutely no statistically significant increases in suicidal behaviors in children or adolescents with depression. Can we extrapolate from data on Prozac that all SSRI will be the same in both efficacy and side effects? No, all physicians and researchers will agree that more data needs to be collected. Further studies should be performed in manners that monitor compliance, stratify analysis by age, and provide a clear definition of suicidality. At this time, there is no “clear and easy” scientific answer to the questions of increased suicidality because of the differences in definitions and other variables.
Another common question fielded then is: “Should we change to Prozac?” The answer is exactly the same as before this controversy started. For example, medication should be changed if the current medication’s risks (or side effects) outweigh the benefit. The reason that so many of the different SSRI’s have been used in children and adolescents without FDA’s official brand of approval is because Prozac does not work for everyone. In addition, the risk of not treating a child or adolescent with Major Depressive Disorder is tremendous. I worry that the risk of not treating Major Depression has been seriously underestimated compared to the risks of today’s first line of treatment for depression.
The Staggering Statistics:
To fully appreciate the seriousness of depression in children and adolescents, let us review depression’s epidemiology. According to a recent 10-year review printed in the Journal of the American Academy of Child and Adolescents Psychiatry, the lifetime prevalence rate (rate of occurrence over the teenage years) of major depressive disorder in adolescents is estimated to range as high as 15% to 20 %. This is equal to the rate of depression in adults. In children, rate of occurrence at any give time is between .4% and 2.5%.
The average length of a depressive episode is 7 to 9 months. During these months, functioning typically greatly declines. The depressed youth is at great risk for
severe impairment in school performance and interpersonal relationships. Depression is also associated with an increased risk for suicidal and homicidal thoughts and behaviors, tobacco, alcohol, and other substance abuse, early pregnancy, and increased physical problems. The investigators who followed the youths into adulthood recorded recurrence rates of depression as high as 60%-70%. Additionally, they determined that overall prognosis declined with an increased number of depressive episodes. If the depression is left “sub-clinical” or partially treated, the child or adolescent continues with so many of the same overly negative perceptions about themselves and the world that many of the same serious risk factors remain present.
Evidence through epidemiology studies indicates that Major Depressive Disorder in children and adolescents is occurring more commonly and at a younger age. The most tragic consequence of this fact is that the adolescent suicide rate since 1950 has quadrupled. At this time, suicide represents 12% of adolescent deaths. With these statistics, it is no wonder that the treatment of such a common, potentially lethal disorder has been an intensely debated topic.
Treatment of Major Depression in Children and Adolescents.
The first-line treatment for Major Depression to date has included both therapy and medications. As mentioned, Prozac and its SSRI family of medications have been used commonly due to their lack of physical side effects, ease of administration and lack of major drug-interactions. Prozac has been officially approved by the FDA but other medications, such as Zoloft, also have randomized, controlled trials in hundreds of patients demonstrating efficacy. Unfortunately, I believe that due to these medications overall safety compared to the older antidepressants, the SSRI’s have not always been monitored and respected as a potential cause for problems. The most typical SSRI side effects are mild and relatively benign; they include headache, stomachache, dizziness, sleepiness or insomnia, and possible sexual side effects. In certain patients, side effects can include increased energy experienced as restlessness or even agitation and worsening of mood. If followed closely, this problem is quickly resolved by stopping, changing, or decreasing the medication. When left unattended, the “energized” depressed mood can exacerbate symptoms leading to the possible development of thought of self-harm or even suicide.
As a child and adolescent psychiatrist, I was aware of this potential development before I ever wrote my first SSRI prescription. There have always been patients that respond negatively to all of the antidepressants. Fortunately, the risk factors helping to identify this certain group of potentially problematic patients have been well documented. These risk factors include a history of bipolar disorder, a strong family history of bipolar disorder, a history of rapid mood swings and/or easily agitated behaviors. Any history that sounds close to a previous manic episode should have the clinician on alert. The risks of mixing antidepressants with substances of abuse should also be considered and cautioned. The problem with children and adolescents is that their brains are in development. This means that their psychiatric history is in development. For example, some studies have demonstrated that up to 40% of the children and adolescents who have a Major Depressive Episode eventually develop Bipolar Disorder. These factors clearly make the risk of treating depression in children and adolescents higher than the risk of treating adults. Children and adolescents are not mini-adults and adult data cannot be extrapolated onto them; they are patients in constant flux and cannot be as easily predicted. If anything positive comes out of this controversy, I hope it is that clinicians and parents will understand the importance of close monitoring of all psychoactive medications given to children and adolescents. Young patients should be followed closely during times of initiation, change or increase in dosage of their psychoactive medications. In addition, they should have at least quarterly follow up visits to discuss continued efficacy and possible side effects. The importance of regular follow up is because the young patient’s brain is in constant change as it matures.
To prevent problems, education is crucial. Through therapy, even a young child can learn to help monitor a medication’s efficacy and possible side effects. The more knowledge both patient and parent has, the less likely a problem goes undiscovered. To get the most appropriate education of psychoactive medication in children, I recommend seeing a child psychiatrist.