Children antidepressants

Supportive care Supportive care, especially for elderly and people with renal disease Supportive care rv Mannitol Supportive care Tricyclic antidepressants Children more vulnerable than adults... 

Wilens TE, Biederman J, Spencer TJ Case study adverse effects of smoking marijuana while receiving tricyclic antidepressants. J Am Acad Child Adolesc Psychiatry 36 481 85, 1997... 

Unfortunately, the mood stabilizers have not proved very helpful in the treatment of uncomplicated ADHD. They can, however, help the child or adolescent who has ADHD complicated by severely disruptive behavior. For example, a child with ADHD or ODD who is prone to outbursts of rage that are not controlled by other medications such as antidepressants or clonidine may require a mood stabilizer. 

Take a Medication Holiday. Some side effects are not a problem on a daily basis nonetheless, they can be qnite distnrbing. The best examples are sexual side effects of some antidepressants or the possible effects of stimulants upon the growth of children with ADHD. One approach has been to skip taking the medication for a brief period of time. For example, those with antidepressant-induced sexual dysfunction have sometimes circnmvented this problem by skipping a single day s dose when they plan to have sex. In a similar fashion, parents concerned with the effects of stimulants on their child s growth may have their child skip doses on the week-... 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of trazodone or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Trazodone not approved for use in pediatric patients (see Clinical worsening and suicide risk and Children sections in Warnings). 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of olanzapine/fluoxetine or any other antidepressant in a child or adolescent must balance this risk with clinical need. 

Can antidepressants such as tricyclics or buproprion augment the effect of stimulants on nondepressed children with ADHD Randomized controlled trials have yet to address this question. Nonetheless, such combinations are common in clinical practice. One case report showed leukopenia in a child treated with a combination of MPH and tricyclics for 4 months, although the doses were not specified (Burke et ah, 1995). Another case report indicated that obsessive-compulsive symptoms developed secondary to the combination of MPH and tricyclics (Pataki et ah, 1993). On a cautionary note, MPH has been found to interact with guanethidine to produce paradoxical hypotension. Patients on monoamine oxidose (MAO) inhibitors are likely to develop hypertensive crises if given a stimulant. 

Coadministration of beta-blockers can potentiate rebound hypertension upon discontinuation of medications, and it is therefore recommended that the beta-blocker be withdrawn before the tt2 agonist (Physicians Desk Reference, 2001). Tricyclic antidepressants may also produce changes in sinus node and AV conduction, and it is recommended that they be used cautiously in combination with tt2 agonists (Physicians Desk Reference, 2001). However, in child psychiatric practice, there has been debate about whether there are adverse interactions related to concomitant use of tricyclics and tt2 agonists. Finally, the tt2 agonists may potentiate the effects of CNS depressants (e.g., barbiturates) or other medications that produce sedation, so lower doses of each may be warranted. 

Tricyclic antidepressants also have a documented syndrome associated with withdrawal from medications (Petti and Law, 1981). This syndrome can mimic appendicitis or the flu, and can include such symptoms as nausea and vomiting, headache, lethargy, and abdominal pain. If a child on TCAs presents with withdrawal symptoms, questions of compliance must be addressed. 

Blederman,]. (1991) Sudden death in children treated with a tricyclic antidepressant. / Am Acad Child Adolesc Psychiatry 30 495 97. 

Varley, C.K. and McClellan, J. (1997) Case study two additional sudden deaths with tricyclic antidepressants. / Am Acad Child Adolesc Psychiatry 36 390—394. 

Ryan, N.D., Puig-Antich, J., Rabinovich, H., Fried, J., Ambrosini, P., Meyer, V., Torres, D., Dachille, S., and Mazzie, D. (1988). MAOIs in adolescent majot depression unresponsive to tricyclic antidepressants. J Am Acad Child Adolesc Psychiatry 27 755— 758. 

Abramowicz, M., ed. (1990) Sudden Death in Children Treated with a Tricyclic Antidepressant. Med Lett Drugs Ther 32.53. Abramowitz, A.J. (1994) Classroom interventions for disruptive behavior disorders. Child Adolesc Psychiatr Clin North Am 3 343-360. 

Most child and adolescent studies published thus far have focused on the effects of the tricyclic antidepressants (TCAs) and, more recently, the SSRIs. A few open studies have also shown that monoamine oxidase inhibitors (MAOIs) can be used safely with children and adolescents (Ryan et ah, 1988b), but noncompliance with dietary requirements may present a significant problem for minors. Other antidepressants, including the heterocyclics (HTC) (e.g., amoxapine, maprotiline), buproprion, venlafaxine, and nefazodone, have been found to be efficacious for the treatment of depressed adults (APA, 2000), but they have not been well studied for the treatment of MDD in children and adolescents. Therefore, this chapter mainly describes the use of SSRIs and TCAs for youth with MDD. 

Many of the children and adolescents seen for treatment of depression are experiencing their first depressive episode. Because the symptoms of unipolar and bipolar depression are similar, it is difficult to decide whether a patient needs only an antidepressant or concomitant use of mood stabilizers. As noted above, symptoms and signs such as psychosis, psychomotor retardation, or family history of bipolar disorder may warn the clinician about the risk of the child developing a manic episode. 

Emslie, G., Walkup, J., Pliska, S., and Ernst, M. (1999) Nontricyclic antidepressants current trends in children and adolescents./ Am Acad Child Adolesc Psychiatry 38 517-528. 

FIGURE 47.1 Suggested algorithm for the use of psychotropic medications in the medically ill child or adolescent. CNS, central nervous system GI, gastrointestinal SSRI, selective serotonin reuptake inhibitor TLA, tricyclic antidepressant. 

Similarly, Kaplan and Busner (1997) assessed the prevalence of psychotropic use during 1991 among inpatient pediatric (< 18 years) populations who were treated by child psychiatrists in a New York suburban area. One state, one county-university, and one private hospital were surveyed. Findings showed that overall, 79% (state), 68% (county-university), and 76% (private) of the child and adolescent patients in the population received a psychotropic treatment during the course of the study. The prevalence of antidepressant treatment in the private hospital was very high (80%) but relatively low in the other hospitals (26% each). Antipsychotics were prescribed to 74% of the county hospital patients, and to 57% and 35% of the patients at the other locations. Stimulants were prescribed only rarely (2%, 3%, and 4% of patients). Lithium was prescribed to 35% and 34% of state and county hospital patients, respectively, and to 16% of private hospital patients. Other mood stabilizers (anticonvulsants) were prescribed frequently to private and county hospital patients (31% and 23%, respectively). 

In 1995, Bramble published a study on the prescription frequency of antidepressants by British child psychiatrists (Bramble, 1995). A brief postal questionnaire was circulated to 350 members of the British Royal College of Psychiatrists, Child and Adolescent Psychiatry Specialist Sections. There was a 71% response rate, and 85% of the 238 respondents had employed antidepressants, the most popular of these being amitriptyline and imipramine. Nearly one-third of the psychiatrists at that time used neuroagents occasionally, and the SSRIs were used only very rarely. The antidepressant medication was used for a wide range of child and adolescent disorders beyond those of depression and nocturnal enuresis. Approximately 20% of the prescriptions were given for ADHD (hyperkinetic disorder), conduct disorder, and a few cases of autistic disorder. Clomipramine was apparently given for OCD. On the basis of these 1994 data. Bramble concluded that British child psychiatrists tend to use antidepressant medication far less often than American psychiatrists. 

A survey on the use of antidepressive agents by an entire country s child and adolescent psychiatric services was recently conducted in Denmark (5 million inhabitants) by sending a questionnaire to all child and adolescent psychiatric departments and specialists with private practices. The response rate from all in- and outpatient clinics as well as from specialists with their own practice was 93.5%. Thirty-two departments and specialists received the survey and 30 were returned. Practitioners were asked to go through their files and report the number of children on medication and the indications for the treatment. Altogether, approximately 5000 children and adolescents were in psychiatric care (out of approximately 1 million children and adolescents in the age group 0-19 years). Of these, 400 (8%) were treated with an antidepressant on the date of the survey (February 8). 

Bramble, D.J. (1995) Antidepressant prescription by British child psychiatrists practice and safety issues. J Am Acad Child Adolesc Psychiatry 34 327—331. 

Sorensen C.B., Jepsen E.B., Thomsen P.H., and Dalsgaard S. (2002) Indications for and use of antidepressants in a country s child and adolescent psychiatry—a cross-sectional survey in Denmark. Eur Child Adolesc Psychiatry (in press). 

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