Antidepressants in children

Data supporting efficacy of antidepressants in children and adolescents are sparse. Fluoxetine is the only antidepressant that is FDA approved for treatment of depression in patients less than 18 years of age. 

Daly, J.M. and Wllens, T. (1998) The use of tricyclic antidepressants in children and adolescents. Pediatr Clin North Am. 45 1123-1135. 

As may be expected, studies of antidepressants in treatment of ADHD have not shown a differential effect in ADHD children with or without conduct disorder, depression, or anxiety (Biederman et ah, 1993b). While DMI-treated ADHD children showed a substantial reduction in depressive symptoms compared with placebo-treated patients (Biederman et ah, 1989), DMI appears not to be as powerful an antidepressant in children as the SSRls. (Bostic et ah, 1999). The safety and efficacy of combined SSRl and stimulant pharmacotherapy has been addressed in two open studies and is currently being evaluated in a prospective study conducted by the Resarch Units in Pediatric Psychopharmacology (RUPP) Network (B. Vitiello, personal communication). 

Despite the handicap that the studies were largely developed and conducted with the aim of proving the value of industry products, a metaanalysis of the combined data indicated that antidepressants in children and youth increase the suicide attempt rate and that an estimated 1% to 3% of patients would be at risk of antidepressant-induced suicidality (Hammad et al., 2006). On October 15, 2004, the FDA mandated a black-box warning, and in early 2005, it was finalized (FDA, 2005a). According to FDA requirements for describing adverse drug reactions, a risk of 1% or more is considered common. 

The agency also provided us with a meta-analysis that showed that the estimated efficacy of antidepressants in children was minimal and likely to have been overestimated, because published studies have much more favorable results than unpublished studies. Thus, both clinical experience and published trials are likely to lead to inflated estimates of the efficacy of these drugs. 

Fisher and Fisher (1996) explored the ethical issues surrounding the use of antidepressants in children. They pointed out how published recommendations for the use of antidepressants fly in the face of data within the same publications. They observed, The prescribing of antidepressants for children clearly illustrates how a significant group of practitioners (child psychiatrists and pediatricians) can persist in using a procedure that is actually contradicted by research data and at the same time muster justifications for doing so (p. 101). 

This report was followed by yet another editorial, this time in the British Journal of Psychiatry (Tonkin et al., 2005). Concerning antidepressants in children, it summed up the following ... 

Newman, T. (2004). A black-box warning for antidepressants in children New England Journal of Medicine, 351, 1595—1598. 

Wilens TE, Biederman J, Baldessarini RJ, Seller B, Schleifer D, Spencer TJ, Birmajer B, Goldblatt A. Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and adolescents. J Am Acad Child Adolesc Psychiatry 1996 35(11) 1491-501. 

Data collected under controlled conditions that support the efficacy of antidepressants in children and adolescents are sparse, and no antidepressant, except fluoxetine, is FDA-approved for the treatment of depression in patients less than 18 years of age. In fact, the FDA now requires aU antidepressants to carry a black box warning linking the antidepressants to increased suicidal thoughts and behavior... 

Bupropion is a monocyclic antidepressant that inhibits the reuptake of norepinephrine and dopamine. Bupropion is effective for relieving symptoms of ADHD in children but is... 

The FDA has established a link between antidepressant use and suicidality (suicidal thinking and behaviors) in children, adolescents, and young adults 18 to 24 years old. All antidepressants carry a black box warning advising caution in the use of all antidepressants in this population, and the FDA also recommends specific monitoring parameters. The clinician... 

If depression is a problem, many clinicians prefer an antidepressant as an augmentation strategy. Because of the problems mentioned earlier, most now avoid using TCAs to treat ADHD. Bupropion, SSRIs, and venlafaxine are viable alternatives, and may add to the effect of the stimulant. Bupropion and venlafaxine are believed to offer some additional improvement in attention. SSRIs may be more likely to improve impulsivity. Each should be started at a low dose and increased gradually. None of these are approved for use in children however. 

Apart from symptomatic, general measures (gastric lavage, cooling with ice water), therapy of severe atropine intoxication includes the administration of the indirect parasympathomimetic physostigmine (p. 102). The most common instances of atropine" intoxication are observed after ingestion of the berry-like fruits of belladonna (children) or intentional overdosage with tricyclic antidepressants in attempted suicide. 

Imipramine is the primary representative of typical tricyclic antidepressants. It acts by blocking the mechanism of renptake of biogenic amines. It does not inhibit MAO activity. Imipramine lessens sadness, lethargy, improves mood, and improves the mental and overall tone of the body. It is nsed in depression of varions etiology accompanied by motor cinmsiness and ennresis in children and Parkinson s disease. Primary synonyms of this drag are tofranil, snrplix, imizin, melipramin, and others. 

Suicidaiity in chiidren and adoiescents Antidepressants increased the risk of suicidal thinking and behavior (suicidaiity) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone... 

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). 

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