Antidepressants For Children And Adolescents

Introduction

Mental health, when deteriorating, can be a challenging problem to deal with. It is especially delicate during adolescence. However, to battle depression, physicians have resorted to prescribing antidepressants. 

So, what are antidepressants? They are a class of psychiatric medications primarily designed to decrease symptoms of depression and other mood disorders.¹ They work by changing the levels of neurotransmitters in the brain, such as serotonin, norepinephrine, and dopamine.² 

The goal of antidepressants is to improve mood, reduce feelings of sadness and hopelessness, and restore a more balanced emotional state. 

Mental health issues can creep up at any age, this includes children and adolescents. It is imperative to watch over this as it can significantly affect their growth, well-being and development. Hence, to battle this, antidepressants are sometimes a choice of treatment.

Prevalence of mental health issues in children and adolescents

According to the World Health Organisation (WHO), more than 264 million people were diagnosed with depression in 2020 globally.³ In particular, a meta-analysis of 29 studies including 80,879 youth (globally) has shown that anxiety and depression were 25.2% and 20.5% in children and adolescents, respectively.⁴ These stats have doubled during COVID-19, highlighting the importance of tackling this issue for our new generation. 

Mental health issues can affect our daily functioning and well-being. This can include:^{1, 3, 5, 6}

1. Cognitive impact:
   • Concentration: Anxiety can make it challenging to focus on tasks, leading to decreased productivity and performance.
   • Racing thoughts

2. Emotional impact:
   • Mood swings
   • Depression

3. Physical impact:
   • Sleep disturbances
   • Muscle tension: Chronic anxiety can cause muscle tension, leading to headaches, body aches, and overall discomfort.
   • Fatigue: Constant worry and stress can contribute to mental and physical fatigue.

4. Social impact:
   • Isolation: Individuals with anxiety may withdraw from social activities and relationships due to fear/discomfort.
   • Impaired relationships: Communication difficulties and excessive worry can strain relationships with family, friends, and colleagues.

5. Behavioural impact:
   • Avoidance: Anxiety may lead to avoidance behaviours, where individuals steer clear of situations that trigger their anxiety, limiting their experiences and opportunities.
   • Procrastination: Fear of failure or making mistakes can lead to procrastination and avoidance of responsibilities.

6. Health impact:
   • Increased health risks: Chronic anxiety has been linked to various health issues, including cardiovascular problems, gastrointestinal disorders, and compromised immune function.

7. Quality of life:
   • Diminished quality of life.

Types of antidepressants

Selective serotonin reuptake inhibitors (SSRIs)

A class of drugs known as selective serotonin reuptake inhibitors(SSRIs) are frequently used to treat a variety of mental health issues, most notably anxiety and depression. The brain neurotransmitter serotonin, which is essential for mood regulation, is modulated by SSRIs as part of their mechanism of action.² Examples of these drugs include fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram.² These drugs were chosen due to their safety profile, as they are almost devoid of life-threatening side effects.² All SSRIs work by inhibiting the reuptake of serotonin and as a result, increase the synaptic concentration of serotonin in the cortex causing therapeutic response.⁷

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Another class of drugs, known as serotonin-norepinephrine reuptake inhibitors (SNRIs), are being used as a method of therapy; they are a relatively new set of antidepressants and have a profile of effectiveness comparable to tricyclic antidepressants and higher than SSRIs, especially in severe depression.⁸ This is due to their double polarity reuptake inhibition of serotonin and norepinephrine.⁸ Some SNRIs used include milnacipran and venlafaxine.⁸ SNRIs also showed analgesic efficacy in relieving diabetic neuropathic pain, polyneuropathy pain and neuropathic pain following breast cancer, as well as chronic headaches and fibromyalgia.⁹

Other antidepressant classes

The first agents to be introduced in the 1950s included tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).¹⁰ TCAs were the cornerstone treatment until the 1990s and their action is based on their ability to modulate norepinephrine and serotonin synaptic transmission to different extents.¹⁰ Historically, TCAs have been the most consistently successful antidepressant treatment option for chronic or neuropathic pain.⁹ However, safety and tolerability concerns may limit their use; they can exhibit anticholinergic, hypotensive or sedating reactions and are associated with impaired cognitive function.¹¹

Indications for antidepressant use in children and adolescents

When assessing kids with depression, it is logical to assess them for other psychiatric disorders such as anxiety, attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) as child depression is highly comorbid with other disorders.¹² However, even though children are not as emotionally mature as adults, child depression is very similar to adult depression. Therefore, the same criterias are used to diagnose paediatric and adult depression.¹² Some symptoms are less frequent in children when compared to adolescents/adults such as suicide attempts and lethality of the attempts, however, suicidal ideation is equally frequent.¹² There are several validated and well-known methods used to diagnose paediatric depression. Some of these examples include:¹²

• Child and Adolescent Psychiatric Assessment (CAPA)
• Diagnostic Interview Schedule for Children (DISC)
• Children’s Interview for Psychiatric Symptoms (ChIPS)
• Diagnostic Interview for Children and Adolescents (DICA

The use of antidepressants in treating children/adolescents with depression can have benefits as well as side effects; all antidepressants may induce psychiatric and suicide-related adverse events in certain individuals, among other symptoms such as sedating reactions. ^{11, 13} However, antidepressants demonstrated improved mood and decreased pain. ^{9, 14} Therefore, it is quite important to proceed with antidepressant therapy with care and monitor it closely.

Guidelines and recommendations

The American Academy of Child and Adolescent Psychiatry (AACAP) has provided a guideline for the doses and formulations of antidepressants taken and alternative approaches. It is important to have a multidisciplinary approach regarding a child’s or adolescent’s mental health to provide the best outcome possible. An example of SSRI guidelines provided by AACAP is demonstrated in Table 1.

Table 1. SSRI dosage and formulation ¹.

Note: Prozac is FDA-approved for children aged 8 and above.

Monitoring and side effects

Like any other medications, antidepressants can impose multiple side effects; for example, TCAs are known to have an adverse side-effect profile and are toxic in overdose, so the risk of prescribing TCAs outweighs the possible benefits in children and adolescents (who have a high rate of suicidal behaviour). ¹⁴ SSRIs are a safer option compared to TCA; however, these remain a regulated process to prescribe as their discontinuation may cause side effects (seen in Table 2). Additionally, when medications can pose a health risk, it is important to have a black box warning which is a warning header that notifies the public of serious or permanent/fatal side effects.

 Table 2. Summary of symptoms associated with SSRI discontinuation.¹⁵

Alternatives and complementary approaches

Before considering medication as a method of treatment, it is worth trying alternative therapies that can improve the patient’s life or the efficacy of antidepressants, such as:¹

• Psychosocial treatment: cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and attachment-based family therapy.
• Lifestyle modification: exercise, better diet/sleep, supportive interventions
• Supportive family/school environment.

Challenges and controversies

Some studies suggest that the benefits of SSRIs have been exaggerated, including those of fluoxetine, and the adverse effects have been downplayed. ¹⁴ This makes it difficult to rely on this treatment as a solution for mental disorders; for example, the rate of suicidal thinking/behaviour, including actual suicide attempts, was double in youth taking medications (4%) than those taking placebo/sugar pills (2%). ¹ Additionally, it may put the patients at risk as the treatment may not work for them; not everyone reacts to antidepressants at the same levels, and some may have better tolerance than others, while some may not experience improvement.¹ Furthermore, some cultures may look down on antidepressants and stigmatise their use, which can hinder some people from receiving therapy that can be beneficial for their health.¹

Conclusion

When considering antidepressants as a therapy, it is important to understand how they work, their side effects and benefits as well as be aware of the alternatives. Antidepressants show a variable response between individuals and while some may benefit from them through short-term use, some may require a longer treatment. It is advisable to discuss this with your therapist/healthcare provider to make a well-informed decision about your mental health.