Antidepressants for children: Explore the pros and cons

Antidepressant medications are often an effective way to treat depression and other mental disorders in children and adolescents. However, antidepressants do pose a risk of harmful side effects and complications. In fact, antidepressants are required to carry strong warnings about their possible link to suicidal behavior in children, adolescents and young adults ages 18 to 24.

You may be alarmed about the suicide warnings. But before you panic or refuse to allow your child to be treated with antidepressants, get the facts. Learn what the warnings mean, signs of trouble and other treatment options. This will help you make an informed decision about your child's health.

Why do antidepressants have warnings about suicidal behavior in children?

The Food and Drug Administration (FDA) says that an extensive analysis of clinical trials showed that antidepressants may cause or worsen suicidal thinking or behavior in children and adolescents. The analysis showed that children taking antidepressants had about a 4 percent chance of developing suicidal thoughts or behavior, compared with only a 2 percent chance in children taking a sugar pill (placebo). None of the children in any of the studies actually took his or her own life. Still, the FDA considered the findings so disturbing that in October 2004 it issued a public health advisory and began requiring manufacturers to label antidepressants with strong warnings about the link to suicide in children.

However, not all mental health researchers believe these warnings are necessary. Some studies have reported opposite results — that suicide rates in children decrease when they take antidepressants.

Should children not be treated with antidepressants at all?

Not necessarily. The warnings about a possible link between antidepressants and suicidal thoughts don't mean that antidepressants can't be used to treat children. Nor are the warnings meant to frighten people away from antidepressants. However, the antidepressant warnings should be taken as a caution to carefully weigh the pros and cons of using these medications in youngsters. For many children and adolescents, antidepressants are an effective way to treat depression, obsessive-compulsive disorder or other mental health conditions. If these conditions aren't treated effectively, your child may not be able to lead a happy, fulfilled life or engage in normal, everyday activities. In addition, suicide is a possible complication of depression if it isn't treated.

Which antidepressants must have the warnings about suicide?

Although the FDA analysis examined only nine antidepressants, the agency's concern was great enough to extend the warning to all prescription antidepressants. This warning is known as a "black box" warning. This is the strongest safety warning that the FDA can issue about a prescription medication. The warning is printed in bold type framed in a black border at the top of the paper inserts that come with antidepressants. Antidepressants will also come with a medication guide that advises parents and caregivers about risks and precautions.

What should you do before your child starts taking an antidepressant?

It's important that your child have a thorough evaluation before he or she starts taking an antidepressant. This evaluation should include:

• A physical exam
• A psychiatric exam by a psychiatrist, pediatrician or family doctor

The psychiatric evaluation should include:

• A detailed review of any potential risk factors your child may have that may make it more likely for him or her to engage in self-harm
• An assessment of whether your child may have other mental illnesses such as anxiety disorders, attention-deficit/hyperactivity disorder and bipolar disorder
• An evaluation of whether there's a family history of mental illnesses or suicide

What antidepressants can children take?

Fluoxetine FDA approved
Your child's doctor or qualified mental health professional can prescribe any antidepressant on the market. However, the FDA has officially approved only one antidepressant for the treatment of depression in children — fluoxetine (Prozac).

Off-label options
Doctors can use their medical judgment to prescribe other antidepressants for children. This practice, called off-label use, is a common, and perfectly legal, practice for many types of medications for both children and adults. Fluoxetine is also FDA approved to treat obsessive-compulsive disorder (OCD) in children, as are the antidepressants sertraline (Zoloft), fluvoxamine (Luvox) and clomipramine (Anafranil). Clinical trials of other antidepressants in children with depression, OCD or other disorders have failed to prove that they're significantly more beneficial than a placebo, so they haven't been officially approved for use in children.

How many antidepressant pills should be prescribed at one time?

The FDA advises that prescriptions be provided for the smallest quantity of pills possible. This may help reduce the risk of deliberate or accidental overdose by controlling how many pills your child has access to. This may mean you have to get prescriptions refilled more frequently, but that minor inconvenience can provide added safety for your child. When you get the prescription, be sure to carefully read the medication guide and package insert, and discuss any questions with your child's health care professionals.

What should you do once your child starts taking an antidepressant?

Careful monitoring by parents, caregivers and health care professionals is important for any child or adolescent taking an antidepressant for depression or any other condition. The FDA recommends that your child see his or her health care professional on this schedule:

• Once a week during the first month of treatment
• Every two weeks during the second month of treatment
• A follow-up visit after 12 weeks of treatment
• As recommended after those first 12 weeks

Individual situations vary. Some youngsters may require more frequent or less frequent contact with their doctors or mental health professionals. Make sure you stick to your child's recommended schedule.

What warning signs should you watch for when your child is taking antidepressants?

Sometimes the signs and symptoms of suicidal thoughts or self-harm are difficult to see. They're not always obvious, and your child may not directly tell you that he or she is having such thoughts. Here are some signs and symptoms that your child's condition may be worsening or that he or she may be at risk of self-harm:

• Thoughts about suicide or dying
• Attempts to commit suicide
• Self-injury
• Feeling very agitated or restless
• Panic attacks
• Sleeping problems
• Increasing sadness
• An extreme increase in talking or activity
• Aggression, violence or hostility
• New or worsening anxiety
• Social or academic problems at school
• Spending more time alone

Contact your child's health care professional right away if any of these signs and symptoms occur, if they get worse, or if they worry you, your child, a teacher or other caregiver.

When is the risk of suicide or self-harm at the highest while taking antidepressants?

The highest risk of suicidal thinking and behavior occurs:

• During the first few months of treatment with an antidepressant
• When the dosage is increased or decreased

Parents and caregivers should closely observe children on a daily basis during these transition periods. Remain observant for worrisome changes for the whole time your child takes antidepressants. But don't stop antidepressant treatment without the guidance of your child's health care professional. Suddenly stopping an antidepressant may cause serious withdrawal-type symptoms.

How can medication meant to help treat depression and other illnesses lead to suicidal behavior in children?

Researchers speculate about a variety of potential reasons. In some cases, children may have bipolar disorder. Treating these children with antidepressants could cause an episode of mania — extreme emotional highs — that leads to risky, impulsive behavior and possibly self-harm. Antidepressants may also trigger anxiety, agitation, hostility, restlessness and impulsivity. These effects may occur if the child's depression gets worse, or they could indicate that your child is starting to develop suicidal thoughts.

What are the alternatives to treatment with an antidepressant?

If you're not comfortable with your child taking antidepressants or your child has had a bad reaction to antidepressants, talk to your child's doctor or mental health professional about other treatment options. For instance, a variety of counseling techniques are available, including:

• Psychotherapy
• Cognitive behavior therapy
• Family therapy

Family therapy may be helpful in some cases, to involve the whole family in psychotherapy.