Today’s post is the fourth in a series on Hot Topics in Children’s Mental Health offered in recognition of National Children’s Mental Health Awareness Week (May 6-12), and National Children’s Mental Health Awareness Day (May 9). We’ll look at a topic today that’s generated lots of controversy…the safety of antidepressant medication in children and teens.
Few topics in child and adolescent mental health have generated as much controversy over the last decade as the debate about the safety of antidepressant medication given to kids. In 2004, the FDA issued a “black box” warning claiming that antidepressant use in children and teenagers is associated with increases in suicidal thinking and behavior, which was expanded in 2007 to include adults between the ages of 18 and 24. In my opinion, the larger controversy about antidepressant use in children and teens is not “are they safe?” but “do they work?” and if they work, what do they work for? Some of those questions were addressed here.
In an effort to help parents make sense of what they read and hear, we’ll examine the findings of two large studies.
The first study (funded by the National Institute of Mental Health) was conducted by Dr. Jeff Bridge and his team at the University of Pittsburgh, analyzing results of 27 clinical trials of antidepressants…fifteen studies involved kids with depression, six with Obsessive-Compulsive Disorder (OCD) and six with non-OCD anxiety…encompassing 5,310 patients under the age of 19.
Important take-home points…
No child or adolescent patient to date in any trial of antidepressant medication submitted to the FDA or included in Dr. Bridge’s analysis actually committed suicide.
The number of patients who must receive a specific treatment for one to benefit (Number Needed to Treat-NNT) or for one patient to be harmed (Number Needed to Harm-NNH) varied for antidepressants depending upon the condition the child or teen was receiving treatment for in the study.
Major Depression: Number Needed to Treat=10 Number Needed to Harm=112
OCD: Number Needed to Treat=6 Number Needed to Harm=200
Non-OCD Anxiety: Number Needed to Treat=4 Number Needed to Harm=143
To clarify, patients with depression were eleven times more likely to experience significant benefit from antidepressant medication than to experience medication-related suicidal thinking or behavior, patients with OCD were thirty-four times more likely to experience benefit and patients with non-OCD anxiety were thirty-six times more likely to experience benefit.
The second study (also funded by the National Institute of Mental Health) was conducted by researchers at the University of Chicago examined suicidal thoughts and behaviors in 9,165 patients (including 708 youth) treated with fluoxetine or venlafaxine for depression (all of the youth were treated with fluoxetine). In the four studies of youth on fluoxetine, the medication was effective in treating symptoms of depression, and no evidence of increased suicide risk was seen. At the same time, there was no evidence that a reduction in depressive symptoms produced a decrease in suicide risk in youth, as is the case with adults. The author of the study has speculated that other factors beyond depressed mood likely contribute to suicidal thinking and behavior in kids.
So…what advice do I give to parents around use of antidepressant medication when they ask “What would you do if this was your kid?”
First, I’d point out that the potential benefits of medication appear to outweigh the potential risks, especially for kids with anxiety, but in my experience the risk of an increase in suicidal thoughts/behavior associated with antidepressant medication appears to be greater than zero. I would be most concerned about an increased risk in kids with some other condition (in addition to depression or anxiety) that interferes with emotional self-regulation and/or impulse control (ADHD, trauma, kids with behaviors similar to those seen in Borderline Personality Disorder). One hypothesis put forth to explain a possible increase in risk involves the suggestion that antidepressants might cause disinhibition n a subset of patients…the pathways in the prefrontal cortex of the brain don’t fully mature for most people until their early to mid-20s, coinciding with the time after which antidepressants are no longer associated with increased suicidal risk.
Second, since cognitive-behavioral therapy (CBT) appears to be an effective alternative to medication for kids with anxiety and depression, kids with mild to moderate symptoms should probably receive a trial of CBT prior to a trial of medication.
Finally, I remind parents that antidepressants have been shown to be of significant benefit in kids with anxiety, moderately effective in kids with OCD and of modest benefit in kids with depression. It’s also important that parents understand the limitations of medication and the evidence suggesting medication use offers no guarantee that a child won’t make a serious suicide attempt.
Next: Is antipsychotic medication safe for kids?
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