VCU child psychiatry expert offers guidance on safely prescribing antidepressants to youths

By Michael Ford and A. Bela Sood

RICHMOND, Va. – Before treating depressed youths with antidepressants such as Prozac, Paxil and Zoloft, doctors should ask about suicide attempts, suicidal thinking and plans for suicide, according to a top child psychiatrist at Virginia Commonwealth University.

Dr. A. Bela Sood, associate professor of psychiatry, chair of the Division of Child and Adolescent Psychiatry and medical director of the Virginia Treatment Center for Children at VCU, says recent studies on the controversial drugs – part of a class of pharmaceuticals known as selective serotonin reuptake inhibitors (SSRIs) – indicate that SSRIs benefit many youths with major depressive disorder. But potential side effects, including impulsive behavior, suggest that doctors should individualize treatment plans and carefully monitor SSRI usage in aggressive and impulsive children who might be prone to risky or suicidal behavior.

The findings are included in the March issue of the journal Current Psychiatry, available at www.currentpsychiatry.com.

“Various studies and our clinical experience have shown that antidepressant drugs, including SSRIs, have helped many children and adolescents suffering from depression and allowed them to overcome their interpersonal problems, improve their school performance, fight substance abuse and generally improve their quality of life,” says Sood. 

“But issues also have been raised recently about the possibility that SSRIs increase the risk of suicide. Until more research is conducted to demonstrate the benefits and risks of SSRIs in children and adolescents with major depression and other disorders, it would be prudent to take extra care in prescribing these antidepressants to youths.”

Depression occurs in 8.3 percent of those under 18 and can lead to suicide if untreated.

In her article, Sood suggests that doctors prescribing SSRIs:

• Monitor depressed youths for risky or suicidal behavior. She suggests that doctors discuss with parents the potential for suicidal behavior in youths with untreated depression.

• Minimize side effects. The article notes that children can tolerate moderately high doses of SSRIs but usually are started on lower dosages than those given to adolescents and adults. Higher doses could increase side effects, which include nausea, diarrhea, decreased or increased appetite, headaches, restlessness, tremor and insomnia as well as aggression and impulsive behavior. SSRIs should be prescribed with caution in youths with baseline aggression and impulsive tendencies because of the possibility of worsening these behaviors. 

• Prevent drug interactions. Because SSRIs often are used in conjunction with other medicines to combat the severity of mental illness in children, doctors must be aware of possible drug interactions, Sood says. 

• Avoid withdrawal. She says withdrawal symptoms following abrupt cessation of some type of SSRIs such as paroxetine (Paxil) and venlafaxine (Effexor) can be severe, and doctors should consider a planned withdrawal over one to two weeks. 

Although only Prozac has been approved for treatment of children, doctors have been increasingly prescribing Prozac and other SSRI drugs to children with depression and other disorders.  Recently, SSRIs have come under attack from some patients and families who blame SSRIs for suicides or violence in patients who have taken the drugs.  Britain in December prohibited use of most antidepressants in children, and some drug companies have warned U.S. doctors not to prescribe their drugs to children. The FDA has not changed its labeling requirements for SSRIs, but it currently is analyzing data from drug makers and studies on SSRIs and suicide attempts. It is expected to release recommendations next summer. The FDA has advised doctors to use caution if they prescribe antidepressants to anyone under 18.

“Medicines often work differently in children,” Sood said. “We must recognize that children are not ‘mini adults’ and adjust our treatment of youth depression accordingly.”