Use of selective serotonin reuptake inhibitors in children and adolescents

Depression is a serious condition, associated with considerable morbidity and mortality; selective serotonin reuptake inhibitors (SSRIs) were commonly used in its treatment in child and adolescent psychiatry until recently. In the wake of the recent UK Committee on Safety of Medicines (CSM) advice, we conducted a rapid review of current available information on SSRIs and suicidality (suicidal ideation, self-harm and suicide attempt) in children and adolescents from clinical trials and epidemiological studies. There is insufficient safety information from the randomised controlled trials to confirm a definite association between SSRIs and suicidality. Furthermore, analysis of suicide and antidepressant prescribing trends in three countries and a large case-control study do not support the hypothesis that there is a link between use of SSRIs and death caused by suicide. Regulatory agencies and the media should have strict guidelines for the management of information relating to the treatment of this condition so that clinicians can make properly informed decisions. We suggest clinical guidelines for managing depression in children and adolescents. SSRIs should not be considered for use as first-line treatment in mild or moderate depression of childhood, where psychological interventions such as cognitive behaviour therapy or interpersonal therapy are the mainstay. SSRIs should be considered when there is severe depression that does not respond to psychological interventions; when the child is suicidal and is admitted as an inpatient, is severely depressed or has bipolar depression despite adequate doses of mood-stabilisation agents; or when the child or family prefers pharmacotherapy to psychological interventions and gives informed consent. Local bodies of clinicians or peer groups should agree protocols and acceptable guidelines, taking into consideration the type of patients being assessed, the availability of nonpharmacological intervention, and the benefit-risk ratio of the pharmacological intervention. It is important that parents (and patients when possible) be given accurate information regarding the current controversy over SSRI prescribing. More research into the use of SSRIs in childhood depression is urgently required.