Antidepressants Health Article

Antidepressants

Medications used to treat depression.

Depression in children and adults is similar to the clinical course in adults. It can be reliably diagnosed by a trained mental health professional through clinical interviews with the child or adolescent and outside observers (parents, teachers). Depression causes significant impairment in school, in the family, and in peer relationships. It is associated with other psychiatric disorders, suicidal thoughts, and suicide attempts. Both psychotherapy and medication can be effective treatments for depression, either alone or in combination.

The two most common types of antidepressants are tricyclic antidepressants (TCAs) and selective serotonin re-uptake inhibitors (SSRIs). Examples of TCAs include nortriptyline (also known by the brand name Pamelor), imipramine (Tofranil), and desipramine (Norpramin). Examples of SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Clinical studies have shown that some children and adolescents benefit from these medications.

Tricyclic antidepressants (TCAs)

Before using TCAs, it is necessary to have a medical history and examination of the child, including an electrocardiogram (EKG). Not everyone develops side effects when taking TCAs, but the most common side effects include: dry mouth, impaired ability to focus vision at close range, constipation, urinary hesitation, dizziness, weight gain, and sedation. TCAs may produce minor cardiovascular changes such as orthostatic hypotension (low blood pressure when the person stands up, often causing light-headedness), hypertension, rapid heart beat, and minor changes in the electrical activity of the heart, which may show in the electrocardiogram (EKG). Most of these side effects can be minimized by slowly increasing or reducing TCA dosage.

During the treatment with TCAs, patients should be monitored by a physician trained in the management of these medications. It is recommended that he or she perform regular blood pressure, heart rate, and EKG monitoring. TCAs may interact with other medications; therefore, parents should inform their children's physicians that the child is taking a TCA. Finally, the TCAs should not be stopped abruptly because doing so may induce mild withdrawal side effects (malaise, chills, stomachache, flu-like symptoms). Though they are safe if carefully monitored and taken as prescribed, TCAs can be lethal if taken in overdose. Therefore parents must be responsible for storing and administering the medication in order to avoid accidental or intentional overdose.

It is important to report that four to five cases of sudden death have been reported in children taking the TCA medication desipramine. (Biederman et al., 1995). However, it is not clear whether the death of these children was due to the medication or other causes.

Selective serotonin re-uptake inhibitors (SSRIs)

The reports that SSRIs are effective in treating adults with major depressive disorder (MDD), together with the findings that SSRIs have a relatively benign side effect profile, low lethality after an overdose, and once-a-day administration, have encouraged the use of SSRIs in children and adolescents.

Several studies have reported 70-90% response rate to fluoxetine or sertraline for the treatment of adolescents with major depressive disorder (MDD), (Birmaher et al., 1996b), but the results of these studies are not conclusive because they have methodological limitations. A recent, large, well-performed investigation showed that fluoxetine was more effective for the treatment of depressed children and adolescents than placebo. Despite the significant response to fluoxetine, many patients had only partial improvement.

Overall, the SSRIs have similar effectiveness and side effects as TCAs. The most common side effects include nausea, stomachache, diarrhea, headaches, mild tremors, sweating, sleep disturbance, sedation, restlessness, lack of appetite, decreased weight, vivid dreams, and sexual dysfunction (inability to have an orgasm or delayed ejaculation). Most of these side effects are temporary and may be diminished by reducing the dose or discontinuing the medication. There are no specific laboratory tests required before administering SSRIs. SSRIs do have potentially harmful interactions with several commonly prescribed drugs; therefore, all physicians should be informed if someone is taking an SSRI.

Children and adolescents who do not respond to treatment

The most common reasons for failure of treatment are inadequate medication dosage or length of medication trial, lack of compliance with treatment, exposure to chronic or severe life events that require different modalities of therapy, existence of other psychiatric disorders (e.g., substance abuse, anxiety disorder), and misdiagnosis. There are very few studies of children and adolescents with depressions that are deemed "treatment resistant." In adults with resistant depression, several types of combinations of medications and ECT (electroconvulsive therapy) have been found to be useful.