An antidepressant is a medication used primarily in the treatment of depression. Depression can occur if some of the chemicals called neurotransmitters in the brain are not functioning effectively. There are three specific chemicals that can affect a person's mood: serotonin, norepinephrine, or dopamine. Antidepressants affect one or more of these chemicals in different ways to help stabilize the chemical imbalance often seen in depression. Antidepressant drugs are not happy pills, and they are not a panacea. They are prescription-only drugs that come with risks as well as benefits and should only be taken under a doctor's supervision. Because children and adolescents experience depression just as adults do, they are sometimes prescribed antidepressants by their physician.
Description
Antidepressants are medicines used to help people who have depression. Antidepressant medications may be indicated for those children and adolescents with bipolar depression, psychotic depression, depression with severe symptoms that prevent effective psychotherapy or counseling, and depression that does not respond to psychotherapy. However, given the psychosocial dynamics that often coexist with depression, antidepressants are usually insufficient as the only treatment for children who have the disorder. Psychotherapy is often recommended as an adjunct treatment along with the prescribed antidepressant. The use of antidepressants among children has been growing steadily since the late 1980s.
All antidepressant medications have a slow onset of action, typically three to five weeks. Although side effects may be observed as early as the first dose, significant therapeutic improvement is always delayed. Most antidepressants are believed to work by slowing the removal of certain chemicals from the brain. These chemicals are called neurotransmitters, which are needed for normal brain function. Antidepressants help people with depression by making these natural chemicals more available to the brain. There are many different kinds of antidepressants, including the ones listed below.
Monoamine oxidase (MAO) inhibitors
MAO inhibitors work by blocking the action of a chemical substance known as monoamine oxidase in the nervous system. Studies done in animals suggest that MAO inhibitors may slow growth in children. Little information on the use of MAO inhibitors in children under 16 years old was available as of 2004.
Tricyclics
Tricylic antidepressants should not be taken with the gastric acid inhibitor cimetidine (Tagamet), since this increases the blood levels of the tricyclic compound. TCAs have many interactions, and specialized references should be consulted. Specifically, it is best to avoid other drugs with anticholinergic effects. Tricyclics should not be taken with the antibiotics grepafloxacin and sprafloxacin, since the combination may cause serious heart arrythmias.
Monoamine oxidase (MAO) inhibitors—A type of antidepressant that works by blocking the action of a chemical substance known as monoamine oxidase in the nervous system.
Selective serotonin reuptake inhibitors (SSRIs)—A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, thus raising the levels of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
Tricyclic antidepressant—A class of antidepressants, named for their three-ring structure, that increase the levels of serotonin and other brain chemicals. They are used to treat depression and anxiety disorders, but have more side effects than the newer class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).
SSRIs
SSRIs should not be used with any drug that increases serotonin concentrations, including MAO inhibitors, tramadol, sibutramine, meperidine, sumatriptan, lithium, St. John's wort, ginkgo biloba, and some anti-psychotic agents. A "serotonin syndrome" may occur, where mental status changes and where agitation, sweating, shivering, tremors, diarrhea, and uncoordination, and fever may develop. This syndrome may be life-threatening. SSRIs interact with a number of other drugs that act on the central nervous system. Care should be used in combining SSRIs with major or minor tranquilizers or with anti-epileptic agents such as phenytoin (Dilantin) or carbamazepine (Tegretol).
MAO inhibitors
MAO inhibitors have many dietary restrictions, and people taking them need to follow the dietary guidelines and physician's instructions very carefully. A rapid, potentially fatal increase in blood pressure can occur if foods or alcoholic beverages containing tyramine are ingested by a person already taking MAO inhibitors. Foods containing tyramine include sour cream; parmesan, mozzarella, cheddar and other cheeses; beef or chicken liver; cured meats; game meat; caviar; dried fish; bananas; avocados; raisins; soy sauce; fava beans; and caffeine-containing products like colas, coffee and tea, and chocolate. Beverages to be avoided include beer, red wine, other alcoholic beverages, non-alcoholic and reduced alcohol beer, and red wine products.
Precautions
In 2004, the FDA issued a health advisory recommending close observation for worsening depression in both adults and children treated with certain antidepressants. The FDA requested that a warning of a possible association between the use of SSRIs and suicidal behavior be inserted in the labeling of these medications. Studies have found no direct link between these antidepressants and worsening depression or increased suicide in children. In fact, no suicide has been reported among the more than 4,100 people studied who take SSRIs. However, the FDA continues to study this issue. Some believe the increased risk of suicide is not related to the SSRIs themselves, but a phenomenon seen when the symptoms of depression first begin to improve. This phenomenon occurs when the depressed person starts to gain more energy but is not yet fully relieved of the depressive symptoms. The drugs under review include bupropion (Wellbutrin), citalopram (Celexa), fluoxetine (Prozac), mirtazapine (Remeron), nefazodone (Serzone), paroxetine (Paxil), sertraline (Zoloft), escitalopram (Lexapro) and venlafaxine (Effexor). It should be again noted that the only drug that has received approval for use in children with major depressive disorder is fluoxetine (Prozac). Several of these drugs, including sertraline (Zoloft) and fluoxetine (Prozac) are approved for the treatment of obsessive-compulsive disorder in pediatric patients. The drug escitalopram (Lexapro) does not appear to help depressed children and adolescents, according to one clinical study.
Parental concerns
Major depression in children and adolescents is a serious condition that should be treated in a way that includes careful follow-up and monitoring. If the physician
determines that medication is indicated, parents should ensure their child continues to receive ongoing assessment. Selection of an antidepressant for their child is done on an individual basis, as drugs may work differently for different people. What is effective for some may not be effective for others. If one antidepressant is ineffective, then there is probably another one that can be tried. All potentially effective treatments can be associated with side effects. A careful weighing of risks and benefits, with appropriate follow-up to help reduce risks, is the best that can be recommended.
See also Depression.
BOOKS
Mondimore, Francis Mark. Adolescent Depression. Baltimore, MD: Johns Hopkins University Press, 2002.
PERIODICALS
Ables, Adrienne Z., and Otis L. Baughman III. "Antidepressants: Update on New Agents and Indications." American Family Physician 67, no. 3 (February 1, 2003): 547–54.
ORGANIZATIONS
National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201–3042. Web site: <www.nami.org>.
National Mental Health Association. 2001 N. Beauregard Street, 12th Floor, Alexandria, Virginia 22311. Web site: <www.nmha.org>.
WEB SITES
National Institute of Mental Health. Available online at <www.nimh.nih.gov/> (accessed October 16, 2004).
National Mental Health Association. Available online at <www.mentalhealth.org> (accessed October 16, 2004).
