Antidepressants for children and teenagers: what works?

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More and more children and teenagers have poor mental health. Depression and anxiety are particularly common. For some, it was made even worse by the COVID-19 pandemic.

It is vital young people receive the help they need as early as possible to prevent lasting mental health difficulties.

Psychological (talking) therapies are considered the main treatment. The National Institute for Health and Care Excellence (NICE) recommends these therapies as the first treatment for depression and anxiety in children and teenagers. Unfortunately, they are not always available.

Antidepressants are another important treatment option, but their use is controversial. There are only limited studies on how well they work, and how safe they may be. This is particularly true in certain groups such as younger children.

Mental health services struggle to meet demand. Many young people cannot access the help they need, or have to wait a long time for treatment. In 2018, 4 in 5 young people had to wait more than 4 weeks to start treatment, with many waiting months.

In a recent Evidence Collection, the National Institute of Health and Care Research (NIHR) examined the evidence on antidepressants for children and teenagers, bringing together high quality research supported by the NIHR. The Collection covers how antidepressants are being prescribed, and their effectiveness and safety. Below we outline the major findings of the Collection.

Trends in prescribing antidepressants

Prescriptions for teenagers are rising. Research has found that the number of 12 to 17 year olds prescribed antidepressants more than doubled between 2005 and 2017. More recent information suggests that prescriptions have continued to increase, especially during the pandemic.

Many teenagers are prescribed antidepressants without first seeing a specialist. NICE clinical guidelines suggest all children and teenagers are assessed by a child and adolescent psychiatrist before being prescribed antidepressants. Yet research shows this only happens for 1 in 4.

Limited access to mental health services and a lack of child and adolescent psychiatrists seem to prevent GPs from following the guidelines. If a GP feels a teenager needs urgent treatment, they may prescribe antidepressants despite the guidelines. This may be life saving if they are very depressed.

Which antidepressants are effective and safe for children and teenagers?
Depression: Fluoxetine may be the best antidepressant and venlafaxine should be avoided

Five recent reviews supported by the NIHR drew conclusions on how safe and effective antidepressants are for treating depression in young people.

All reviews included randomised controlled trials – the best source of evidence available. Yet there is much less evidence for children and young people than for adults, and it is more uncertain.

All reviews found fluoxetine (Prozac) to be more effective for treating depression than placebo.

All reviews found that the antidepressant venlafaxine (Efexor) was associated with an increased risk of suicidal thoughts or attempts, compared to placebo. The findings for other antidepressants were more uncertain. This highlights the need for young people taking antidepressants to be carefully monitored.

Most trials included in the reviews did not include children and teenagers at risk of suicide. In the ‘real world’, young people seeking help for depression may have suicidal thoughts. Excluding this group from studies weakens their conclusions about antidepressants. Patients, carers and clinicians should continue to balance the potential benefits of treatments with how acceptable they are. This includes the possible risk of suicide in a young person with depression. Psychological therapies remain an important part of any treatment approach.

Anxiety disorders: Fluvoxamine, sertraline and fluoxetine may help

Three recent reviews supported by the NIHR drew conclusions on how safe and effective antidepressants are for treating anxiety disorders in children and young people. OCD is usually considered to be an anxiety disorder but is considered separately in the reviews.

Anxiety disorders

Fluvoxamine (Faverin) was consistently found to be more effective than placebo for treating anxiety disorders. Other SSRIs (fluoxetine, sertraline and paroxetine) were more effective than placebo by some but not all measures of anxiety.

Sertraline (Lustral) consistently reduced the risk of suicidal thoughts and behaviours in young people more than placebo. Paroxetine (Seroxat) increased them.

OCD

Sertraline and fluoxetine (Prozac) were consistently found to be more effective than placebo for treating OCD. The combination of sertraline and CBT was also effective according to one review.

The reviews did not contain information about risk of suicidal thoughts and behaviours in OCD.

No antidepressants are licensed in the UK for anxiety in children and teenagers under 18 years (except for OCD). Yet both specialists and GPs prescribe them. The reviews in this Collection indicate that certain antidepressants are effective and may be safe. Up to date guidelines are needed for the full range of anxiety disorders in children and teenagers.

Conclusion

Thousands of children and teenagers in the UK are taking antidepressants for depression and anxiety. The numbers continue to rise and many have not seen a specialist.

Very few of the studies included in major reviews looked at long-term treatment. Treatment was usually for between 2 and 16 weeks. This is problematic because symptoms of depression and anxiety can last a long time and require long‐term treatment. More research is therefore needed into the safety and effectiveness of long-term antidepressant use in young people.

Treatment decisions need to balance the drugs’ effectiveness with the possible risk of extreme side effects. This includes how severely depressed the young person is as well as suicidal thoughts and behaviours. The limited evidence around this highlights how important it is to carefully monitor young people taking these drugs.

Young people must be able to access mental health services they need. In the NHS Long Term Plan, the Government commits to expanding mental health services for children and young people and reducing unnecessary delays. This should improve the support available.

Read the full NIHR Evidence Collection here.

ENDS

Written by Dr Jemma Kwint, Senior Research Fellow (Evidence) and Lauren Hoskin, Communications and Engagement Manager, at the National Institute for Health and Care Research.

Dr. Jemma Kwint leads on NIHR Evidence’s Collections, which bring together recent research on topics of strategic importance for the UK health and social care system. She has a background in postdoctoral medical research embedded in an NHS setting and extensive experience of working within the NIHR. Prior to joining CED, Jemma worked for 10 years identifying and prioritising research topics for NIHR commissioning.

Lauren Hoskin is a communications professional specialising in organisations that make a positive impact in the world. She is experienced in science communication, graphic design, website development, PR and social media management.

 

Please note that this is an external blog and may not reflect the views of ACAMH.

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