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The waiting game

Evidence toolbox: Use of SSRIs in children and adolescents

Summaries of new Cochrane reviews that could influence your next consultation

Is there any evidence to support the use of SSRIs in children and adolescents?

Depressive disorders are common in young people. Selective serotonin reuptake inhibitors (SSRIs) are often used, however, evidence of their effectiveness in children and adolescents is not clear.

Furthermore, there have been warnings against their use in this population because of concerns about increased risk of suicidal ideation and behaviour.

Our objective was to determine the efficacy and adverse outcomes, including suicidal behaviour and ideation, of SSRIs compared to placebo in the treatment of depressive disorders in children and adolescents.

Method We searched the CCDAN Trials Register, MEDLINE, PSYCHINFO and CENTRAL. Reference lists were checked, letters were sent to key researchers and internet databases searched. We included published and unpublished randomised controlled trials. Two or three review authors selected trials, assessed quality and extracted data. We used a fixed-effect meta-analysis. Relative risk was used to summarise dichotomous outcomes and the mean difference to summarise continuous measures.

Results Ten trials provided usable data. At eight to 12 weeks, there was evidence that children and adolescents ‘responded' to treatment with SSRIs (RR 1.28, 95% CI 1.17 to 1.41). There was also evidence of an increased risk of suicidal ideation and behaviour for those prescribed SSRIs (RR 1.80, 95% CI 1.19 to 2.72). Fluoxetine was the only SSRI where there was consistent evidence (three trials) that it reduced depression symptoms in both children and adolescents (CDRS-R treatment effect -5.63, 95% CI -7.38 to -3.88), and ‘response' to treatment (RR 1.86, 95% CI 1.49 to 2.32). Where rates of adverse events were reported, this was higher for SSRIs.

Authors' conclusions There were methodological issues with the results, including high attrition, issues on measurement and clinical usefulness of outcomes, often variously defined across trials. Also, patients seen in clinical practice are likely to be more unwell, and at greater risk of suicide, than those in the trials, and it is unclear how this group would respond to SSRIs. This needs to be considered, along with the evidence of an increased risk of suicide-related outcomes in those treated with SSRIs. It is unclear what the effect of SSRIs is on suicide completion. While untreated depression is associated with the risk of completed suicide and impacts on functioning, it is unclear whether SSRIs would modify this risk.

Reference Hetrick S, Merry S, McKenzie J et al. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 2007, issue 3 CD004851. DOI: 10.1002/14651858 CD004851 pub2.

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