Should SSRIs be used in children with depression?
It is estimated that 1% of primary schoolchildren and 3-5% of adolescents are affected by clinical depression,1 but few receive effective treatment. It can be difficult to distinguish depression from adolescent emotional lability and depressed children and young people may present with somatic symptoms, irritability or behavioural problems.2
Treatment presents difficulties. GPs are advised not to prescribe antidepressants, there is a shortage of psychological therapists and waiting times for child and adolescent mental health services can be long.
A meta-analysis of 27 randomised placebo-controlled trials has looked at the use of antidepressants in children with paediatric major depressive disorder (n=15), obsessive-compulsive disorder (n=6) and non-OCD anxiety disorders (n=6). It has found that use of antidepressants may be justified.
The duration of the trials ranged from 6 to 16 treatment weeks and in total included more than 5,000 patients. Nineteen of the studies were conducted solely in the US and 20 were industry funded.
The analysis found that antidepressants were effective in all three conditions, but that the benefit in depression was modest (NNT=10, 95% CI 7-15). The NNT for OCD and non-OCD anxiety disorders was six (95% CI 4-8) and three (95% CI 2-5) respectively.
The risk of suicidal ideation and suicidal attempts was increased in patients taking antidepressants, but to a lesser extent than previously estimated, with a NNH in the depression trials of 112.
For depressed adults, short-term trials show that 50-60% of patients respond to antidepressants and about 30% respond to placebo, giving a NNT of 4-5.3 In contrast, a NNT of 10 would suggest that antidepressants are not a very effective treatment for depression in children and adolescents.
However, the response rate is the same (61%). The analysis found that 50% of the participants responded to placebo treatment, which may indicate either a higher natural recovery rate or a higher psychological response to placebo in young people.
The authors conclude that there is a favourable risk/benefit profile, justifying the cautious use of antidepressants as a first-line treatment option.
It is likely, however, that they have underestimated the risk of suicidal behaviour. Youths at risk were excluded from the trials and data were only collected retrospectively as part of adverse event reporting.
Another trial reported that, for adolescents with major depression, combination of an SSRI with CBT in accordance with the NICE guideline does not confer any additional benefit over treatment with an SSRI alone.4
This leaves a number of difficult and unanswered questions. Where there are difficulties in accessing CBT, should SSRIs be offered as stand-alone treatment? Should GPs prescribe antidepressants at all, knowing that most of the benefit is from a placebo effect and there are continuing concerns regarding safety? Where there are long delays in accessing secondary care, are we justified in withholding a treatment with a 60% response rate?
Bridge JA, Iyengar S, Salary CB et al. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment. JAMA 2007;297:1683-96Reviewer
Dr Phillip Bland