Psychopharmacology in Children and Adolescents
For a long time, children and adolescents were thought of in the psychiatry community as “little adults.” Young people were often assessed and treated for mental health concerns in the same ways that their adult counterparts were. However, over the last 2 decades, our understanding of the nuances of child and adolescent psychiatry has grown exponentially. Our evidence base for pharmacological treatment has expanded with the use of high-quality, randomized controlled trials examining the effects of various psychotropic medications in young people.
Despite these advances, many parents/guardians/families are still reticent when considering psychiatric treatment for their child. Negative reporting in news media about the increase in prescription psychotropic medication use among minors has led some to fear that children and adolescents are being over-diagnosed and overprescribed. Still others harbor fear generated from Black Box Warnings (found on antidepressants and psychostimulants), which have also contributed to negative stigma around psychiatric treatment for children. In the face of these fears, it is imperative that psychiatric providers offer families evidence-based information, perform thorough and high-quality assessments, and practice judicious prescribing to allay fears, enhance outcomes, and dispel inaccurate or unfounded concerns about how children with psychiatric disorders can or should be treated.
What Medications Are Approved to Treat Anxiety, Depression and OCD in Children and Adolescents?
Antidepressants, particularly those known as SSRIs (selective-serotonin reuptake inhibitors), are commonly used as first-line therapy to treat depression, anxiety and OCD. There are several SSRIs that have been studied and approved for use in young people, including Prozac (fluoxetine), Lexapro (escitalopram), Zoloft (sertraline), and Luvox (fluvoxamine). These medications work to prevent serotonin, released by a neuron, from being cleared out of the intercellular space before it can bind and communicate with the next neuron. This in turn sustains the activity of serotonin at the intercellular space, commonly described as “enhancing serotonin signaling”. This enhanced signaling is associated with improvement of depressive symptoms and reduction of anxiety.
What Medications are Approved to Treat Attention-Deficit/Hyperactivity Disorder (ADHD, or ADD)?
First-line (the preferred or best) treatment for Attention Deficit Disorder (ADD) is psychostimulants. The two most commonly prescribed psychostimulants are methylphenidate (Brand: Ritalin) and amphetamine (Brand: Adderall). These medications work in the prefrontal cortex to improve attention and reduce distractibility, impulsive behavior and hyperactivity. Another class of medications, called alpha-agonists, can also help to reduce hyperactivity and impulsive aggression. Alpha-agonists can also help hyperactive children to be calm and fall asleep in the evening. Alpha-agonists commonly prescribed for the treatment of ADD include guanfacine (Tenex or Intuniv) and clonidine (Kapvay). Other medications used to treat ADD can also be used in the treatment of mood disorders. Medications that work largely on norepinephrine, including Strattera, can be helpful in the treatment of ADD when psychostimulants cannot be tolerated or are contraindicated due to cardiac issues. Another antidepressant, called Wellbutrin, works on dopamine and norepinephrine and is commonly prescribed “off-label” for the treatment of ADD. Medications for the treatment of ADD are described in greater depth in our article about Attention Deficit Disorder (link here), while this article will focus on the medications commonly used as first-line therapy to treat depression, anxiety and OCD.
What Are the Side Effects of Antidepressants?
Common side effects of antidepressants include things like GI upset (nausea, diarrhea, vomiting), headache, changes in sleep, tremors, or increased bruising or bleeding. Most side effects are immediate but temporary; they occur in the first week or two of treatment but improve/dissipate as the body acclimates to the new medication. Antidepressant medications should not be stopped abruptly in cases where they have already been taken for some time. Although these medications are not habit forming or addictive, sudden discontinuation may lead to “withdrawal symptoms.” These symptoms can be uncomfortable and may include cold and flu-like symptoms, dizziness, dysphoria, sleep problems, and headache. SSRIs can be safely discontinued with the help of your prescriber, who guides you through gradual reduction of the medication to ensure that discontinuation is easy and well-tolerated.
What Does the Black Box Warning on Antidepressants Mean?
Many parents are fearful of allowing their children to take SSRIs because this class of medication comes with a Black Box Warning. This warning, issued by the FDA, states that children, teens, and young adults taking SSRIs may experience increased suicidal thoughts or actions while taking SSRIs. This warning is based on a review of data from randomized clinical trials of SSRIs. This data indicates that suicidal thoughts and behaviors seem to occur more commonly in young populations treated with SSRIs. This article in the prestigious New England Journal of Medicine may be particularly helpful in shedding further light on this issue as it highlights the deleterious impact that this Black Box Warning has had in dissuading young people from obtaining helpful medical treatment.
Unfortunately, the FDA’s Black Box Warning has kept many people from seeking the treatment they need because they are afraid of what SSRI medications might do to them. Meanwhile, little is known about the mechanisms (if any) that may be contributing to increased suicidality in young people treated with SSRIs. Some question whether this purported increased risk of suicidal thoughts and behaviors is actually valid and wonder whether the meta-analysis of data from controlled studies produced sound conclusions.
In practice, SSRIs are generally very well tolerated, safe for use across broad populations, and can offer life-changing relief from burdensome anxiety and depression symptoms. And, while the risk of developing suicidal ideation from antidepressant treatment is real, it is relatively low. This risk can be mitigated by regular follow-up with your psychiatric prescriber, close monitoring of youths taking SSRIs, and ensuring that youths have support from friends, family, and mental health professionals.
How Long Will My Child Have to Take an Antidepressant? Will They Have to Take it Forever?
The American Academy of Child and Adolescent Psychiatry recommends that if a young person being treated for anxiety and depression for the first time achieves recovery using an SSRI for 6-12 months, they can then seek to reduce and eventually discontinue their SSRI use. If, however, a young person is being treated for anxiety, depression or OCD and they relapse, the duration of SSRI treatment may need to be maintained longer than 1 year to prevent future relapse.
Can My Child’s Depression or Anxiety Be Treated Without Medication?
In a word – yes! For example, Cognitive Behavioral Therapy (CBT) is one of the more researched psychotherapies and has been shown to be just as effective as treatment with an SSRI. However, a combination of SSRIs and CBT has shown to be a more powerful intervention than using either of these treatment types alone.
Furthermore, CBT is not the only form of therapy available to young people suffering from anxiety or depression. There are several efficacious modalities that help young people to cultivate coping skills, learn to self-regulate, and maintain wellness in the face of significant stress. However, not everyone responds even to excellent psychotherapy, so in some situations the decision to add medication to the treatment can yield a huge benefit in effectively treating psychiatric disorders.