Position statement

International Society for Bipolar Disorders (ISBD) Antidepressant Medications for Children and Adolescents: Information for Parents, Caregivers and Families The ISBD supports careful scrutiny of the risks and benefits of all medications. In order to assist families and caregivers in fully participating in their loved one’s treatment plan, we have undertaken a careful review of the concerns raised regarding the use of antidepressants in the pediatric population. This document seeks to provide families with the best information currently available. Child and Adolescent Advisory Committee Members Boris Birmaher, MD, David Axelson, MD, Mario Cruz, MD, Cathy Petchel, MA, Mary Margaret Kerr, EdD, Sandra DeLuca, MSN, Ron Philips, BS, Samuel Gershon, MD, Donna Carothers, Chad Daversa Background Recently, regulatory agencies in both the UK and the US have released statements regarding the use of antidepressants in the pediatric population. These statements have focused on the safety and effectiveness of the Specific Serotonin Reuptake Inhibitor (SSRI) class of antidepressants, which include: SSRIs are considered to be an improvement over the older varieties of antidepressants because they are better tolerated by the majority and the risk of overdose is lessened. Safety The primary safety concerns associated with the use of antidepressants in children and adolescents are 1) worsening of the depressive symptoms being treated and 2) suicidal behavior. However, it is important to note that a recent analysis of the rates of suicidal behaviors in all published studies showed no significant differences between the SSRIs and placebo (Brent and Birmaher 2004). It is also important to remember that, to date, there are no reports of completed suicide in any of the controlled trials of the SSRIs, although there is documentation of a small number of suicide attempts. It is also interesting that the use of SSRI’s for the treatment of pediatric anxiety disorders has not been accompanied by a rise in suicidal behaviors. Further studies are needed to determine whether the suicide attempts recorded were related to the illness, medication or the interaction of the illness Recommendations for Parents, Families and Caregivers of Depressed and Bipolar Children The need for a collaborative care environment The reality we are faced with today is that the care of depressed patients is increasingly being placed in the hands of primary care physicians; therefore, families and physicians must work together to monitor patients for potentially life threatening behaviors, regardless of the root cause. Parents of children with depressive symptoms can best relieve their apprehension about treatment with antidepressants by playing an active role in their child’s treatment. It is very important for parents to establish a positive relationship with a treatment provider in order to optimize the collaborative care environment. Prior to starting treatment with antidepressants, parents should discuss their concerns openly and candidly with physicians. While some children may respond well to initial treatment with psychotherapy, more severe depression may require the use of an antidepressant. After speaking with the treatment provider, the decision to treat any child with antidepressants should be clearly understood by the family. Monitoring: During the course of treatment, parents and physicians should closely monitor children for the emergence of the following symptoms*: * May suggest a different treatment strategy and require referral to psychiatrist Or for signs of mania,* which may include: • Exaggerated or inappropriate happiness, silliness or giddiness • Exaggerated optimism that does not match a given situation • Behaving as if he or she were invincible • Exaggerated talkativeness or fast-paced, loud speech, a “motor mouth” • Hypersexuality or inappropriate sexual behavior *Several of the symptoms occurring together may point to an underlying bipolar disorder and suggest a different treatment strategy and require a referral to a psychiatrist. Parents should be especially alert for changes in mood and behavior during the time surrounding the beginning of any new medication, or the change of medication. Some patients may experience decreased inhibition with new medications, which may enhance the risk for suicidal behavior in some children. However, Children should not stop taking any medication, including SSRIs, without consulting the treating physic an i . Abrupt and unsupervised discontinuation of the development of symptoms specifically related to removal of medication The development of a collaborative care environment requires a multi-dimensional approach to treatment, and parents and physicians should make use of all available resources (including psychotherapy, support groups, educational materials, and others) in managing the depressive symptoms and monitoring for signs of suicidal thoughts and behaviors. End Note: A June 2004 report on early findings from a National Institute of Mental Health (NIMH) funded study confirms that Prozac is more effective than placebo (no active drug) in the treatment of depressed children. There were no completed suicides in this trial, although the issue of suicidal behavior is still very much a concern. Final published results of this study are expected sometime in the fall of 2004. Resource List ISBD. (2003) Juvenile Bipolar Disorder Series: A Parent’s Guide to Early Detection. www.isbd.org Poling K, Brent D, Birmaher B. (2000) Understanding and Coping with Bipolar Illness: A Survival Manual for Families. Star Center Publications, UPMC Health System, Western Psychiatric Institute and Clinic. Pittsburgh, PA NMHA. (2004) The use of psychotropic medications to treat children’s mental health needs. www.nmha.org Vittiello B, Swedo S. (2004) Antidepressant Medications in Children. N. Engl J. Med. April 8. 350:15. Brent DA, Birmaher B. (2004) British Warnings on SSRIs Questioned. J. Am. Acad. Child Adolesc. Psychiatry 43;379-380 This position statement was submitted by the Child and Adolescent Committee to the ISBD Board of Councilors and was approved For further information efer to the website at www.isbd.org.

Source: http://www.bipolarworld.net/pdf/Position%2520Statement_Parentversion_5DC.pdf