In 2004, the Food and Drug Administration mandated a black box warning be added to the labeling on antidepressant drugs, warning of increased risk of suicidal thoughts and behavior in children and adolescents. The decision sparked some concerns among practitioners about prescribing this category of medications to younger patients. Discussions about the risks and benefits of using antidepressants in children and adolescents continue today.

Below, John T. Walkup, MD, director of the Division of Child and Adolescent Psychiatry at the Weill Cornell Medical Center and New York-Presbyterian Hospital in New York City, looks at this issue and offers his views on antidepressant use in this patient population.

What issues should psychiatrists consider when weighing the risks of treating children or adolescents with antidepressant drugs versus alternative strategies?

If a child or adolescent has mild depression, behavioral therapy may be a viable alternative to treatment with antidepressants. The same may also be true for patients in this age group who are battling an anxiety disorder or obsessive compulsive disorder (OCD). 

Children and adolescents with anxiety disorders and OCD typically see the greatest benefit from a combined approach of antidepressants and behavioral therapy.However, prescribers should definitely consider using antidepressants in combination with psychological treatment for adolescents with moderate to severe depression. 

There are really not too many other proven and effective treatment strategies for this group of patients. Traditional psychotherapy and commonly used cognitive behavioral therapy strategies do not appear to help patients suffering from moderate to severe depression. Antidepressants remain the most effective treatment in this population.

How has the addition of a black box warning on antidepressant drugs affected prescribing practices for these drugs to children and adolescents in recent years? How does new research affect these discussions?

There was a lot of initial concern when the FDA issued the black box warning in 2004. The decision had a chilling effect on prescribing practices, especially among primary care practitioners, who were doing a lot of the prescribing in children and adolescents. As a result, many kids went untreated, especially because there weren’t outstanding alternatives to medication. 

However, recent meta-analyses of antidepressant treatments suggest a benefit-to-risk ratio that is much more favorable to treatment than initially described by the FDA. I would suggest that the two federally funded studies of antidepressants in teens with depression are the most indicative of the outcomes teens and their parents can expect when expert psychiatrists use antidepressants for moderate to severe depression. 

With respect to suicidal risk, most teens in depression treatment studies have suicidal thoughts even before antidepressant treatment.That risk decreases with treatment. It appears increasingly clear that it is very difficult, even for trained specialists, to decipher whether suicidal behavior and thoughts are a result of a patient’s depression or are linked to antidepressant use. This further complicates this issue.

Are there cases when the option of treating children with antidepressant medications should be ruled out altogether due to safety of efficacy issues?

While treatment should be individualized, I think for depression, anxiety and OCD, antidepressant medication has a clear benefit-to-risk ratio in favor of prescribing these drugs to children and adolescents. I think that evidence shows that it’s clearly better to provide young patients with rapid treatment in these cases. 

When treatment is delayed, patients have a higher risk for a poor response or that their condition will become chronic. The take-home message is to offer early and effective treatment. Don’t fool around; get on top of it.

One study showed that parents with depression were accurately able to predict new onset mood disorder (NOMD) in children. How should clinicians weigh parental views when diagnosing and treating child for a depressive disorder, particularly when it comes to information provided by a parent who suffers from a depressive disorder?

Parents who have undergone successful treatment for depression are typically very credible when it comes to identifying signs and symptoms of a depressive disorder in their children. For example, if the parent is recognizing depressive symptoms in a child at age 15, similar to what the parent had when he or she was younger, the clinician should take that information seriously.