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The FDA has warned that antidepressant use in children and adolescents is linked with an increased risk of suicidal ideation. This does not mean that SSRIs are never appropriate for kids with anxiety and depression, but it does mean caution is required.

Are you the parent of a child or adolescent with a depressive or anxiety disorder who has been advised to take a selective serotonin reuptake inhibitor (SSRI), or are you a young person looking for information for yourself? 

You may have heard that SSRI antidepressants — the first class of medication generally prescribed to children and adolescents dealing with major depression or anxiety disorders — increase the chance that a young person will suffer from suicidal thoughts and behaviors. 

The US Food and Drug Administration (FDA) first warned that SSRIs could lead to suicidal ideation in children and adolescents in 2004, and extended their warning to include young adults up to the age of 25 in 2007. No suicides occurred among the young people taking SSRI antidepressants included in the FDA review, but four percent of this group experienced suicidality, and some of them attempted suicide — double the number of those who were taking placebos. [1, 2, 3]

What does the FDA's warning mean for the treatment of depression and anxiety in children and adolescents? Are SSRIs ever safe for this age group?

The Safety Of SSRI Antidepressants Among Children And Adolescents Suffering From Depression

Once the FDA's black box warning took effect and awareness spread of the increased risk of suicidality in children and young people taking SSRIs, their prescription to this age group significantly decreased in several countries [4, 5]. Research has since found that this reduction in prescribing SSRI antidepressants was actually correlated with an increase in suicide rates among young people [6].

What could be going on here?

Suicidal ideation itself is one of the symptoms of depression [7] — and the reluctance to prescribe antidepressants to children and adolescents may have meant that some depressive patients no longer received the medication that could have helped them. 

In other words, SSRI antidepressants may be associated with a slightly increased risk of suicidality, but their benefits in treating the symptoms of depression appear to be much greater than their risk in patients for whom talk therapy represents insufficient treatment. [8]

This means that it is indeed appropriate to prescribe SSRIs to some children and adolescents with depression, but only if their symptoms are moderate to severe, and if psychotherapy has proven insufficient or the patient finds it difficult to attend therapy because of their depression. 

British guidelines suggest that Fluoxetine (Prozac) is the safest SSRI for use in children and adolescents, after research found this common drug to have a "favorable [...] balance of risks and benefits [...] in the treatment of depressive illness in under-18s". Beyond this first-line pharmacological treatment, clinicians may in some cases suggest Citalopram or Sertraline (Zoloft). [9]

Children and adolescents who are prescribed an SSRI should be carefully monitored for progress and suicidal thoughts and behaviors, and if suicidality does occur, the recommended course of action is to make immediate contact with the young person's healthcare provider rather than abruptly stopping the medication — which can itself lead to withdrawal symptoms or cause a relapse of the depression. [2]

Safety Of SSRI Antidepressants Among Children And Adolescents With Anxiety Disorders

While we have seen that prescribing antidepressants to children and adolescents suffering from depressive disorders is complex, anxiety in children is a different matter. This is because the therapeutic benefits of SSRI antidepressants are much greater in young people suffering from anxiety disorders rather than those suffering from depression, and their use simultaneously poses a significantly reduced risk of self-harm. [10]

However, because many children with anxiety disorders also have comorbid depression [11] — in which case all the reservations about SSRI prescription related to depressive disorders apply — pediatric patients taking SSRIs for anxiety disorders still require careful monitoring, including for signs of depression. [9]

The safest SSRI antidepressants for anxiety in children likewise include Fluoxetine, Citalopram and Sertraline (Zoloft).

So, Should Your Anxious Or Depressed Child Be Taking An Antidepressant?

Cognitive behavioral therapy represents the first line of treatment for children suffering from mild depression or anxiety, and it is often effective in reducing symptoms when used as a stand-alone treatment [12].

In children suffering from moderate to severe depression, or anxiety disorders like separation anxiety in children, obsessive compulsive disorder, or generalized anxiety disorder, a combination of CBT and antidepressants has, however, been found to be the most effective.

When antidepressants are prescribed to children suffering from anxiety disorders or major depression, SSRIs have emerged as the treatment of choice, the least risky option, despite the slight risk of increased suicidal feelings and behavior. Where SSRIs are deemed necessary, Fluoxetine (Prozac) has been found to have the best risk to benefit ratio, making it a prime choice for those young people who need medication for their depression or anxiety — alongside careful monitoring of their condition, including possible suicidal feelings. [13]

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