Pediatric pearls with a focus on depression.
Adult psychiatrists often provide first-line therapies for children and adolescents. It can work well if we stay up-to-date on the basics, so I’ve gathered some pediatric pearls from this year’s American Psychiatric Association Annual Meeting, with a focus on depression.
There are only two FDA-approved medications for major depressive disorder in children and adolescents: fluoxetine (Prozac) and escitalopram (Lexapro). It’s best to start with these, both for scientific and medicolegal reasons. Among them, fluoxetine is usually first-line because it has more positive studies and is approved for a broader age range: 8 years and older. Escitalopram comes next, and after that are two off-label treatments that have mixed results: citalopram and sertraline.1
The list of effective antidepressants in pediatric depression is short, and it’s not for lack of trying. Among the ones that tried but failed are paroxetine, venlafaxine, mirtazapine, nefazodone, desvenlafaxine, vilazodone, duloxetine, and even the monoamine oxidase inhibitor selegiline (EMSAM), which failed to separate from placebo in a trial of 308 adolescents. The problem is that the placebo works so well in this population. The placebo response in children is 50%, compared with 30% in adult depression trials.1 That means that a lot of children will improve with good support and tincture of time, but it also means that many will end up on antidepressants that they didn’t really need.
For children with depression, the four most critical social problems to attend to are:
1. Parental depression
2. Child abuse
4. Substance abuse
When they are active, these problems can keep treatment from working, according to Karen Wagner, MD, PhD, President of the American Academy of Child and Adolescent Psychiatry. It’s not enough to assess them; they also need to be addressed. For example, if a child is the victim of bullying, Dr Wagner will advise parents to raise the issue directly with the school.1
The risk of suicidal ideation and attempts is similar with the various antidepressants, according to Dr Wagner. That risk is elevated in children and adolescents and gradually falls to zero after age 25. Specifically, the risk is 3% with antidepressants and 2% with placebo. Two things that raise the risk are prescribing beyond the maximum recommended dose, and using two antidepressants at the same time.1
Anxiety and depression can look the same, with avoidance, worry, and somatic symptoms prominent in both. One key difference is the age of onset. Anxiety disorders tend to start between ages 6 and 12, while the typical onset for pediatric depression is 13 to 16. Most children with anxiety have multiple DSM-5 disorders that morph into each other as the child ages. It starts with separation anxiety in the early school days, then generalized anxiety, which turns into social anxiety around puberty and panic disorder in the teens. Physical complaints are common through these transitions. Duloxetine (Cymbalta) is the only FDA-approved medication in this population. It is approved for generalized anxiety disorder in children age 7 and older, even though it failed in a study of pediatric depression.2
Screening for bipolar disorder (BD) is particularly important in youth because adolescent depression is itself a strong risk factor for BD. Other signs of BD include family history of the disorder, personal history of worsened mood on antidepressants, subsyndromal manic symptoms, and psychotic features. Manpreet Singh, MD, recommends caution with antidepressants in children at risk for BD, and going very low and slow if they are used at all. She suggests asking the parents if they have had mania, and screening for mania in all children with mood disorders.3 The Mood Disorder Questionnaire is available in an adolescent version, and this test is more reliable when the parent fills it out, according to Dr Wagner.1
Child psychiatrists do not have clear guidelines on when to discontinue antidepressants. In youth, the risk of recurrence is 50% for unipolar depression and 75% for bipolar depression.1 Most presenters would consider a trial off medication if the child has been stable for 1 to 2 years. Tapering tends to work best when the dose is lowered slowly and when stress levels are low, such as during summer vacation.
1. Wagner K. Update on pharmacological treatment for pediatric mood disorders. Presented at: American Psychiatric Association Annual Meeting; May 18-22, 2019; San Francisco, CA.
2. Walkup J. Treatment of pediatric anxiety disorders. Presented at: American Psychiatric Association Annual Meeting; May 18-22, 2019; San Francisco, CA.
3. Singh MK. Meet the author: Clinical Handbook for the Diagnosis and Treatment of Pediatric Mood Disorders. American Psychiatric Association Annual Meeting; May 18-22, 2019; San Francisco, CA.
Dr Aiken does not accept honoraria from pharmaceutical companies but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, which he coauthored with Jim Phelps, MD.
About the Author
Chris Aiken, MD, is the Director of the Mood Treatment Center, Editor in Chief of The Carlat Psychiatry Report, and Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He has served as a subinvestigator on phase III clinical trials, and his research interests include diagnosis of mood disorders, novel pharmacologic agents, and natural and environmental approaches to mental health. He is the coauthor with Jim Phelps, MD, of Bipolar, Not So Much, a self-help book for Bipolar II (W.W. Norton & Co; 2017). He does not accept honoraria from pharmaceutical companies.