The Pharmaceutical Journal
Vol 275 No 7369 p398
1 October 2005

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Drugs not to be initial therapy for depressed children

Antidepressant medication should not be used for the initial treatment of children and young people with moderate to severe depression, clinical guidelines published by the National Institute for Health and Clinical Excellence and the National Collaborating Centre for Mental Health this week recommend.

Children and young people with moderate to severe depression should be offered, as a first-line treatment, a specific psychological therapy, such as cognitive behavioural therapy, interpersonal therapy or family therapy of at least three months’ duration.
If depression is unresponsive to psychological therapy after four to six sessions, a multidisciplinary review should be carried out and alternative or additional psychological therapies considered. Antidepressant medication should only be offered in combination with a concurrent psychological therapy.

For those aged 12 to 18 years with moderate to severe depression, fluoxetine should be considered in addition to psychological therapy. For children aged five to 11 the addition of fluoxetine should be cautiously considered. Children with mild depression should not be offered antidepressant medication at all, the guidelines say.
Children and young people taking antidepressants should be monitored regularly, with a focus on adverse drug reactions, and patients and their parents or carers should be informed about the rationale for drug treatment, the delay in onset of effect, the time course of treatment, possible side effects and the need to take the medicines as prescribed. When discontinuing antidepressant medication, it is recommended that treatment is phased out over six to 12 weeks, with the exact dose being titrated against the level of discontinuation or withdrawal symptoms.

“NICE guidelines are not retrospective and so prescriptions for antidepressants for under-18s should be challenged sensitively,” Stephen Bazire, chief pharmacist at Norfolk and Waveney Mental Health Partnership NHS Trust, warned. “Although NICE recommends fluoxetine, there will be many occasions when other antidepressants will have to be used and when the use of some SSRIs in conditions such as obsessive compulsive disorder may require higher doses of fluoxetine and other antidepressant drugs,” he added. “Stopping or switching antidepressants will require particular care.”

The guidelines are available via PJ Online (www.pjonline.com/links/pj).