JUNE 2025
Aim
To emphasise considerations of prescribing antidepressant medications in adolescents experiencing major depression.
Background
Major depression is a highly prevalent condition in adolescence associated with significant morbidity. Major depression is the commonest new psychiatric condition arising in adolescence and is the commonest diagnosis associated with suicide attempts and suicide. While first line treatment for mild to moderate depression is counselling, this may not be effective alone in many cases of moderate and severe depression. Assertive treatment of moderate or severe depression is important to reduce risks and improve psychosocial functioning.
Antidepressants
Antidepressant medications have been shown to be effective when administered together with psychological treatments in adolescents.
The Selective Serotonin Reuptake Inhibitors (SSRIs) are the first line class of antidepressants for adolescent depression. While the evidence for the use of antidepressants in preadolescents for major depression is unconvincing, there is a role for the use of SSRIs where the preadolescent has co-morbid anxiety disorder, such as social anxiety, generalised anxiety, obsessive compulsive disorder or separation anxiety disorder. While all prescribing of antidepressants in Australia is off label for child and adolescent depression, fluoxetine and escitalopram have been approved by the American Food and Drug Administration (FDA) for adolescent major depression based on the extant randomised control studies.
Implications for clinical practice
The use of antidepressants should be a collaborative exercise with the young person, their carer and the treating paediatrician or General Practitioner (GP).
Common side effects of SSRIs such as nausea, headache, bloating, constipation/diarrhoea, sweating/flushing, weight changes ideally should be flagged prior to starting medication. It should be noted that sexual side effects such as reduced libido and anorgasmia are not uncommon. Rare side effects such as manic switching, serotonin syndrome and increased suicidal thoughts and behaviours are seen with antidepressants.
It is common for adolescents to have poor compliance across all medication groups, and so their involvement, consent/assent is critical in achieving regular dosing. If side effects are not first flagged with the adolescent, they are very likely to research the medication adverse effect or consult with others on social media, possibly leading to discontinuation and affecting the therapeutic alliance.