Antidepressants encompass a number of different classes of medications. Most commonly used in children are Selective Serotonin Receptive Inhibitors (SSRI’s). There are five different medications that fall into this category, with the most common ones used being Cipralex (Escitalopram), Prozac (Fluoxetine) and Zoloft (Sertraline). There are ALL EQUALLY effective. We do not know why some people tend to respond to one vs another (the research to understand who responds to what medication more, is only in its infancy stages, with the first study in Toronto currently underway for adults).
How a certain medication is chosen may be personal preference (perhaps a family member or friend has responded to one), side effect profile, cost etc. These medications have all been studied in adults, and shown to be effective in treating anxiety and depression for adults. This has led them to be Health Canada approved, ie indicated for depression and anxiety in adults (aged 18-65).
Studies over the past few decades have also been done for these medications in children, treating depression or anxiety. The studies were FDA (US Government) funded, and were positive, ie worked in treating the disorders they were studied in. Given the results of these studies, the FDA has approved a number of the medications to treat depression or anxiety in children and adolescents in the USA. For many reasons (one likely being that most of the medications are now generic), these medications are not Health Canada approved to treat children and adolescents, but it is not because they do not work. Treating patients with medications that are not Health Canada approved for that age group and indication is called “off label use”. Regardless of this “off label use” of the medications, as child psychiatrists, we continue to use the medications because the evidence is there to show that they are efficacious.
In addition to SSRI’s, other classes of antidepressants include Serotonin Norepinephrine Receptor Inhibitors (SNRI), Norepinephrine Dopamine Receptor Inhibitors (NDRI), Norepinephrine Antagonist and Selective Serotonin Receptor Inhibitor (NaSSA). Whichever medication is recommended, the psychiatrist likely had a reasoning behind why it was chosen, and you can ask why if you really want to get behind the physician’s thought process.
Side effect profiles are one of the common considerations when a specific medication is recommended. Different medications have differing percentages of nausea, stomach upset, headaches, muscles aches, sleep/appetite effects, fatigue, sexual dysfunction etc. Which one is recommended may be based on what side effect a patient is willing or unwilling to tolerate.
Finally and most importantly, all antidepressants have a Black Box Suicide Related Adverse Events Warning. It is important to note that the term “suicide related adverse event” is very broad, and can encompass any comment from a child saying, “I don’t want to live”, to cutting behaviors. The data gathered was retrospective in nature, and there was no causation link found that antidepressants cause suicide. Furthermore, in reviewing suicide research, the majority of people who commit suicide successful generally showed NO ANTIDEPRESSANTS levels in their autopsies, despite there being antidepressants prescribed on file to these patients.
In the end, there is a correlation between the use of antidepressants and suicide related adverse events. What we don’t know is if it is the underlying anxiety/depression that is causing what is considered to be suicide related adverse events or the medications themselves.
The take home message I give families about the black box warning is that it is meant to initiate the conversation between patient and family/physician about suicide. At any point in time, whether one is on or off medication, one is encouraged to talk about suicidal thoughts if one is experiencing it Studies have shown that talking about the thoughts are helpful, in that it can relieve a sense of stress, shame and secrecy. There is no evidence that asking or talking about suicide leads one to develop suicidal thoughts. Hence, regular follow up is critical after starting medications so that any adverse events including suicidal thoughts can be assessed. This is the reason behind my specific medication policy and lack of prescribing over the phone/email/fax. These technological advances, although convenient to patient and families in the lack of need to miss time for a doctor’s appointment, cannot adequately provide a comprehensive risk assessment that can only be done in person.
In the end, whether deciding to go on medications is a personal decision and one that your physician can help guide you with. Be aware that if a physician has recommended medication use, they likely have given all of the above thought and related to your particular case before the recommendation is made. Should one decide to not follow medical advice, that is certainly one’s prerogative as long as one is also aware that untreated depression/anxiety also has significant risks including worsening of symptoms, development of other disorders/symptoms and perhaps, even suicide.
Finally, medication use IS NOT FOREVER. One medication trial generally lasts a few months, and so one does need to commit to taking the medication as prescribed for 3-4 months before deciding whether it is working or not. However, if the medication is not working, the physician will not keep you on it. If a medication does work, the recommendation is to stay on it until one has been symptom free (of anxiety and depression) for 6-12 months, and then to gradually decrease under a physician’s guidance while watching for recurrence of symptoms.
Sept 17, 2017