Pediatric Antidepressant Pharmacotherapy
Key Principles
- Start low, go slow approach is essential
- Regular monitoring for suicidal ideation required
- Treatment should be part of comprehensive care plan
- Duration of treatment typically 6-12 months after symptom resolution
FDA-Approved Indications in Pediatrics
- Major Depressive Disorder (MDD): Fluoxetine (≥8 years), Escitalopram (≥12 years)
- Obsessive-Compulsive Disorder (OCD): Several SSRIs approved for ages ≥6-7 years
- Anxiety Disorders: Selected agents approved for specific anxiety conditions
Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine
Clinical Applications
- First-line for pediatric depression
- OCD in children ≥7 years
- Anxiety disorders
Dosing
- Starting: 5-10 mg daily
- Typical range: 10-20 mg daily
- Maximum: 60 mg daily
- Long half-life reduces withdrawal risk
Sertraline
Clinical Applications
- OCD (FDA approved ≥6 years)
- Anxiety disorders
- Depression (off-label)
Dosing
- Starting: 12.5-25 mg daily
- Typical range: 50-100 mg daily
- Maximum: 200 mg daily
Escitalopram
Clinical Applications
- Depression (≥12 years)
- Anxiety disorders
Dosing
- Starting: 5 mg daily
- Typical range: 10-20 mg daily
- Maximum: 20 mg daily
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine
Clinical Applications
- Generalized Anxiety Disorder (≥7 years)
- Depression (off-label)
- Chronic pain conditions
Dosing
- Starting: 20-30 mg daily
- Typical range: 30-60 mg daily
- Maximum: 120 mg daily
Venlafaxine
Considerations
- Limited pediatric data
- Higher discontinuation risks
- Blood pressure monitoring required
Other Antidepressant Classes
Bupropion
Clinical Applications
- Depression with prominent fatigue
- ADHD comorbidity
- Lower sexual side effect profile
Dosing
- Starting: 75 mg daily
- Typical range: 150-300 mg daily
- Maximum: 450 mg daily
Mirtazapine
Clinical Applications
- Depression with insomnia
- Anxiety disorders
- Eating disorders
Considerations
- Sedating effects
- Weight gain potential
- Evening dosing recommended
Monitoring & Safety Considerations
Initial Phase
- Weekly monitoring for first 4 weeks
- Suicidal ideation screening
- Behavioral changes assessment
- Sleep patterns
- Appetite changes
Common Side Effects
- Gastrointestinal: Nausea, diarrhea
- Sleep changes: Insomnia or somnolence
- Appetite changes
- Headache
- Activation syndrome (irritability, anxiety)
Long-term Monitoring
- Growth parameters
- Sexual development
- Academic performance
- Social functioning
Special Considerations
Black Box Warning
- Increased risk of suicidal thoughts/behaviors
- Highest risk in first few months
- Need for close monitoring
Treatment Resistance
- Adequate trial duration (8-12 weeks)
- Optimization of current medication
- Consideration of augmentation strategies
- Reassessment of diagnosis
Discontinuation
- Gradual taper recommended
- Monitor for withdrawal symptoms
- Plan for relapse prevention
- Continuation of psychotherapy
Further Reading
