Major depressive disorder is a significant pediatric and adolescent health problem associated with significant morbidity. These patients suffer from impaired social functioning, school difficulties and have an increased risk of physical illness and substance abuse. It is also associated with an increased risk of mortality by suicide. Treatment should therefore be initiated with both psychotherapy and pharmacotherapy.
Choosing of antidepressant is however a challenge for pediatric patients. This is because of the smaller evidence available for antidepressant efficacy compared to adult patients. Selective serotonin reuptake inhibitors (SSRIs) are the first line antidepressants in both pediatric and adult patients with only a few of these antidepressants FDA approved to be used in pediatrics.
The lack of FDA approval for pediatric patients is mostly attributed to the lack of sufficient testing. This means that some antidepressants used in pediatrics are prescribed off—label. Use of off-label drugs is common in pediatrics. Off label drugs use is when drugs are used for treatment of conditions different from the ones they were originally intended for (Gore et al., 2017).
Off-label drug use is recommended in children if they do not receive adequate improvement after using first line drugs (Dwyer & Bloch, 2019). In patients with depressive disorders, improvements can be seen when switching form one SSRI to another e.g., when a switch from Prozac to Zoloft is made (Boyce et al., 2020).
However, certain considerations need to be made when drugs are used off label. These include the child’s body weight and stage of development. This is relevant because these factors can affect how the child will tolerate the drug (Collier et al.,2017). Metabolism is also affected by these factors and consequently the amount of drugs prescribed. Another important consideration is the side effects associated with the drugs. SSRIs, for example, are more likely to cause suicidal ideations in pediatric and adolescent patients than in adults.
Boyce, P., Hopwood, M., Morris, G., Hamilton, A., Bassett, D., Baune, B. T., Mulder, R., Porter, R., Parker, G., Singh, A. B., Outhred, T., Das, P., & Malhi, G. S. (2020). Switching antidepressants in the treatment of major depression: When, how and what to switch to?. Journal of Affective Disorders, 261, 160–163. https://doi.org/10.1016/j.jad.2019.09.082
Collier, H., Nasim, M., & Gandhi, A. (2017). Prescribing in obese children: how good are paediatricians?. Archives Of Disease In Childhood, 102(1), 61–62. https://doi.org/10.1136/archdischild-2016-310603
Dwyer, J. B., & Bloch, M. H. (2019). Antidepressants for Pediatric Patients. Current Psychiatry, 18(9), 26–42F. https://pubmed.ncbi.nlm.nih.gov/31511767/
Gore, R., Chugh, P. K., Tripathi, C. D., Lhamo, Y., & Gautam, S. (2017). Pediatric Off-Label and Unlicensed Drug Use and Its Implications. Current Clinical Pharmacology, 12(1), 18–25. https://doi.org/10.2174/1574884712666170317161935
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