This Month in Psychopharmacology

SSRIs, SNRIs Show Small But Significant Benefit for Children and Adolescents With Common Mental Illnesses

Following publication of a recent meta-analysis analyzing the efficacy and tolerability of antidepressants for pediatric major depressive disorder (Cipriani et al, 2016), there continues to be much debate over the utility and risk-to-benefit ratio of antidepressant use within the pediatric population. In the present meta-analysis, Locher and colleagues investigated the safety and efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) in the treatment of some of the most common psychiatric conditions found among pediatric patients–depressive disorders, anxiety disorders, obsessive compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). In this analysis (which included nearly 7,000 pediatric patients), they found that, in general, SSRIs and SNRIs are more effective than placebo. However, further analyses indicated that the effect size was significantly larger for pediatric anxiety disorders than for pediatric depressive disorders; that the placebo response was high, particularly in trials investigating SSRI/SNRI use for pediatric depressive disorders; and that treatment-emergent adverse events, serious adverse events, and discontinuation due to adverse events were significantly elevated in patients receiving an antidepressant compared to those receiving placebo. These data support the need for future studies to more carefully stratify pediatric patients who present with depression according to additional factors (e.g., age-of-onset, mixed features, etc.) in order to better determine for which patients the benefits of SSRI/SNRI use will adequately outweigh the risks. These conclusions are very much in line with the recently published guidelines for mixed depression that stress the importance of identifying subthreshold symptoms of (hypo)mania and family history of mood disorders prior to prescribing antidepressant monotherapy in all patients who present with depression, including children and adolescents (Stahl et al, 2017).


References

Cipriani A, Zhou X, Del Giovane C et al. Comparative efficacy and tolerability of antidepressants for majoro depressive disorder in children and adolescents: a network meta-analysis. Lancet 2016;388(10047):881-90.

Locher C, Koechlin H, Zion SR et al. Efficacy and safety of selective reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: A systematic review and meta-analysis. JAMA Psychiatry 2017; Epub ahead of print.

Stahl SM, Morrissette DA, Faedda G et al. Guidelines for the recognition and management of mixed depression. CNS Spectr 2017;22(2):203-19.