SSRI treatment for under-18s

Let me see if I've got this straight. Industry bias in reporting the results of trials of selective serotonin reuptake inhibitors (SSRIs) is probable,¹ although an employee of a multinational drug company in another country doubts that this is so.² Another therapist (the author of a book reviewed in CMAJ) feels that mental illness has become far too commercialized (and the reviewer notes that, for pointing this out, the book's author has been personally maligned).³ Data are lacking because they are not known (because of a globally inadequate system for reporting adverse drug reactions⁴), are not available (because they have not been published⁵) or cannot be discussed by physicians who have engaged in nondisclosure contracts.⁶ SSRIs may be associated with an incidence of serious side effects (including withdrawals) of up to 25%, and the placebo response rate can be as high as 40% to 60%, although there may be a 70% response rate on some criteria of depression.⁶ There is no evidentiary basis to prescribe or not prescribe SSRIs in patients under 18 years of age, and, either way, all of these uses are “off label” for patients in this age group. Furthermore, no clear leadership position is evident among child psychiatrists, almost all of whom are aligned with this controversy in some way.

As a personal standard, I try never to complain without offering some constructive suggestion. Having perused a selection of the currently available world literature on this topic, my impression is that SSRIs should be used with caution in this age group, and only as a last resort, after the failure of all other obvious psychosocial and environmental interventions, and with close attention to symptoms of mood instability (serious adverse behavioural and emotional reactions including agitation, irritability, behavioural disinhibition and suicidality).

Mark A. Voysey Adolescent Psychiatrist Toronto, Ont.