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Antidepressants are not new, and have been
used since the 1950’s without much controversy. All this changed in
1988, when the release of antidepressants with fewer side effects, such as
fluoxetine (Prozac), meant that more people, and younger people, were able
to take them. With so many taking these medicines, there soon came a few
reports of bad reactions. At first was hard to tell if these reactions were
caused by the drug or by the illness that was being treated. For example,
some people with depression became violent or committed suicide while
taking fluoxetine, but fluoxetine is often prescribed to people who are at
risk for violence or suicide to begin with.
Although these questions have
not been fully researched, clinical experience and the available studies do
point towards some answers. Antidepressants do not directly cause violence;
in fact, they are often used successfully to lower aggression, violence and
suicidal behavior. However, they can cause several rare side effects which
can be very uncomfortable: akathisia (restlessness), anxiety, agitation and
mania.
Psychiatrists have known about
these reactions for a long time because they happen naturally in people who
aren’t on medicine. We know that they are treatable, and we know that
they can sometimes lead to violence. They are described in more detail below:
1) Akathisia
This
is a feeling of inner restlessness or agitation. People often feel that
they can’t sit still and have to keep moving, and may get up and pace
from their chair frequently.
2) Anxiety
Although
antidepressants usually reduce anxiety, on rare occasions they can increase
it. This “paradoxical anxiety” is more likely to happen in the
first few weeks of treatment or if the dose is too high.
3) Bipolar or Manic Reactions
Some
people with depression may actually have bipolar depression, which means
that their mood can swing from sad and low to high, excited and agitated.
Antidepressants may cause mood swings in people with this condition, and if
this “manic state” goes on too long it can lead to impulsive or
aggressive behavior. Signs of mania include high energy, needing very
little sleep, racing thoughts, extreme confidence or happiness,
irritability or agitation, and reckless or impulsive behavior. People
with a family history of bipolar disorder are at a higher risk of this
happening.
Antidepressants in Children and Adolescents
In
2003, news came of a slightly elevated suicide risk in children (under 18)
who take antidepressants [1].
Although the risk was small, and none of the children studied
actually committed suicide, this problem may be real and seems to be
related to hostility, mood swings and aggression in some children who take
the medicine. If this reaction occurs, it is likely to happen in the first
few weeks of treatment. In March of 2004, the FDA decided that, although
studies were still inconclusive, people should be warned about this
potential and children should be watched closely when starting
antidepressants. The FDA also called
for more research, and since then several important studies have been
released which have added weight to the evidence that antidepressants are
safe and effective in children, especially when combined with
psychotherapy.
We also know that depression, if
left untreated, can be harmful to a child’s personal development and
lead to changes in the brain which make it more difficult to treat. There
are risks, then, both in medicating and not medicating children with
depression.
If you are thinking of stopping
your child’s antidepressant, talk to your doctor first since abrupt
stopping can cause withdrawal symptoms syndrome that include dizziness,
nausea, tremors, and anxiety. These symptoms tend to be worse for
paroxetine (Paxil).
Footnotes:
[1] In
the first study, with paroxetine (Paxil), 1-2% of children on a sugar-pill
(placebo) had suicidal behavior, as compared to 2-3.5% of children taking
paroxetine (Paxil). The second study found that 2% of children and
adolescents taking venlafaxine (Effexor) had thoughts of suicide, compared
with none who took the sugar pill (placebo). A separate study was more
reassuring: it turns out that when data from all antidepressant studies in
children are combined and averaged, involving more than 2,000 children,
there is no increased risk of suicide with antidepressants. Other antidepressants have been studied
in children with good results. Fluoxetine (Prozac) and sertraline (Zoloft)
both have several placebo-controlled trials showing benefit for children
with depression, and fluoxetine has been approved by the FDA for childhood
depression.
References:
Wagner KD, et al. Efficacy of Sertraline
in the Treatment of Children and Adolescents with Major Depressive
Disorder: Two Randomized Clinical Trials. Journal
of the American Medical Association (August 27, 2003): Vol. 290, No. 8, pp.
1033–41.
March, J, et
al. Fluoxetine, cognitive-behavioral therapy, and their combination for
adolescents with depression: Treatment for Adolescents With Depression
Study (TADS) randomized controlled trial. Journal
of the American Medical Association (August 18,
2004) Vol. 292, No. 7, pp. 807-20.
American College of
Neuropsychopharmacology, Preliminary Report
of the Task Force on SSRIs and Suicidal Behavior in Youth. January 21, 2004.
Food and Drug Administration, Report
on Pediatric Psychopharmacology, August 20, 2004.
Updated 9/20/4 by Chris Aiken,
M.D.
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