Learn why antidepressants have warnings about suicidal thinking in children and teens, what to do before your child starts taking an antidepressant, and the warning signs of a potential problem. By Mayo Clinic Staff

Antidepressant medications are often an effective way to treat depression and anxiety in children and teenagers. However, antidepressant use in children and adolescents must be monitored carefully, as rarely there can be severe side effects. In fact, antidepressants carry a Food and Drug Administration (FDA) black box warning regarding a possible risk of increased suicidal behavior in some individuals under the age of 25.

Although at first you may find the suicide warnings alarming, it's important to get the facts. Find out what the warnings mean and ask about all treatment options. This will help you make an informed decision about your child's health and weigh the benefits and risks of treatment options with your child's doctor.

The FDA reported that an extensive analysis of clinical trials showed that antidepressants may cause or worsen suicidal thinking or behavior in a small number of children and adolescents. The analysis showed that 4 percent of those taking antidepressants had an increase in suicidal thoughts, compared with 2 percent of those taking a sugar pill (placebo).

None of the children in any of the studies actually took his or her own life. Still, the FDA considered the findings of enough concern that it issued a public health advisory and began requiring manufacturers to label antidepressants with strong warnings about the link to suicidal thinking and behavior in children, adolescents and young adults ages 18 through 24.

However, not all mental health researchers believe these warnings are necessary. Newer research indicates that the benefits of antidepressants may be greater than the risk of suicide. And some research indicates that suicide rates in children decrease when they take antidepressants.

Although the FDA analysis examined only nine antidepressants, the FDA extended the warning to all prescription antidepressants. This is known as a black box warning — the strongest safety warning that the FDA can issue about a prescription medication. The warning is printed in bold type framed in a black border at the top of the paper inserts that come with antidepressants.

Because of the risk of suicide from depression, it's difficult to establish a clear causal relationship between antidepressant use and suicide. Researchers speculate about a variety of potential reasons for an increased risk. In some children, antidepressants may also trigger anxiety, agitation, hostility, restlessness or impulsive behavior. These effects may indicate that the child's depression is getting worse or that the child is starting to develop suicidal thoughts.

The warnings about a possible link between antidepressants and suicidal thoughts do not mean that antidepressants should not be used to treat children. Nor are the warnings meant to frighten people away from antidepressants. However, the antidepressant warnings should be taken as a caution to carefully weigh the pros and cons of using these medications in children and teenagers against the real risk of suicide as a result of untreated depression.

For many children and teens, antidepressants are an effective way to treat depression, anxiety, obsessive-compulsive disorder or other mental health conditions. If these conditions aren't treated effectively, your child may not be able to lead a satisfying, fulfilled life or do normal, everyday activities.

It's important that your child have a thorough evaluation before he or she starts taking an antidepressant. A psychiatric evaluation by a psychiatrist, or a pediatrician or family doctor who is experienced in pediatric psychiatric issues, should include:

  • A detailed review of any potential risk factors your child may have that increase the risk of self-harm
  • An assessment of whether your child may have other mental illnesses, such as anxiety disorders, attention-deficit/hyperactivity disorder or bipolar disorder
  • An evaluation of whether there's a family history of mental illnesses or suicide

The FDA approved two antidepressants for the treatment of depression in children and teenagers — fluoxetine (Prozac) for age 8 or older, and escitalopram (Lexapro) for age 12 or older. Fluoxetine is also FDA approved to treat obsessive-compulsive disorder (OCD) in children, as are the antidepressants sertraline (Zoloft), fluvoxamine (Luvox) and clomipramine (Anafranil).

Doctors may use their medical judgment to prescribe other antidepressants for children, such as citalopram (Celexa), for what's called off-label use. This is a clinically common practice for many types of medications for both children and adults.

Antidepressants come with a medication guide that advises parents and caregivers about risks and precautions. Be sure to carefully read the medication guide and package insert, and discuss any questions with your child's health care professionals.

The FDA advises that doctors prescribe the smallest quantity of pills possible to help reduce the risk of deliberate or accidental overdose. Careful monitoring by parents, caregivers and health care professionals is important for any child or teenager taking an antidepressant for depression or any other condition.

The highest risk of suicidal thinking and behavior occurs:

  • During the first few months of treatment with an antidepressant
  • When the dosage is increased or decreased

Parents and caregivers should closely observe the child on a daily basis during these transition periods and watch for worrisome changes for the whole time the child takes antidepressants.

The FDA also recommends that your child receive close monitoring by his or her health care professional during the first few months of treatment. Frequency of contact with doctors or mental health professionals depends on your child's needs. Make sure you stick to your child's recommended appointment schedule.

Sometimes the signs and symptoms of suicidal thoughts or self-harm are difficult to see, and your child may not directly tell you about such thoughts. Here are some signs that your child's condition may be worsening or that he or she may be at risk of self-harm:

  • Talk of suicide or dying
  • Attempts to commit suicide
  • Self-injury
  • Agitation or restlessness
  • Panic attacks
  • Increasing sadness
  • Extreme increase in talking or activity
  • Aggression, violence or hostility
  • New or worsening anxiety
  • Social or academic problems at school
  • Spending more time alone

Contact your child's health care professional right away if any of these signs occur, if they get worse, or if they worry you, your child, a teacher or other caregiver.

Don't stop antidepressant treatment without the guidance of your child's health care professional. Suddenly stopping an antidepressant may cause flu-like symptoms or side effects referred to as discontinuation syndrome.

Most children who take antidepressants will improve with medication. However, combining medication with talk therapy (psychotherapy) is likely to be even more effective. Many types of therapy may be helpful, but cognitive behavioral therapy and interpersonal therapy have proved effective in the treatment of depression.

  • Cognitive behavioral therapy. In cognitive behavioral therapy, a mental health provider can help your child improve coping skills, communication and problem-solving skills. Your child can also learn how to become aware of harmful ideas and behaviors, replace them with positive approaches, and regulate emotions. This type of therapy can be effective with children and teenagers.
  • Interpersonal therapy. With a focus on relationships, this therapy may help your teenager adapt to changes in current relationships and develop new ones.

For some children and teenagers with mild symptoms, talk therapy alone may be beneficial.

May 21, 2013