Children and adolescents
When depression occurs in children and adolescents, more care is necessary. Even very young children can make attempts on their own lives, and the darkness they are dealing with should not be minimized. A child who takes a whole bottle of multivitamins is considered an extremely high risk for suicide, and inpatient admission should be considered.
Although the method was not lethal, the intent was, meaning that he or she is more likely to make another attempt in the future. Early involvement with psychiatric services is necessary, which may be challenging depending on the child’s age and access to care.
In 2004, the FDA examined data on more than 4,000 children and adolescents on antidepressants and found that 4% thought about or tried suicide, compared with 2% of those on placebo (though there were no completed suicides). As a result, a black box warning was applied in 2005 to the labeling of all antidepressants, noting an increased risk of suicide, which was expanded to include those younger than age 24 by 2007.
However, a comprehensive review of pediatric trials between 1988 and 2006 suggested that the benefits of antidepressant medication likely outweighed the risks (National Institute of Mental Health).16 The rate of prescribing antidepressants for this population has significantly declined since the warning was implemented.17
Using the “rule of fours” can be helpful when initiating or changing any psychotropic medications for high-risk individuals, no matter the age. Basically, after the medication change, the patient should be seen once a week for four weeks, every other week for four weeks, once a month for four months, then every two to three months for a minimum of four visits.
Ideally, the same provider would assess the individual at every visit; with our and our patients’ busy schedules, this is often not possible. However, the medical provider can be seen one week, a therapist twice a month, and then you can check in by phone for a final visit. This can be even easier with a school counselor coordinating some of the check-ins as well.
For those individuals who are or are planning to be pregnant and have depression, the risk-benefit conversation should be had as early in the pregnancy or planning stages as possible. Ideally, a patient’s depression would be well controlled with therapy and social support prior to pregnancy and continued through until long after the delivery.
However, that does not often occur, owing to multiple factors. When choosing a medication to prescribe, consider one with the best safety profile, combined with a patient’s history of past response with minimal side effects. Most SSRIs are category C with the exception of paroxetine, which is category D. Several medications should be avoided or replaced immediately: valproate, carbamazepine, lithium, benzodiazepines, and MAOIs.
There is some evidence of mild withdrawal symptoms in the neonate, and parents and pediatric providers need to be aware of this. Often the question arises of whether the mother should try to “tough it out” to minimize the risk. However, mothers who have uncontrolled depression are less likely to take care of their health (e.g., keep appointments, take vitamins) and more likely to engage in risky behaviors during pregnancy, such as self-medicating with drugs or alcohol.
After delivery, depressed moms often bond more poorly with their infants, resulting in decreased breastfeeding and an increased risk of neglect or outright abuse. First-time moms may be eligible for the Nurse–Family Partnership (nursefamilypartnership.org), which can help assist them through the challenges of pregnancy and raising an infant; many other programs exist on a state-by-state basis, often coordinated through the local health department.