Antidepressants should never be a first-line treatment for child/adolescent depression. Recent studies have shown no benefit of adding fluoxetine to CBT in the treatment of even moderate-severe depression.
Fluoxetine is generally the first medication choice for pediatric depression because there is FDA approval for MDD (as well as OCD) in youth. It has the most evidence to support efficacy for
pediatric MDD, especially in children <12 years.
Fluoxetine also has a long half-life if non-adherence is a
concern, which minimizes the risk of withdrawal.
Unlike the other SSRIs, it is also available as an oral
solution (liquid).
Citalopram, escitalopram, or sertraline might be picked over fluoxetine if there are potential drug interactions with fluoxetine, or if there are significant concerns about a long half-life agent because the patient
has risk factors for bipolar disorder.
How Long Should Children and Adolescents Remain on Antidepressants?
Antidepressant treatment length is not well studied in this population, and is based on adult research. General guidelines recommend staying on an antidepressant between 6 to 12 months after achieving remission in those with no prior history of depression. In individuals with multiple episodes or a past history of severe depression, remaining on an antidepressant for at least 1 year is recommended.
Treatment of Major Depressive Disorder in Children and Adolescents
MacQueen, G. M. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. Special populations: youth, women, and the elderly. The Canadian Journal of Psychiatry, 61(9), 588-603.
Minimal or Non-response of Treatment to Major Depressive Disorder in Children and Adolescents
MacQueen, G. M. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. Special populations: youth, women, and the elderly. The Canadian Journal of Psychiatry, 61(9), 588-603.
1st line | Add SSRI to psychotherapy |
2nd line | Switch to another SSRI (if unresponsive to fluoxetine) |
3rd line† | Venlafaxine, tricyclic antidepressant |
Treatment-Resistant Major Depressive Disorder in Children and Adolescents
MacQueen, G. M. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. Special populations: youth, women, and the elderly. The Canadian Journal of Psychiatry, 61(9), 588-603.
1st line | SSRI + psychotherapy |
2nd line | Switch to another SSRI (if unresponsive to fluoxetine) |
3rd line† | • Venlafaxine (Level 2)
• TCA (Level 3)
• Neurostimulation treatment (ECT or rTMS) |