An antidepressant is a medication used primarily in the treatment of
depression. Depression can occur if some of the chemicals called
neurotransmitters in the brain are not functioning effectively. There are
three specific chemicals that can affect a person's mood:
serotonin, norepinephrine, or dopamine. Antidepressants affect one or more
of these chemicals in different ways to help stabilize the chemical
imbalance often seen in depression. Antidepressant drugs are not happy
pills, and they are not a panacea. They are prescription-only drugs that
come with risks as well as benefits and should only be taken under a
doctor's supervision. Because children and adolescents experience
depression just as adults do, they are sometimes prescribed
antidepressants by their physician.
Antidepressants are medicines used to help people who have depression.
Antidepressant medications may be indicated for those children and
adolescents with bipolar depression, psychotic depression, depression with
severe symptoms that prevent effective psychotherapy or counseling, and
depression that does not respond to psychotherapy. However, given the
psychosocial dynamics that often coexist with depression, antidepressants
are usually insufficient as the only treatment for children who have the
disorder. Psychotherapy is often recommended as an adjunct treatment along
with the prescribed antidepressant. The use of antidepressants among
children has been growing steadily since the late 1980s.
All antidepressant medications have a slow onset of action, typically
three to five weeks. Although side effects may be observed as early as the
first dose, significant therapeutic improvement is always delayed. Most
antidepressants are believed to work by slowing the removal of certain
chemicals from the brain. These chemicals are called neurotransmitters,
which are needed for normal brain function. Antidepressants help people
with depression by making these natural chemicals more available to the
brain. There are many different kinds of antidepressants, including the
ones listed below.
MAO inhibitors work by blocking the action of a chemical substance known
as monoamine oxidase in the nervous system. Studies done in animals
suggest that MAO inhibitors may slow growth in children. Little
information on the use of MAO inhibitors in children under 16 years old
was available as of 2004.
Tricyclics have been used to treat depression for a long time. They
include amitriptyline, desipramine, imipramine, nortriptyline, and
trimipramine. Tricyclic anti-depressants work by shoring up the
brain's supply of norepinephrine and serotonin, chemicals that are
abnormally low in depressed patients. This effect allows the flow of nerve
impulses to return to normal. The tricyclics do not act by stimulating the
central nervous system or by blocking monoamine oxidase.
SSRIs are a group of antidepressants that includes drugs such as
citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), and escitalopram (Lexapro). In the early 2000s SSRIs have
replaced tricyclic antidepressants as the drugs of choice in the treatment
primarily because of their improved tolerability and safety if taken in
overdose. These medicines tend to have fewer side effects than the
There are several antidepressants available as of 2004 that, because they
are not chemically structured like the other types of antidepressants, are
grouped into the category "other" or miscellaneous.
Bupropion (Wellbutrin), mirtazapine (Remeron), and venlafaxine (Effexor)
are among those in this category.
Selective serotonin reuptake inhibitors (SSRIs) are considered an
improvement over older antidepressants because they are better tolerated
and are safer if taken in an overdose. The prescription of SSRIs has risen
dramatically in the past several years in children and adolescents age 10
to 19. Some research points out that this increase has coincided with a
significant decrease in
rates in this age group, but it is unknown if SSRIs are directly
responsible for this improvement. As of 2004, fluoxetine (Prozac) was the
only SSRI that the Food and Drug Administration (FDA) has approved for the
treatment of children's depression. Fluoxetine (Prozac), sertraline
(Zoloft), and fluvoxamine (Luvox) are approved by the FDA for the
because studies have shown they are safe and effective medicines for
adolescents with this disorder. An early 2000s study showed that
citalopram (Celexa) significantly reduced symptoms of major depression in
children and adolescents. Sertraline (Zoloft) was also found in studies to
be effective with youths, slightly more so for adolescents than younger
children. Physicians may frequently prescribe many of the SSRI
antidepressants besides fluoxetine (Prozac) for children to treat
depression, even though they have not been approved for this use by the
FDA. This is called "off-label" use. Off-label refers to the
use by doctors of FDA-approved drugs for purposes other than those
approved by the agency.
Tricyclic antidepressants (TCAs) are primarily used to treat depression in
adults. The most commonly used ones are nortriptyline (Pamelor),
desipramine (Elavil), and imipramine (Tofranil). They function similarly
and have similar risks and side effects. They are not as effective in
treating depression in children who have not reached
and for these children should only be used as a second line agent. There
is marginal evidence to support the use of tricyclics in the treatment of
depression in adolescents, but the effect is likely to be moderate.
Although they are actually not very effective as antidepressants with
children, they can be quite helpful for a variety of other problems,
including attention deficit disorder, enuresis (
), and obsessive-compulsive disorder. The American Academy of Child and
Adolescent Psychiatry (AACAP) does not recommend TCAs as a first-line
treatment for youths requiring medicine for depressive disorders. However,
the AACAP acknowledges that some young people with depression may respond
better to TCAs than to other antidepressants.
Studies on MAO inhibitors have only been performed on adult patients, and
there is as of 2004 no specific information comparing the use of MAO
inhibitors in children with use in other age groups. However, animal
studies have shown that these medicines may slow growth in young children
and are therefore not generally recommended for use in children. Parents
should be sure to speak with the doctor regarding whether the use of these
medicines is appropriate before giving a monoamine oxidase inhibitor to
Bupropion (Wellbutrin) seems to be a better antidepressant for children
than the tricyclic antidepressants. Again, as of 2004 bupropion has not
been approved for this use by the FDA. It has also proven to be an
effective treatment for children diagnosed with attention deficit
disorder. The manufacturer of venlafaxine (Effexor) has issued a statement
that the drug is not effective in
treating depression in children and teenagers and is recommending that
venlafaxine (Effexor) not be used in pediatric patients. Early 2000s
studies have found increased reports of thinking about suicide and
self-harm, among children and teens taking venlafaxine (Effexor).
Mirtazapine (Remeron) must be used with caution in children with
depression. Studies have shown occurrences of children thinking about
suicide or attempting suicide in clinical trials for this medicine.
In 2004, the FDA issued a health advisory recommending close observation
for worsening depression in both adults and children treated with certain
antidepressants. The FDA requested that a warning of a possible
association between the use of SSRIs and
be inserted in the labeling of these medications. Studies have found no
direct link between these antidepressants and worsening depression or
increased suicide in children. In fact, no suicide has been reported among
the more than 4,100 people studied who take SSRIs. However, the FDA
continues to study this issue. Some believe the increased risk of suicide
is not related to the SSRIs themselves, but a phenomenon seen when the
symptoms of depression first begin to improve. This phenomenon occurs when
the depressed person starts to gain more energy but is not yet fully
relieved of the depressive symptoms. The drugs under review include
bupropion (Wellbutrin), citalopram (Celexa), fluoxetine (Prozac),
mirtazapine (Remeron), nefazodone (Serzone), paroxetine (Paxil),
sertraline (Zoloft), escitalopram (Lexapro) and venlafaxine (Effexor). It
should be again noted that the only drug that has received approval for
use in children with major depressive disorder is fluoxetine (Prozac).
Several of these drugs, including sertraline (Zoloft) and fluoxetine
(Prozac) are approved for the treatment of obsessive-compulsive disorder
in pediatric patients. The drug escitalopram (Lexapro) does not appear to
help depressed children and adolescents, according to one clinical study.
MAO inhibitors have largely been supplanted in therapy because of their
high risk of significant side effects, most notably severe, possibly fatal
high blood pressure, if foods or alcoholic beverages containing tyramine
are consumed. Other side effects include
tremors, muscle twitching, confusion, memory impairment,
agitation, insomnia, weakness, drowsiness, chills, blurred vision, and
heart palpitations. Treatment with MAO inhibitors should never be halted
abruptly, and should not be stopped without first consulting a physician.
Although TCAs have been shown to be effective in many clinical situations,
their use is associated with potentially serious side effects. The most
important of these is the potential for an irregular heartbeat, which can
at times (though rarely) be fatal. The vast majority of TCA-related deaths
happen when an overdose is taken. Physician will likely monitor blood
levels, as well as perform echocardiograms to monitor heart functioning.
Other side effects include dry mouth,
difficulty urinating, blurred vision, sedation, weight gain, central
nervous system and cardiovascular toxicity, delirium, and risk of suicide
by overdose. The risk of side effects can be reduced with careful
Several side effects are possible with SSRIs. Special care should be paid
in the first few weeks of taking the prescribed drug. Should nervousness,
agitation, irritability, mood instability, or sleeplessness emerge or
worsen during treatment with SSRIs, parents should obtain a prompt
evaluation by their doctor. Some of the side effects that can be caused by
SSRIs include dry mouth,
nervousness, insomnia, and headache. Those taking fluoxetine (Prozac)
might also have a feeling of being unable to sit still. Children already
on any of the SSRIs should remain on the drug if it has been helpful, but
they should also be carefully monitored by a physician for evidence of
side effects. Once begun, treatment with these medications should not be
abruptly stopped, because the child may experience further agitation and
restlessness. Families should not discontinue treatment without consulting
Bupropion (Wellbutrin) has several side effects, including drowsiness,
lightheadedness, headache, constipation, dry mouth, nausea, and
Occasionally patients may experience tiredness, muscle twitching, weight
loss, blurred vision, and trouble sleeping. The main side effect is
appetite suppression. In some children this may also lead to
(low blood sugar). It is recommended that children on Wellbutrin should
eat mid-morning, mid-afternoon, and bedtime snacks in addition to the
usual three meals in a manner similar to that of diabetics. The main risk
of Wellbutrin is that it increases the likelihood of seizures, though the
incidence is rare. Some of these seizures may be related to hypoglycemia
and so may be prevented by sticking to the diet as described
The antidepressant Prozac is used to treat depressive disorders.
(© David Butow/Corbis Saba.)
above. The drug should not be used when there is a past history of
seizures or a
history of epilepsy.
MAO inhibitors have many dietary restrictions, and people taking them need
to follow the dietary guidelines and physician's instructions very
carefully. A rapid, potentially fatal increase in blood pressure can occur
if foods or alcoholic beverages containing tyramine are ingested by a
person already taking MAO inhibitors. Foods containing tyramine include
sour cream; parmesan, mozzarella, cheddar and other cheeses; beef or
chicken liver; cured meats; game meat; caviar; dried fish; bananas;
avocados; raisins; soy sauce; fava beans; and caffeine-containing products
like colas, coffee and tea, and chocolate. Beverages to be avoided include
beer, red wine, other alcoholic beverages, non-alcoholic and reduced
alcohol beer, and red wine products.
SSRIs should not be used with any drug that increases serotonin
concentrations, including MAO inhibitors, tramadol, sibutramine,
meperidine, sumatriptan, lithium, St. John's wort, ginkgo biloba,
and some anti-psychotic agents. A "serotonin syndrome" may
occur, where mental status changes and where agitation, sweating,
and uncoordination, and
may develop. This syndrome may be life-threatening. SSRIs interact with a
number of other drugs that act on the central nervous system. Care should
be used in combining SSRIs with major or minor tranquilizers or with
anti-epileptic agents such as phenytoin (Dilantin) or carbamazepine
Tricylic antidepressants should not be taken with the gastric acid
inhibitor cimetidine (Tagamet), since this increases the blood levels of
the tricyclic compound. TCAs have many interactions, and specialized
references should be consulted. Specifically, it is best to avoid other
drugs with anticholinergic effects. Tricyclics should not be taken with
grepafloxacin and sprafloxacin, since the combination may cause serious
Monoamine oxidase (MAO) inhibitors
—A type of antidepressant that works by blocking the action of a
chemical substance known as monoamine oxidase in the nervous system.
Selective serotonin reuptake inhibitors (SSRIs)
—A class of antidepressants that work by blocking the
reabsorption of serotonin in the brain, thus raising the levels of
serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and
—A class of antidepressants, named for their three-ring
structure, that increase the levels of serotonin and other brain
chemicals. They are used to treat depression and anxiety disorders, but
have more side effects than the newer class of antidepressants called
selective serotonin reuptake inhibitors (SSRIs).
Major depression in children and adolescents is a serious condition that
should be treated in a way that includes careful follow-up and monitoring.
If the physician
determines that medication is indicated, parents should ensure their
child continues to receive ongoing assessment. Selection of an
antidepressant for their child is done on an individual basis, as drugs
may work differently for different people. What is effective for some may
not be effective for others. If one antidepressant is ineffective, then
there is probably another one that can be tried. All potentially effective
treatments can be associated with side effects. A careful weighing of
risks and benefits, with appropriate follow-up to help reduce risks, is
the best that can be recommended.
Mondimore, Francis Mark.
Baltimore, MD: Johns Hopkins University Press, 2002.
Ables, Adrienne Z., and Otis L. Baughman III. "Antidepressants:
Update on New Agents and Indications."
American Family Physician
67, no. 3 (February 1, 2003): 547–54.
National Alliance for the Mentally Ill.
Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA
22201–3042. Web site: http://www.nami.org.
National Mental Health Association.
2001 N. Beauregard Street, 12th Floor, Alexandria, Virginia 22311. Web
National Institute of Mental Health.
Available online at http://www.nimh.nih.gov/ (accessed October
National Mental Health Association.
Available online at http://www.mentalhealth.org (accessed
October 16, 2004).