Complications
Although rare, activation or a manic or hypomanic episode can be induced by antidepressants. A careful review of family history and symptoms is important to rule out a bipolar illness or low tolerance of antidepressants.
In addition, careful monitoring and ongoing assessment of symptom change and response are important to detect such occurrence early, and to take appropriate steps to avoid negative outcomes.
Suicidal ideation occurs more frequently than suicidal behavior and suicide attempts in young people with depressive disorder. However, depression is the most frequent psychiatric illness among suicide completers.[174] Suicidal thoughts and behaviors may occur prior to or during treatment.
There is a slight increased risk of suicidality (1% to 2%) associated with antidepressant use (3% to 4%) compared with placebo (2%).[121][122] The Food and Drug Administration issued a black box warning on suicidality associated with pediatric use of antidepressants in 2004.[110]
Ongoing assessment of safety is important, and children need to be monitored closely, especially during the early weeks of initiating antidepressant treatment, and during dose change.
It is important to alert caregivers to this possibility and to co-develop a safety plan with the child.[175]
Minors should not manage their own medication at home under most circumstances.
Children and adolescents with depressive disorder may be irritable and angry. Childhood depression is also highly comorbid with disruptive behavior disorders. Occasionally, antidepressants may increase agitation.
Careful assessment of irritability, anger, and aggressive behavior, prior to and during treatment, is important to prevent serious consequences.
Care level and medications may need to be adjusted, and other disorders may need to be considered.
Depression increases the risk of substance use disorder.[66] They are less common in younger children but increases in older adolescents. If a child is not responding to treatment, a concurrent use or misuse of a substance needs to be ruled out.
Questions about substance use need to be asked routinely and, if regular substance use is identified, motivational interviewing about perceived impact of substance use and desire to reduce its use is indicated. When there are concerns about atypical presentations or intoxications, periodic drug screening may help clarify drug exposures. Drug screening is not required for depression treatment in children and adolescents without known substance use problems.
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