Selecting an Antidepressant for the Treatment of Pediatric Depression

Abstract

When pharmacological treatment is deemed appro-priate for a child or adolescent with major depressivedisorder, I consider using fluoxetine first. Based onexisting data, the efficacy of fluoxetine in pediatricdepression is better documented than for any otherantidepressant as it is supported by three independentmultisite clinical trials (Emslie et al., 1997, 2002;TADS Team, 2004). Fluoxetine is also the onlyantidepressant whose efficacy has been directly com-pared with that of cognitive-behavioral therapy, aloneand in combination with fluoxetine (TADS Team,2004), and the only medication that is currentlyapproved by the U.S. Food and Drug Administration(FDA) for the treatment of depression in children andadolescents.This position does not imply that fluoxetine is moreeffective or safer than other antidepressants, but onlyreflects the fact that the amount of data in support offluoxetine efficacy in children and adolescents withmajordepressionis,atthistime,largerthanforanyothermedication. Also, that fluoxetine should be consideredfirstdoesnotmeanthatitshouldbeinvariablyprescribed first. There can be individual patientsituations in which a second-line antidepressant maybepreferredbasedonpracticalreasons.Forexample,ifIencounterafamilywhohasdevelopednegativeexpecta-tions from fluoxetine treatment because another closerelative, such as a sibling or parent of the child, wasunsuccessfully treated with fluoxetine, although theyfound another antidepressant helpful, I am inclined tofollow the family_s preference. Clinical experience hastaught me that successful treatment decisions are basedon applying scientific evidence to the individual patientcontext, expectations, and preferences.Fluoxetineshouldnotbetheonlyantidepressantusedin the treatment of children and adolescents with majordepression. It is estimated that about 20%Y40% ofdepressed youths treated with fluoxetine do notadequately improve on this medication, thus openingthequestionofwhatdotonext.Althoughno