Depressive disorders are common in young people and have significant negative impacts. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for the treatment of depressive disorder in children and adolescents. The review of 12 trials highlighted limitations with the data, making it difficult to answer questions about the effectiveness and safety of SSRIs in clinical practice. Overall, there was evidence of greater reduction in depressive symptoms to a predetermined level deemed a "response" on SSRI compared to placebo. However, response was variously defined across trials making interpretation of this outcome difficult. Fluoxetine was the only SSRI where there was consistent evidence from three trials showing that it was effective in reducing symptoms of depressive disorder in both children and adolescents. Those receiving fluoxetine had a greater improvement, scoring on average 5.63 lower on the Children's Depression Rating Scale-Revised (CDRS-R) scale (range 17-113) than those on placebo. It is unclear whether this small difference is a meaningful outcome for children and adolescents with depressive disorders. Nor is it apparent how children and adolescents with co-morbid conditions and at risk of suicide would respond to SSRIs, given this group were largely excluded from the trials.
There is evidence that those prescribed SSRIs are at an increased risk of suicidal ideation and attempts (RR 1.80, 95% CI 1.19 to 2.72) consistent with a number of similar reviews in the area. Additionally, there was an increased risk of other adverse events. It is unclear how this relates to the risk of suicide completion. The trials were not designed to measure any of the suicide related outcomes adequately. At the same time, untreated depression is associated with the risk of completed suicide and impacts on academic and social functioning, however, it is not clear whether treatment with an SSRI will modify this risk in a clinically meaningful way for children and young people.
Clinicians need to provide accurate information to children and adolescents and their families about the uncertainties regarding the benefits and risks of SSRI medication for depressive disorders.