Medication for depression

NICE guidance on managing depression in children and young people outlines that psychological interventions are the recommended treatment in mild depression. In moderate to severe depression, pharmaceutical treatment in combination with psychological interventions can be considered.

Medication should be initiated and overseen by a psychiatrist within child and adolescent mental health services (CAMHS). Fluoxetine is recommended first-line by NICE when medication treatment is deemed appropriate.

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) and the starting dose will be based on the child’s age. Depending on their response the dose may be gradually increased over two to four-week intervals. As with all antidepressants it can take up to two to four weeks for the medication to have a positive impact on a patient’s mood. Patients need to be aware of this so they have realistic expectations of their treatment.

SSRIs such as fluoxetine can often be associated with GI side-effects such as nausea and diarrhoea during the initial weeks of treatment. Often these side-effects are mild and transient but, if they are not, further advice would need to be sought from the prescriber.

SSRIs can also be associated with insomnia so, ideally, they should be taken in the morning to minimise the potential risk of any sleep disturbances.

Another common side-effect associated with SSRIs is sexual dysfunction – this can involve loss of libido or erectile dysfunction. These side-effects may be particularly impactful to an adolescent who is just starting to explore sexual feelings and experiences.

Missing doses

It is important with all antidepressant medications to take doses consistently to maximise their efficacy. Missing doses can also result in a potential risk of withdrawal symptoms. However, with fluoxetine specifically, it is unlikely that missing occasional doses would cause withdrawal symptoms as fluoxetine has a very long half-life of one to four days.

If treatment with fluoxetine is ineffective or poorly tolerated, then the young person’s psychiatrist may consider a switch to a different SSRI such as sertraline or citalopram.

Herbal medications such as St John’s wort are not recommended by NICE for the treatment of depression in young people.

A significant issue associated with anti-depressants in young people is an increased risk of suicidal ideation and suicidal acts during the initial phases of treatment. This is because antidepressants can increase both energy and motivation levels prior to the depression starting to lift, so there is an increased risk that the person may act on suicidal intent before their mood starts to improve.

All young people should therefore be monitored very closely for any increase in suicidal ideation when starting antidepressant medication. If during a consultation a patient discloses that they are experiencing suicidal ideation or reveals thoughts or plans to harm themselves, it is essential that these risks are highlighted to the patient’s GP and CAMHS immediately.

If a patient is in crisis and has active plans to harm themselves or end their life, there is an immediate need to refer the patient to your local urgent care service. Urgent mental health support can also be sought by contacting 111 and selecting option 2. Finally, pharmacists concerned that a patient’s life is in imminent danger should ring 999 or contact the local A&E department.