Depression in children and teenagers is a real illness that affects mood, thinking, sleep, school and friendships. Until the 1970s many doctors believed depression occurred only in adults. Today it is recognized as common, especially in adolescence, and treatable. For moderate to severe depression, doctors often recommend an antidepressant together with psychotherapy. Many parents worry about the safety of these medicines, in part because of the FDA’s boxed warning about suicidal thoughts. This guide explains what the research shows, which medicines are approved for young people, what side effects to expect and how families can keep treatment as safe as possible.
Key points
- Fluoxetine (age 8 and up) and escitalopram (age 12 and up) are FDA-approved for depression in young people.
- Since 2004, all antidepressants carry a boxed warning about increased suicidal thoughts and behavior in people under 25.
- In pooled trials, about 4% of youths on an antidepressant had suicidal thoughts or behavior, compared with about 2% on placebo. No suicides occurred in these trials.
- In the TADS study, fluoxetine combined with CBT helped teens more than either treatment alone.
- Close monitoring in the first weeks and never stopping suddenly are the most important safety steps.
How depression is recognized in children
Children often cannot put sadness into words. Depression may show up as irritability, angry outbursts, loss of interest in play or friends, complaints of stomachaches or headaches, falling grades, sleeping too much or too little, or talk about being “stupid” or “bad.” Doctors use questionnaires such as the Children’s Depression Inventory (CDI), developed by Maria Kovacs, and the PHQ-A for adolescents, together with interviews and reports from parents and teachers. See how mental illness in children is diagnosed.
Antidepressants used in children and teens
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants in young people. They have fewer side effects than older antidepressants and are much less dangerous in overdose.
| Medicine | Brand | FDA approval in youth |
|---|---|---|
| Fluoxetine | Prozac | Depression from age 8; OCD from age 7 |
| Escitalopram | Lexapro | Depression from age 12 |
| Sertraline | Zoloft | OCD from age 6 (used off-label for depression and anxiety) |
| Fluvoxamine | (generic) | OCD from age 8 |
| Citalopram | Celexa | Not approved under 18; sometimes used off-label |
| Paroxetine | Paxil | Not approved; trials in youth were not convincing, so it is generally avoided |
Venlafaxine (Effexor), an SNRI, showed higher rates of suicidal behavior in youth trials and is not a first choice. Older drug classes such as tricyclics and MAOIs are rarely used in children.
The FDA boxed warning
In 2004, after reviewing all available pediatric trials, the FDA added a boxed warning to every antidepressant. In 2007 the warning was extended to young adults up to age 24. It states that antidepressants increase the risk of suicidal thinking and behavior in children, adolescents and young adults, especially in the first months of treatment and after dose changes.
What the numbers show
- The FDA analysis pooled 24 placebo-controlled trials with about 4,400 children and teens.
- About 4% of those taking an antidepressant had suicidal thoughts or behavior, compared with about 2% on placebo.
- No completed suicides occurred in any of these trials.
A 2007 analysis in the Journal of the American Medical Association by Jeffrey Bridge and colleagues looked at 27 trials and concluded that the benefits of antidepressants for depression, anxiety and OCD in youth appear to outweigh the risk of suicidal thoughts. Benefits were largest for anxiety disorders and OCD. Depression itself is the main risk factor for suicide, so leaving moderate or severe depression untreated is not a safe choice either.
Medication and therapy together: the TADS study
The Treatment for Adolescents with Depression Study (TADS), funded by the National Institute of Mental Health, followed 439 teens aged 12 to 17 with major depression. After 12 weeks, about 71% of teens improved with fluoxetine plus cognitive behavioral therapy (CBT), 61% with fluoxetine alone, 43% with CBT alone and 35% with placebo. Suicidal events were less common in the combined group than with fluoxetine alone, which suggests that therapy adds a layer of protection. Learn more about cognitive therapy and interpersonal therapy.
Common side effects
- Stomach upset, nausea, diarrhea or reduced appetite
- Headache
- Trouble sleeping, vivid dreams or daytime sleepiness
- Restlessness, jitteriness or “activation,” especially early on
- Easier bruising or bleeding, particularly when combined with ibuprofen, naproxen or aspirin
- Sexual side effects in teens, which they may be reluctant to mention
Many side effects are mild and fade within a few weeks. Doctors usually start with a low dose and increase slowly.
Warning signs to report right away
- New or worse thoughts of suicide or self-harm
- Severe agitation, panic attacks or restlessness
- Unusual anger, aggression or impulsive acts
- A big rise in energy, little need for sleep, racing thoughts or reckless behavior, which may signal mania
- Withdrawal from family and friends or sudden worsening of mood
If your child talks about suicide or you think they are in danger, call or text 988, the Suicide and Crisis Lifeline, or call 911.
A safety plan for families
- Stay in close contact during the first month. The original FDA guidance called for weekly contact in the first four weeks. Your doctor will set a schedule, often with visits or calls every week or two at first.
- Give the medicine as prescribed and keep it locked up. A parent should hold the supply, especially for a teen at risk.
- Secure firearms and other lethal means at home, and lock up all medicines, including over-the-counter pain relievers.
- Be patient. Improvement often begins after 2 to 4 weeks, and the full effect can take 6 to 8 weeks or more.
- Never stop suddenly. Stopping abruptly can cause dizziness, irritability, flu-like symptoms and a return of depression. After recovery, doctors typically continue treatment for 6 to 12 months and then taper slowly.
- Check new medicines with the pharmacist. Combining SSRIs with other serotonin-raising drugs, such as some migraine and pain medicines, dextromethorphan or St. John’s wort, can cause serotonin syndrome (agitation, fever, sweating, fast heartbeat, muscle stiffness). It needs urgent care.
Frequently Asked Questions
Do antidepressants cause suicide in children?
They can increase suicidal thoughts in a small number of young people, usually early in treatment. No suicides occurred in the trials reviewed by the FDA, and untreated depression carries its own serious risk. Close monitoring is the key.
Which antidepressant is usually tried first?
Fluoxetine is often first for children, because it has the most evidence and FDA approval from age 8. Escitalopram is an approved option from age 12.
How long will my child need to take an antidepressant?
Most guidelines recommend continuing for 6 to 12 months after symptoms improve, then tapering under a doctor’s supervision.
Is therapy alone enough?
For mild depression, therapy and support are usually tried first. For moderate to severe depression, combining therapy with medication often works best.
This article is general information and does not replace advice from your child’s doctor.
