What are the guidelines for starting a 13-year-old on an antidepressant (Selective Serotonin Reuptake Inhibitor (SSRI)) for mood swings, irritability, self-injurious behavior, suicidality, and anxiety?

From the Guidelines

Starting a 13-year-old on an SSRI for mood swings, irritability, self-injurious behavior, suicidality, and anxiety requires careful consideration and should only be done under psychiatric supervision, with fluoxetine (Prozac) typically being the first-line SSRI, starting at 10mg daily for one week, then increasing to 20mg daily if tolerated, as recommended by the most recent guidelines 1.

Key Considerations

• The treatment should continue for at least 6-12 months after symptom improvement, with close monitoring, especially during the first month, with weekly appointments to assess for increased suicidality, which can paradoxically worsen initially 1.
• Other SSRIs like sertraline (50-200mg) or escitalopram (10-20mg) may be considered if fluoxetine is ineffective or poorly tolerated, with a thorough evaluation for bipolar disorder necessary before starting treatment, as SSRIs can trigger mania in predisposed individuals 1.
• Medication should always be part of a comprehensive treatment plan including psychotherapy, particularly cognitive behavioral therapy, with parents monitoring for side effects including nausea, headaches, sleep disturbances, and behavioral activation 1.
• The potential for dose-related behavioral activation/agitation early in treatment supports slow up-titration and close monitoring, especially in younger children, and underscores the importance of educating parents/guardians and patients in advance about this potential side effect 1.

Important Safety Information

• All SSRIs have a boxed warning for suicidal thinking and behavior through age 24 years, with the pooled absolute rates for suicidal ideation across all antidepressant classes and all non-OCD anxiety indications reported to be 1% for youths treated with an antidepressant and 0.2% for youths treated with a placebo 1.
• Close monitoring for suicidality is recommended by the FDA, especially in the first months of treatment and following dosage adjustments, with a thorough evaluation for bipolar disorder necessary before starting treatment, as SSRIs can trigger mania in predisposed individuals 1.
• Family involvement in treatment decisions and monitoring is crucial for successful outcomes, with parental oversight of medication regimens being of paramount importance in children and adolescents 1.

From the FDA Drug Label

Pediatric (children and adolescents) — In the short–term (8 to 9 week) controlled clinical trials of fluoxetine supporting its effectiveness in the treatment of major depressive disorder, patients were administered fluoxetine doses of 10 to 20 mg/day

Treatment should be initiated with a dose of 10 or 20 mg/day. After 1 week at 10 mg/day, the dose should be increased to 20 mg/day. However, due to higher plasma levels in lower weight children, the starting and target dose in this group may be 10 mg/day.

Starting a 13-year-old on an antidepressant (SSRI) for mood swings, irritability, self-injurious behavior, suicidality, and anxiety:

• The guidelines recommend initiating treatment with a dose of 10 or 20 mg/day of fluoxetine.
• After 1 week at 10 mg/day, the dose should be increased to 20 mg/day.
• However, due to higher plasma levels in lower weight children, the starting and target dose in this group may be 10 mg/day.
• Key considerations:
  • Close monitoring for symptoms such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down 2.
  • Patients, their families, and their caregivers should be encouraged to be alert to the emergence of these symptoms and report them to the patient’s prescriber or health professional 2.

From the Research

Guidelines for Starting a 13-year-old on an Antidepressant

The guidelines for starting a 13-year-old on an antidepressant, specifically a Selective Serotonin Reuptake Inhibitor (SSRI), for mood swings, irritability, self-injurious behavior, suicidality, and anxiety are as follows:

• The combination of fluoxetine with Cognitive Behavioral Therapy (CBT) is considered an effective treatment for adolescents with major depressive disorder, with a response rate of 71.0% 3.
• Dialectical Behavioral Therapy (DBT) has been shown to be effective in reducing suicidal and self-injurious behavior, as well as improving emotion regulation, in adolescents with borderline personality disorder symptoms 4, 5, 6.
• The combination of an SSRI and CBT has been found to be more effective than either treatment alone in reducing symptoms of depression and anxiety in youth 7.
• DBT can be effectively implemented in acute-care child and adolescent psychiatric inpatient units, and has been shown to reduce behavioral incidents and improve symptoms of depression and suicidality 5.

Considerations for Treatment

When considering treatment for a 13-year-old with mood swings, irritability, self-injurious behavior, suicidality, and anxiety, the following factors should be taken into account:

• The presence of suicidal ideation or behavior, which may require more intensive treatment such as DBT or hospitalization 4, 5, 6.
• The severity of symptoms, which may impact the effectiveness of treatment 7.
• The presence of comorbid conditions, such as borderline personality disorder, which may require specialized treatment such as DBT 4, 6.
• The importance of involving parents or caregivers in treatment, particularly in the case of DBT 4, 6.

Treatment Options

Treatment options for a 13-year-old with mood swings, irritability, self-injurious behavior, suicidality, and anxiety may include:

• Fluoxetine, either alone or in combination with CBT 3, 7.
• DBT, either alone or in combination with medication 4, 5, 6.
• CBT, either alone or in combination with medication 3, 7.