Antidepressant use in children: a less depressing story

To the Editor: A recent editorial in the British Medical Journal reported advice from the UK Committee on Safety of Medicines that most types of selective serotonin-reuptake inhibitors (SSRIs) should not be used in the treatment of major depression in children.1 The editorial sparked interest in the Australian media, resulting in articles in large metropolitan newspapers with titles such as “Army of kids on antidepressants”.2 General practitioners were targeted as the cause of reported “over-prescribing”.

Unfortunately, while the media drew data from the national BEACH program (Bettering the Evaluation and Care of Health; a continuing study of general practice activity3), the data presented were inflated: a “child” was defined as someone aged under 20 years (while the UK advice related to children under 18 years), and national figures were extrapolated from the upper confidence limit.

Reliable estimates of GP prescribing of antidepressants to children in Australia are needed. We derived age-specific rates of antidepressants prescribed per encounter in Australian general practice for the period April 2001 to March 2004 from the BEACH data (Box 1).

The data showed that children were prescribed antidepressants far less often than adults. Those aged under 12 years were rarely prescribed antidepressants. Most of those prescribed were tricyclics, which are more commonly used in management of enuresis than of depression.

The media’s inclusion of 18–19-year-olds as “children” greatly increased the reported rate.2 The prescribing rate of antidepressants in children aged under 18 years was 0.47 per 100 encounters (5 per 1000 encounters), but was six times higher for 18–19-year-olds (2.82 per 100 encounters).

Most antidepressants prescribed for 12–17-year-olds were SSRIs. Fluoxetine is the only SSRI currently approved for use in children in the UK.4 In Australia, caution is advised when prescribing any antidepressant to children, but venlafaxine and the SSRI paroxetine are specifically advised against.5 Nevertheless, venlafaxine and paroxetine were more often prescribed (accounting for 10% and 8%, respectively, of total antidepressants for children) than fluoxetine (5%). However, GPs provided concomitant counselling at almost 20% of contacts with children aged under 12 years where an antidepressant was prescribed, and at 40% with 12–18-year-olds (Box 2). GPs were also more likely to refer the children to a specialist than when prescribing antidepressants for adults.

We do not know how many of these children have been referred to a specialist at a previous encounter, nor how often antidepressant medication is initiated by a specialist. However, it will be interesting to see whether the new advice reduces the current level of prescribing of antidepressants (SSRIs in particular) in children.