“SSRIs in children and adolescents: Where do we stand?” (Current Psychiatry, March 2004) is excellent and timely.
As a child psychiatrist working in inpatient and outpatient settings, I have often seen activation and dysphoria in depressed children taking selective serotonin reuptake inhibitors (SSRIs). Drs. A. Bela Sood, Elizabeth Weller, and Ronald Weller reflect my view that “bipolar illness may be a possible explanation.” Without a high index of suspicion for bipolarity and a thorough family history, physicians are likely to be surprised when suicidality emerges after starting an antidepressant.
SSRIs clearly have contributed to the wellbeing of children with mood and anxiety disorders and are safe and effective in clinical practice. Unfortunately, the article does not address the dangers of using SSRIs in youths with bipolar disorder.
Stephen J. Wieder MD
Newburyport, MA
The authors respond
Dr. Wieder raises a pertinent clinical question regarding use of SSRIs in children at risk for bipolar disorder. SSRIs could cause hypomania or mania in depressed children with a clear history of bipolar disorder. When the clinical picture is not as clear, however, keep the following data in mind.
Follow-up studies have shown that 20% to 40% of adolescents with major depression develop bipolar type I disorder within 5 years after onset of depression.1 The clinician must strongly consider using prophylactic mood stabilizers along with SSRIs in depressed adolescents who present with psychomotor retardation, psychosis, family history of bipolar illness, and previous hypomanic disinhibition secondary to SSRI use, as these predict future bipolar disorder.2,3 Baseline irritability and aggression should also contraindicate SSRI monotherapy in unipolar depression, as exacerbation of rage and impulsivity with SSRIs seems to be high in this population.
A. Bela Sood, MD
Virginia Commonwealth University Health Systems
Elizabeth B. Weller, MD
Children’s Hospital of Philadelphia, University of Pennsylvania
Ronald Weller, MD
University of Pennsylvania
- Rao U, Ryan ND, Birmaher B, et al. Unipolar depression in adolescents: clinical outcome in adulthood. J Am Acad Child Adolesc Psychiatry 1995;34:562–78.
- Geller B, Fox LW, Clark KA. Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year old depressed children. J Am Acad Child Adolesc Psychiatry 1994;33:461–8.
- Strober M, Carlson G. Bipolar illness in adolescents with major depression. Arch Gen Psychiatry 1982;39:549–55.