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Tricyclic Antidepressants Better for Adolescents than for Children: Presented at ECNP

By Mark Pownall
Special to DG News

BARCELONA, SPAIN -- October 30 -- Tricyclic antidepressants are statistically better than placebo in adolescents with depression, but they are no better than placebo in children.

Dr. Celso Arango-Lopez, from the adolescent unit at the Gregorio Maranon Hospital, in Madrid, Spain, presented findings on this class of agents in paediatric depression in a presentation here October 7 at the 15^th Congress of the European College of Neuropsychopharmacology (ECNP).

A new review by Hazell P et al (Cochrane Database Syst Rev 2002;(2):CD002317) found tricyclic antidepressants were not effective in children but found marginal evidence to support their use in adolescents (p=0.04). However, Dr. Arango-Lopez said, several other reviews found no difference between these agents and placebo in children with depression.

Small trials of both fluoxetine and paroxetine had been carried out, but there was very little data on the use of selective serotonin reuptake inhibitors (SSRIs) in children and adolescents, according to Dr Arango-Lopez. However, SSRIs are most widely used in younger age groups, he acknowledged.

He warned, however, that using the weight of children to estimate the dose needed risked giving children a less than therapeutic dose of treatment, because of less absorption, more distribution of drug and increased metabolism.

The effectiveness of treatment in children and adolescents is important because of the increasing prevalence of depression in this population, he said. Between 2 and 5 percent of school age children have depression, while 4 to 9 percent of adolescents have reported feeling depressed in several surveys.

"And the age of onset is diminishing," Dr Arango-Lopez added. "We are seeing more and more younger kids that are depressed, and these children have social dysfunction and academic underachievement." In addition, he said, these patients are at high risk of future episodes of depression, with 70 percent recurrence rate within five years, and the younger the age of onset, the worse the prognosis.

The lowest rate was just before puberty with a "massive" increase in adolescence and a peak in early adulthood.

Depression can be difficult to diagnose with any precision or certainty in children and adolescents. Because their grief reactions and other emotional responses were often immediate and short-lived, he said, a child can register on a standard questionnaire as very depressed one day and healthy and normal the next.

"There is a lack of test-retest consistency," he added. Complex emotions and cognitive ideas mean administering a standard test to children, and even some adolescents, is difficult to carry out effectively, he explained.

The clinical picture can be complicated by the poor reliability of children describing their symptoms, the high placebo effect among this group, and the presence of co-morbidities, such as attention deficit hyperactivity disorder or conduct disorders.

The differences between child and adolescent depression on the one hand, and adult depression on the other, prompted Dr Arango-Lopez to suggest that there may be a different genotype for depression in younger age groups, and that the mechanisms causing the apparently similar symptoms are, in fact, quite distinct.

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