Initial pharmacotherapy for major depression in children
For the indications for antidepressant therapy in major depression in children, see Principles of treating major depression in children. Pharmacotherapy is ideally started by a clinician with expertise in using psychotropics in children. If pharmacotherapy is used, it should be combined with psychological therapy.
Selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressant class in children and individual SSRIs are likely to have similar effectiveness. There is a risk of developing agitation, activation and suicidal thoughts when starting treatment with any SSRI, particularly in the first 7 to 10 days. However, of the SSRIs, paroxetine is not recommended in children because it has been associated with a greater risk of suicidal thoughts and behaviours and other serious adverse events. Because there is more safety data for fluoxetine in children, it is the preferred SSRI. SSRIs are effective treatments for anxiety disorders in children and adolescents, so may be particularly useful if there is a comorbid anxiety disorder. No SSRIs are approved to treat major depression in children in Australia.
There is limited evidence to guide dosing of SSRIs in children. The dosage regimens in these guidelines are predominantly based on expert opinion and are included as a guide to suitable dosing. If the dosage regimens in these guidelines prove inadequate (eg higher doses are needed), expert advice should be sought because alternative regimens may be appropriate.
Starting patients on a low dose initially may help to decrease initial adverse effects (eg nausea, restlessness, agitation)—see Antidepressant adverse effects for information on managing adverse effects. This should be balanced against the time taken to achieve therapeutic concentrations of the antidepressant.
Do not use pharmacotherapy for children 6 years or younger.
In children older than 6 years and younger than 12 years, if pharmacotherapy is considered necessary for major depression, use:
1 fluoxetine 5 mg orally, in the morning1 . Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 30 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing major depression (child) fluoxetine
OR
2 citalopram 5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing major depression (child) citalopram
OR
2 escitalopram 2.5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 2.5 to 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 10 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing major depression (child) escitalopram
OR
2 fluvoxamine 12.5 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 100 mg is reached. Doses above 50 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing major depression (child) fluvoxamine
OR
2 sertraline 12.5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 100 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. major depression (child) sertraline
When deciding upon a suitable dosing regimen in children 12 years and older, consider the child’s developmental (physical) maturity—developmental maturity can vary between individuals of the same age (eg some 12-year-olds might be metabolically similar to young children, whereas others are similar to adults). At the lower end of the dose range, the recommended doses approximate those used in younger children, whereas the maximum doses approximate those used in adults and young people. In children 12 years and older, if pharmacotherapy is considered necessary for major depression, use:
1 fluoxetine 5 to 10 mg orally, in the morning1 . Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing fluoxetine
OR
2 citalopram 5 to 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing citalopram
OR
2 escitalopram 2.5 to 5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 2.5 to 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing escitalopram
OR
2 fluvoxamine 12.5 to 25 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Doses above 50 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing fluvoxamine
OR
2 sertraline 12.5 to 25 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing. sertraline