In severe cases, the symptoms can usually be alleviated by reintroducing the SSRI and tapering it gradually over a longer period. If DS reoccurs, fluoxetine may be added before reattempting to taper off the offending SSRI, and eventually fluoxetine can also be slowly tapered off (Hosenbocus et al, J Can Acad Child Adolesc Psychiatry 2011;20(l):60-67).
About 1.8% to 2.8% of pregnant women use an SSRI during pregnancy. While we do not treat newborn babies in our practices, we often see their young mothers, so a good understanding of the risks and benefits of psychiatric medications to the fetus is always a good topic to review. There are risks associated with using any medication in pregnancy, but there are also proven risks with untreated depression and anxiety in pregnancy.
In-utero exposure to SSRIs may lead to withdrawal symptoms, also known as poor neonatal adaptation or PNA, in about 30% of exposed newborns. PNA usually develops within 48 hours and lasts for two to six days. It is characterized by mild neurological, gastrointestinal, respiratory, and autonomous symptoms.
Symptoms are usually mild and self-limiting. In milder cases, supportive measures, such as frequent small feedings, swaddling, and increased skin-to-skin contact with the mother, are usually sufficient. In severe case, the infant may need treatment in the Neonatal Intensive Care Unit (NICU). Phenobarbital is a safe and effective treatment in these cases (Kieviet N et al, Neuropsychiatr Dis Treat 2013;9:1257- 1266).
In addition, there is conflicting evidence regarding the development of persistent pulmonary hypertension in about 1% of the newborns exposed to an SSRI in utero.
A review of AEs of SSRIs in the pediatric population is incomplete without discussing risk of suicide. In October 2004, the FDA issued a black box warning after it found that newer antidepressants caused increased suicidal ideation and behavior (4%) as compared to placebo (2%) in patients under the age of 18, although there were no completed suicides.
In 2012, the Cochrane database published its most recent review on this topic. Taking into account 17 trials, it found the relative risk of suicide-related outcomes for children and adolescents treated with antidepressants to be 1.58 (CI 1.02-2.45) (Hetrick SE et al, Cochrane Database of Systematic Reviews 2012;11:CD004851). These findings warrant judicial use and close monitoring while using SSRIs in children and adolescents.
Sexual Side Effects
While literature related to SSRI- induced sexual AEs in adolescents is lacking, adult literature has reported its prevalence ranging from 15% to 70%. Sexual AEs usually manifest as orgasmic disorder, and less commonly as sexual desire or arousal disorder.
Direct questioning about sexual practices and functioning is the most effective way to assess sexual AEs in adolescents. Treatment in milder cases may involve the “wait and watch” strategy. However, in moderate to severe cases, consider decreasing the dose of the SSRI; providing drug holidays; replacing the culprit SSRI with bupropion (Wellbutrin), SNRI, mirtazapine (Remeron), or alternate SSRI; or adding a dopaminergic agent such as buproprion, buspirone (BuSpar), or a stimulant (Elbe D & Savage R, J Can Acad Child Adolesc Psychiatry 2010;19(1):40-45).
Other Side Effects
Serotonin syndrome is a rare and potentially life-threatening condition caused by excessive serotonergic activity in the central nervous system. Case reports of serotonin syndrome in adolescents have been described, but larger studies are lacking.
SSRI overdose in children has been reported to be relatively safe, causing minimal symptoms of toxicity in most cases. Seizures and ECG changes are uncommon, but occur more frequently with citalopram (Celexa) as compared to other SSRIs.
CCPR’s VERDICT: Like all medications, SSRIs should be used with caution in children and adolescents. Whenever possible, start at low doses, titrate gradually, and monitor closely, especially during the first few weeks. Many of the bothersome side effects can be prevented using this easy strategy. For those that can’t, discussing options with your patients and their parents can help you make the best decision for addressing the side effect.