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Graduate Student Journal of Psychology                                                                             Copyright 2005 by the Department of Counseling & Clinical Psychology
2005, Vol. 7                                                                                                                          Teachers College, Columbia University                          ISSN 1088-4661

Child and Adolescent Depression:
Should Antidepressants Be Used in Treatment?

Erica Saypol
Teachers College, Columbia University

This paper examines the controversy over the use of selective serotonin-reuptake inhibitors (SSRIs)
in the treatment of children and adolescents. Arguments for and against the use of SSRIs with pedi-
atric populations are evaluated. Supporting SSRI treatment are findings that SSRIs are effective,
the potential accessibility of medication, and findings that SSRIs have played a role in the overall
decline in adolescent suicide rates. Arguments against the use of SSRIs among child and adolescent
populations include findings of associated increases in suicidality and of potential impulsivity and
violence in response to the medication. Arguments against treating children and adolescents with
SSRIs also include the complications of side effects, dosage, and duration of treatment, and con-
cerns over an approach limited to the neurobiological level. The role of psychotherapy, both alone
and in combination with SSRI treatment is discussed.

The controversy over the use of antidepressants in the
treatment of children and adolescents has received a great
deal of media attention following the Food and Drug Ad-
ministration’s (FDA) September 2004 decision to require a
“black-box” warning label for the use of these medications
with pediatric patients. While such a decision does not con-
traindicate the treatment of pediatric patients with such
medications, the black box represents the most serious type
of warning label, cautioning strongly about the risks associ-
ated with a medication. In the case of antidepressant use in
children and adolescents, the risk involves a potential in-
crease in suicidality (i.e., suicidal ideation and behavior).

Many of the same arguments for and against the black-
box warning can serve as arguments for and against the use
of antidepressant medications in children and adolescents.
The goal of this paper is to address the specific question of
whether or not a particular class of antidepressant medica-
tions, selective serotonin-reuptake inhibitors (SSRIs),
should be used in the treatment of children and adolescents
with depression1. Research evidence supporting the efficacy

Correspondence concerning this article should be addressed
to Erica Saypol, Box 102, Department of Counseling and Clinical
Psychology, Teachers College, Columbia University, 525 West
120th Street, New York, NY 10024.

                                                  
1 The scope of this paper is limited to an examination of the treat-
ment of children and adolescents with SSRIs and excludes the
other major class of antidepressants that has been used in the
treatment of this population, including tricyclic antidepressants
(TCAs). Research on the latter suggests that they are no more
effective than placebo in the treatment of children and adolescents
(Carr & Boyd, 2003), and that they are associated with danger of
overdose (Mahler, 2004).

of SSRIs in reducing the symptoms of depression among
children and adolescents represents the strongest argument
in favor of their use in pediatric treatment. In addition,
greater accessibility to these medications (as compared to
psychotherapy) among children and adolescents may also
support their role in treatment. Finally, findings that suggest
that SSRIs are associated with a decrease, rather than an
increase, in completed suicides among children and adoles-
cents lend support to their use in reducing actual incidences
of suicide among depressed children and adolescents.

Although the evidence supporting the treatment of
children and adolescents with SSRIs is persuasive, so too
are the arguments against the use of this medication with
pediatric populations. The most powerful evidence against
the use of these medications in the treatment of children and
adolescents comes from research demonstrating that the
medication is associated with an increase in suicidality
(e.g., Jureidini et al., 2004; Newman, 2004). Furthermore,
there are findings that SSRIs may be linked to an increase
in agitation, impulsivity, and violence among pediatric pa-
tients (e.g., Glass, 2004). Those who argue against the use
of SSRIs in children also point out that the findings sup-
porting their efficacy are quite small in magnitude as com-
pared to the increased risks of suicidality. Pharmacological
treatment of depression in general also brings concerns over
side effects, questions of dosage and length of treatment,
and treatment decisions for relapses, which are of height-
ened concern in the treatment of growing and developing
children. Another argument against the treatment of chil-
dren and adolescents with SSRIs lies in the limitations of
approaching a psychological disorder solely on the neuro-
biological level. In other words, even if SSRIs are highly
effective, pharmacological treatment of depression fails to
address the feelings of depression on a psychological level
and to foster the development of coping mechanisms. Such



ERICA SAYPOL

30

mechanisms can play a critical role as patients wait for
medication to become effective, as they face future Major
Depressive Episodes, and as they grapple with the vicissi-
tudes of life. This limitation of pharmacological treatment
will be discussed and evaluated along with recent evidence
supporting the efficacy of psychotherapy among child and
adolescent patients.

Evidence Supporting the Treatment of
Children and Adolescents with SSRIs

Efficacy

A number of recent studies offer support for the effec-
tiveness of SSRI medications in the treatment of child and
adolescent depression (e.g., Wagner et al., 2003; Treatment
for Adolescents With Depression Study (TADS) Team,
2004). Although small when compared to the number of
studies of antidepressant treatment among adult patients,
the recent research findings offer persuasive evidence of the
efficacy of SSRIs among child and adolescent patients.
Wagner et al. (2003) demonstrated that depressed children
and adolescents treated with sertraline (Zoloft) showed sig-
nificantly greater improvement than did those treated with a
placebo. Specifically, Wagner et al.’s research involved two
identically designed studies conducted at multiple hospital,
practice, and academic settings in the US, India, Canada,
Costa Rica, and Mexico. Participants included 376 children
and adolescents between the ages of 6 and 17, who were
randomly assigned to the double-blind sertraline or placebo
treatment conditions.

Prior to treatment, participants’ diagnoses of Major
Depressive Disorder were confirmed and their symptoms
were evaluated using the Children’s Depression Rating
Scale-Revised (CDRS-R) and the Clinical Global Impres-
sion of Severity of Illness (CGI-S). Participants received
medication for a period of 10 weeks, with some adjustments
permitted to attain effective dosages. The CDRS-R and
CGI-S assessments were given multiple times throughout
the duration of the study to evaluate responses to the medi-
cation. Significantly higher levels of improvement were
found among patients treated with sertraline on both meas-
ures. On the CDRS-R, the sertraline group experienced a
decrease in mean depression scores from week one to week
ten of 22.84 points, whereas the placebo group experienced
a mean score decrease of 20.19 points. On the CGI-S, the
mean score decreases were 1.22 in the sertraline condition
and 1.01 in the placebo condition.

The findings of Wagner et al.’s (2003) studies reveal a
significant improvement among pediatric patients treated
with sertraline as well as a large placebo effect. Studies of
antidepressant treatment of adults and the small group of
other studies of children and adolescents also reveal similar,
sizeable placebo effects. Yet, the significant findings should
not be discredited for a number of reasons. First, it is possi-
ble that in a number of ways, psychotherapy may also have

played a role in the improvement of patients in both condi-
tions. Specifically, though not permitted to be treated with
cognitive-behavioral therapy (CBT), participants were al-
lowed to continue other types of psychotherapy in which
they had been engaged prior to joining the study. In fact, 8
placebo condition participants were in psychotherapy dur-
ing the study and 29 had been in psychotherapy prior to the
study; for both groups, Wagner et al. suggested that the
benefits of extra-study psychotherapy may have been re-
sponsible for improvement in symptoms. Additionally,
Wagner et al. pointed out that for all participants, because
of the frequency of sessions for medication adjustment,
monitoring, and symptom assessment (almost weekly
throughout the study), an informal therapeutic interaction
may have taken place between participants and investiga-
tors. Varley (2003) posits that “these findings suggest that
children may be more responsive than adults to nonspecific
measures of support that are included in the placebo re-
sponse, particularly because children and adolescents are in
a more dependent and reactive developmental state” (p.
1092). It is important to recognize that a small significant
effect of sertraline was found above and beyond these po-
tentially psychotherapeutic effects.

A second reason Wagner et al. (2003) offer for the
large placebo effect is the high level of variability within
conditions; participants were treated in different types of
treatment centers, by different investigators, in different
countries, and within different cultural contexts. A third
reason for the high placebo effect, which the researchers did
not mention, is that patients may have been moving out of
the depths of depression over time. A condition for partici-
pation was that criteria for a Major Depressive Episode
must have been present for at least 6 weeks prior to joining
the study. The 6-week presentation of symptoms was fol-
lowed by a 2-week screening period before the 10-week
trials took place. In general, Major Depressive Episodes can
last 4 months or longer, if left untreated (DSM-IV-TR).
This, combined with the fact that the length of the episode
included a minimum of 18 weeks (and possibly longer,
since 6 weeks of pre-participation symptoms was the mini-
mum requirement), makes it seem possible that some par-
ticipants may have begun improving naturally. Despite the
large placebo effect, the improvement of children and ado-
lescents in the sertraline treatment condition was significant
and supports the use of at least one SSRI in the treatment of
child and adolescent patients.

Studies of other SSRIs offer additional evidence of
their efficacy in treating child and adolescent patients, but
they also point out the need to assess these medications
individually. Although clustered together because of their
known role in inhibiting the reuptake of serotonin, each
medication appears to operate on a distinct pathway, as
revealed in its effects on multiple neurotransmitters, side
effects, and the differential responsiveness of patients. In
addition to the above findings on the efficacy of sertraline,
a recent major study by the Treatment for Adolescents With
Depression Study (TADS) Team (2004) supports the use of



CHILD AND ADOLESCENT DEPRESSION AND ANTIDEPRESSANTS

31

fluoxetine (Prozac). This study (which will be discussed
subsequently in more detail in the context of psychother-
apy) revealed that fluoxetine was superior to both placebo
and CBT alone, but that the best outcome (and the only
statistically significant finding) involved the combination of
fluoxetine and CBT. By contrast, several unpublished
studies recently suggested that another SSRI, paroxetine
(Paxil), was not significantly more effective than a placebo,
and that the medication (now contraindicated for use with
pediatric patients) may pose particular risk of suicidality
(Wooltorton, 2003; Mathews & Windham, 2004).

Although the body of research on SSRI treatment of
depression in children and adolescents is quite small, there
are several important findings and implications. First, some
studies have demonstrated significant levels of improve-
ment among pediatric patients with depression (e.g., Wag-
ner et al., 2003). Second, even in purely psychopharmaco-
logical studies, frequent interactions with a clinician may
have psychotherapeutic benefits for adolescent and child
patients (Wagner et al., 2003); this finding commands
greater research attention to psychotherapeutic treatment of
depression among children and adolescents. Furthermore,
although large placebo effects and the therapeutic overlap
were viewed as limitations in Wagner et al.’s (2003) study,
such limitations may have serendipitously offered greater
insight into the nuances of the treatment. Third, each SSRI
operates differently, and rather than drawing general con-
clusions about the efficacy of the class of drugs in treating
pediatric cases of depression, critical evaluations of each
individual medication are needed. The need for specific
research is embedded within a larger need for more studies
on the use of SSRI medications with children and adoles-
cents, to permit a better understanding of the efficacy and
other benefits, and the risks associated with each of them.

Accessibility

Another consideration in this debate focuses on the ac-
cessibility of various treatments. Pediatric patients are
largely dependent on parents or caregivers for treatment
approval and decisions, initial insight into their difficulties,
and transportation to and from treatment appointments.
When it comes to getting treatment for depressed pediatric
patients, might parents be more likely to seek treatment
involving SSRIs than psychotherapy? Won Tesoriero
(2004) suggests that many children and adolescents suffer-
ing from depression may receive treatment from pediatri-
cians or primary care physicians because such treatment is
more readily available and less stigmatized than treatment
with a psychiatrist or psychologist. The issue of accessibil-
ity appears to be a serious one, given that there are about
7,000 child and adolescent psychiatrists in the U.S. (com-
pared to about 60,000 pediatricians), and that, in the early
1990s, there was a need for 33,000 child and adolescent
psychiatrists (Won Tesoriero, 2004). The problems of

accessibility appear to be exacerbated among children in
families of low socioeconomic status, children without
health insurance, African Americans, and very young chil-
dren (Olfson, Gameroff, Marcus, & Waslick, 2003). The
possibility that accessibility factors and the stigma associ-
ated with having depressed children would lead parents to
obtain prescriptions from a pediatrician, rather than trans-
porting their child to numerous psychotherapy sessions,
offers some support for the treatment of children and ado-
lescents with medication to assure that they receive some
form of help.

Through a collection of health-service use data, Olfson
et al. (2003) found that whereas more depressed children
and adolescents received psychotherapy than antidepressant
medication (about 75% and 60% of those treated, respec-
tively), the number of psychotherapy visits attended was
found to be quite low. While clinical trials suggest 15 to 25
sessions over a period of 6 to 16 weeks, children and ado-
lescents being treated for depression averaged fewer than
eight sessions a year, with many undergoing only one or
two visits (Olfson et al., 2003). Thus, the possibility arises
of parental disincentives towards psychotherapy, including
both the stigma associated with child depression and the
logistical difficulties of transporting a child to numerous
appointments. However, Won Tesoriero (2004) points out
that following the black-box warning given to antidepres-
sants this past September, parents are finding that many
pediatricians and primary care physicians are no longer
willing to prescribe medications. Thus, parents are finding
it increasingly difficult to find one of an already small
number of child and adolescent psychiatrists to prescribe
the medication.

Although there may have been (and may still be) some
advantages of treatment with SSRIs, there appears to be an
important role for qualitative research to achieve an in-
depth understanding of the factors that influence the parents
and caretakers of children and adolescents with depression.
Such research could lead to an understanding of their plight
that goes beyond speculation and could guide practitioners
and researchers in the development of and education about
effective psychotherapeutic, psychopharmacological, or
combined treatments.

Decrease in Child and Adolescent Suicide

In addition to the efficacy and accessibility of SSRIs,
further support for the use of SSRIs in the treatment of
children and adolescents with depression involves a poten-
tial association between treatments involving these medica-
tions and a decrease in suicide rates among adolescents.
Brent (2004) points out that after a long history of increas-
ing rapidly, suicide rates among adolescents have been fal-
ling for the past 10 years. Although a large part of the de-
crease can be accounted for by stricter gun control, Brent
suggests that corresponding improvements in the detection



ERICA SAYPOL

32

and treatment of depression and the use of SSRIs may have
played a role. Brent cautions that there is a relationship
between suicidality and completed suicide and that the pos-
sibility of SSRIs causing increased suicidality presents an
important risk. Yet, he argues, such a risk suggests the need
to carefully monitor adolescent patients being treated with
SSRIs, rather than to avoid a form of treatment that appears
to be effective in reducing depression and that may support
an overall decrease in adolescent suicide rates.

Difficulty in evaluating the link between SSRIs and
suicidality lies in understanding what the data can actually
mean in practice. According to the former head of the FDA
division that examines psychiatric medications, “You don’t
know whether the phenomena you’re looking at are good
surrogates for actual suicide” (Mathews & Windham, 2004,
D3). In particular, the confusion arises from research find-
ings of an increase in suicidal ideation and attempts, but no
incidences of completed suicide associated with treatment
with SSRIs. The instances of completed suicide are re-
vealed, not in research studies, but in individual case stud-
ies, often provided by parents who speculate after a child’s
death that the SSRI played a role. Both Brent’s (2004) re-
minder of the relationship between suicidality and com-
pleted suicide and features of the design of recent studies
demand that the risk of completed suicide be further as-
sessed. In particular, ethical limitations of research prohibit
the inclusion of adolescents at the highest suicide risk as
subjects in the research (Glass, 2004). For example, in
Wagner et al.’s (2003) studies of children and adolescents
treated with sertraline, “[p]atients who had previously at-
tempted suicide or who were judged to pose a significant
suicidal or homicidal risk” were excluded from participat-
ing in the study (p. 1034). The exclusion of such partici-
pants could lead to an underestimation of the suicidality
risks associated with SSRI treatment.

The empirical data supporting the SSRI-associated in-
crease in suicidality and a case study involving a suicide
following the initiation of SSRI treatment will be presented
below in a discussion of evidence against the use of SSRIs
with children and adolescents. Supporters of the use of
SSRIs in children and adolescents portray the suicidality
findings as evidence of a small but serious risk associated
with the medication, as opposed to the perhaps greater risk
of removing the SSRI treatment option. Specifically, Bo-
land and Keller (2004, as cited in Glass, 2004) state that
“Although some concerns about potentiating suicidal be-
havior may remain, these should be balanced over the clear
risk of suicide in patients with untreated depression” (Bo-
land & Keller, 2004, p. 856, as cited in Glass, 2004, pp.
861-862). Similarly, Brent (2004) concludes that an appro-
priate balance needs to be found “between the risk of sui-
cidality and another, greater risk: the risk that lies in doing
nothing” (p. 1601). The key element missing from these
statements, which will be discussed below, involves the role
of psychotherapy, both alone and in combination with SSRI
treatment and in specifically addressing the risk of suicidal-
ity.

Evidence Against the Treatment of
Children and Adolescents with SSRIs

Suicidality

The most powerful argument against the treatment of
depressed children and adolescents with SSRIs lies in find-
ings that these medications may lead to suicidality among
pediatric patients. Evidence from both clinical research
trials and individual case studies reveals the potential that
SSRIs may produce or exacerbate suicidal thinking and
behavior. The seemingly paradoxical finding has been ex-
plained by the phenomenon of “rollback” (Mahler, 2004).
Specifically, while in the initial depths of a Major Depres-
sive Episode, a person may have thoughts about wanting to
die, but may be unable to elaborate on these thoughts or to
act on them given the decreased energy associated with the
depression. As the SSRI begins to work (but before the per-
son’s mood has reached pre-episodic levels), the person
may experience enough of an increase in his or her energy
level to think seriously about, or act on, a plan to commit
suicide.

The case against the use of SSRIs with pediatric patient
populations can be made in part by an examination of some
of the same research trials used to demonstrate the efficacy
of SSRIs. For example, Jureidini et al. (2004) point out that
analysis of the data in Wagner et al.’s (2003) study reveals
the problematic increase in suicidality associated with ser-
traline. In particular, 9% of children and adolescents in the
sertraline condition (as compared to 3% in the placebo con-
dition), experienced adverse effects serious enough to lead
them to withdraw from the study. Further analysis of the
individual adverse events was not reported, but might be
informative in confirming the extent to which they included
suicidal ideation or attempts. Additionally, Jureidini et al.
draw attention to Wagner et al.’s findings involving adverse
events among patients who remained in the study, which
included more instances of serious adverse events involving
suicidality. Among patients in the sertraline condition, two
suicide attempts and three instances of suicidal ideation
were revealed as compared to two suicide attempts and no
instances of suicidal ideation among patients in the placebo
condition. The numbers are small and the conclusions un-
clear, but the possibility that sertraline caused an increase in
suicidal ideation among these patients (and among those
who withdrew participation) remains.

Newman (2004) presents an argument supporting the
black-box warning for SSRI use with pediatric patients.
Specifically, Newman describes findings from an analysis
of unpublished studies coordinated by the FDA and re-
viewed by suicide experts at Columbia University. These
experts blindly evaluated a series of narratives about ad-
verse events that took place during clinical trials and made
determinations as to whether or not each should be coded as
an instance of suicidality. Without knowing whether they
were reading narratives involving participants receiving



CHILD AND ADOLESCENT DEPRESSION AND ANTIDEPRESSANTS

33

antidepressant medication or placebo pills, these raters
found over twice as many incidences of suicidality among
participants taking antidepressants versus those in placebo
groups. However, a main criticism of this analysis was that
the studies supplying the original data were not uniformly
designed, were not specifically designed to study suicidal-
ity, and were not required to be of high quality. For New-
man, however, this makes the findings all the more con-
vincing, given that the probability of their chance occur-
rence would be 1 out of 20,000 (p = 0.00005) by his calcu-
lation (Newman, 2004, p. 1596).

Newman argues further that such a finding stands in
stark contrast to the efficacy data on SSRIs, in which sig-
nificant effect sizes are small and sizeable placebo effects
are revealed. Newman cites the small effect size in the
TADS (2004) study of fluoxetine, in which the reduction of
CDRS-R scores among patients receiving fluoxetine was
22.6 points versus 19.4 points among those receiving a pla-
cebo. These findings were similar to those of Wagner et al.
(2003) (i.e., 22.84 in the sertraline condition and 20.19 in
the placebo condition). As in Wagner et al.’s study, the
TADS study left more information to be desired regarding
the implications specifically related to suicidality. Again,
the numbers are small, and drawing conclusions is difficult.
Looking at the suicide-related events that did occur, no sig-
nificant differences were revealed between the treatment
groups. However, harm-related adverse events, a category
broader than suicidality and including “any self-harm or
harm to another person or property” revealed a difference:
patients taking fluoxetine experienced more harm-related
adverse events than did patients not receiving SSRIs (Glass,
2004, p. 862). The research studies, especially those in-
volving experts’ blind ratings of adverse events, suggest a
potentially sizeable risk of suicidality associated with the
treatment of children and adolescents with SSRIs. How-
ever, the data are limited by questionable research design
and by the small number of data points (perhaps in part due
to exclusion of high-risk patients from participation).
Clearly, more research is needed to clarify whether or not
the findings of increased suicidality among child and ado-
lescent patients in a few trials can be generalized to the
broader population of depressed children and adolescents.

Further evidence supporting the potential risk of sui-
cidality posed by SSRI treatment of pediatric patients
comes from the testimonials of relatives of those who have
committed suicide following the initiation of SSRI treat-
ment. According to Newman (2004), numerous individuals
offered public testimony about such incidences to the FDA
committee charged with the black-box label recommenda-
tion for these medications. Furthermore, Newman reports
that “several of these cases involved patients who had
shown no hint of suicidality before beginning treatment
with the drugs” (Newman, 2004, p. 1596). The details of
the case of Matt Miller, a 13-year-old boy who committed
suicide a week after beginning treatment with sertraline
(Zoloft), seem to suggest an association between the medi-
cation and suicide (Mahler, 2004). Matt did not appear to be

at high risk for suicide; he had indicated on the Children’s
Depression Inventory one week earlier that although he
thought about killing himself, he would not actually do it.
Matt’s parents are convinced that the medication led to
Matt’s suicide. Matt may have experienced rollback, getting
enough energy back to convert suicidal ideation into a sui-
cide. Alternatively, the medication may have induced a
broader pattern of impulsivity and violence in the young
patient, leading to his suicide (Mahler, 2004).

Impulsivity, Violence, and Hostility

Matt Miller’s parents reported additional changes in
Matt’s behavior during the week he began taking sertraline.
He became visibly agitated and seemed to have experienced
a burst of energy, which he released through activities such
as frequent bike riding. Searching for answers about his
son’s death, Matt’s father came across

…a phenomenon known as akathisia, or ac-
tivation, a state of extreme agitation that can
be induced by some psychotropic medica-
tions and can cause patients to behave in an
uncharacteristically violent manner, which
seemed to describe perfectly Matt’s condi-
tion before his suicide. (Mahler, 2004, p. 62)

Matt’s agitated behavior coupled with the violent
means by which he chose to commit suicide (i.e., by hang-
ing himself), suggested that beyond rollback, impulsivity
and violence may have led to his decision to commit suicide
(Mahler, 2004). Keeping in mind Matt’s case, the findings
of the TADS (2004) take on heightened significance. Spe-
cifically, the study’s finding of a general increase in the
broader category of harm-related adverse effects (Glass,
2004) might be consistent with a risk of activation among
pediatric patients taking SSRIs.

The possibility that pediatric patients taking SSRIs
might develop a pattern of impulsivity that can manifest
itself in suicidality may have neurobiological underpin-
nings. Begley (2004) outlines findings related to the effects
of SSRIs on the brains of children and adolescents. Specifi-
cally, treatment with SSRIs stimulates neurogenesis (the
growth of new neurons), which may be more problematic to
the child’s developing brain than to that of an adult taking
the medication. For example, this neurogenesis appears to
restore the shrunken hippocampus (a brain region associ-
ated with emotion and memory) of the depressed adult’s
brain back to its original size (Begley, 2004). By contrast,
the hippocampus does not show this shrinkage in the brains
of depressed children and adolescents and therefore, “some
scientists wonder whether the new neurons could destabi-
lize fragile brain circuits in kids suffering from mental ill-
ness” (Begley, 2004). Furthermore, researchers are looking
into differences in images of depressed children’s prefrontal
cortices (the region responsible for inhibition and impulse
control) as compared to that of adults. The prefrontal cortex
is still maturing in children and adolescents, and SSRI
treatment may result in difficulties with impulse control.



ERICA SAYPOL

34

Thus, SSRI medications may put children and adolescents
at particular risk for impulsive and violent behavior, which
among depressed children and adolescents seems likely to
include suicidal behavior.

Other Limitations of Psychopharmacological
Treatment

Beyond the potential risks of an increase in suicidality,
or a general increase in violence and impulsivity, there are
several additional arguments against treating children with
SSRI medications. First, general considerations of psycho-
pharmacological treatments, such as side effects (ranging
from the minor headache to suicidality), determination of
dosage, and duration of treatment, require careful risk-
benefit analyses for which the limited body of research may
fall short of supplying sufficient data. Second, SSRI or psy-
chopharmacological treatment of child and adolescent de-
pression approaches the disorder only on the neurobiologi-
cal, rather than the psychological level. As a result, SSRI
treatment does not offer a child coping mechanisms or sup-
port, which may be of critical importance in the face of a
recurrence. Unfortunately, the likelihood that children or
adolescents experiencing Major Depressive Disorder will
experience further Major Depressive Episodes is two to
four times that of children and adolescents without depres-
sion (Wagner et al., 2003). Assuming a diathesis-stress
model of depression, a child or adolescent with depression
has some genetic predisposition or vulnerability to develop
depression in the face of particular stressors. According to
such a model, it would appear that treatment should take
into consideration the exposure to the stressors that trigger
the depression for a child or adolescent. Given their youth
and the difficulties associated with adolescent development,
it appears that treatment should address both current and
potential future episodes. In such a treatment approach,
SSRIs, in the absence of psychotherapeutic interventions
that can foster coping skills, seem quite limited.

Combined Treatment of SSRIs and Psychotherapy

The recent research on the treatment of depression
among adolescents reveals the efficacy of combination
treatments including both SSRI medication and psychother-
apy. In particular, the TADS (2004) demonstrated the effi-
cacy of such combined treatments. The study involved 439
patients between 12 and 17 years of age who were ran-
domly assigned to one of four conditions: fluoxetine alone,
CBT alone, fluoxetine and CBT, and placebo. The outcome
measure involved a reduction in symptoms of depression as
measured by the change in CDRS-R scores over a 12-week
treatment period. The most improvement came from the
combination of fluoxetine and CBT, followed by the
fluoxetine-alone group, then the CBT-alone group, and then
the placebo. The only effect that obtained significance was
the combined treatment over the placebo.

The value of psychotherapeutic treatment revealed by
TADS (2004) went beyond the finding of the combined
efficacy of CBT and fluoxetine. A more subtle effect was
revealed in terms of the potential role of psychotherapy in
reducing the risks of suicidality and generally impulsive
and dangerous behaviors among adolescents treated with
SSRIs. In particular, as compared to the fluoxetine plus
CBT treatment group, the fluoxetine-alone group experi-
enced more harm-related adverse events, including any self-
harm or harm to the person or property of another (Glass,
2004). According to Glass, the TADS findings suggest the
possibility of a protective effect of psychotherapy. Such a
protective effect is a particularly important finding given
concerns about the potential for SSRI treatment to induce
suicidality and general impulsivity. Again, the numbers are
small and thus, definitive conclusions are difficult to draw
from this early research, including conclusions about
whether findings about psychotherapy with adolescents
generalize to the treatment of younger children. There ap-
pears to be a great need for future research clarifying
whether or not there is indeed a causal association between
SSRI treatment and suicidality and impulsive behavior.
There is also a need for research on the potential benefits of
the development of coping skills, support, and protection
against suicidality offered by different forms of psychother-
apy for depressed children and adolescents.

Discussion

There are no straightforward answers in the literature
to the question of whether or not depressed child and ado-
lescent patients should be treated with SSRI medications.
Supporting such treatments are findings that SSRIs are ef-
fective in reducing or eliminating depression, potential is-
sues of accessibility of medication over psychotherapy to
children, and findings that SSRIs have played a role in the
overall decline in adolescent suicide rates. Arguments
against the use of SSRIs among child and adolescent popu-
lations come primarily from research and case study find-
ings of associated increases in suicidality and findings of
potential impulsivity, violence, or agitation in response to
the medication. Furthermore, arguments against treating
children and adolescents with SSRIs include the complica-
tion of an array of side effects of varying severity, issues of
dosage and duration of treatment, and concerns over an
approach limited to the neurobiological level, which pro-
vides no room for the development of coping skills or sup-
port.

The controversy over the use of antidepressant medi-
cations has been heightened by ethical concerns regarding
unpublished data. Of particular concern was the discovery
of internal documentation at a drug company instructing the
withholding of data demonstrating that a particular SSRI,
paroxetine (Paxil), was ineffective in the treatment of ado-
lescents (Kondro & Sibbald, 2004). Furthermore, by con-
ducting a meta-analysis of published and unpublished data
on the use of SSRIs with children, Whittington et al. (2004)



CHILD AND ADOLESCENT DEPRESSION AND ANTIDEPRESSANTS

35

found that, with the exception of fluoxetine (Prozac), the
inclusion of unpublished data altered the overall findings
such that the risks outweighed the benefits of treatment
with several medications. Considering the overall limita-
tions of small effect sizes in this growing area of research,
and the potential suicidality risk, the disclosure of all find-
ings appears critical.

Another interesting, recent development in the debate
came in a recent revision to the FDA’s warning about these
medications (Polk, 2005). Specifically, in early February,
2005, the FDA removed a statement establishing a causal
link between these medications and increased suicidality
from its website and replaced it with a statement that re-
ported an increase in suicidality found in short-term studies
of these medications with children and adolescents. The
replacement sentence was also placed in boldface in the
black box warning on the medication insert, with the origi-
nal (causal) sentence moved into a later section of the text
that discusses suicide risk in more detail. Such a change in
language serves to qualify the original FDA warning, and to
point out that further research is needed to assess the true
safety of the medication for children and adolescents.

At this time, the research data from studies of children
and adolescents are few and there is a great need for further
study to better understand child and adolescent depression,
and to understand the relationship between the medication
and possible outcomes of suicidality and impulsive or vio-
lent behavior. The case studies provided by the parents of
children who have committed suicide during SSRI treat-
ment demand a more in-depth, research-based evaluation of
the treatment of children and adolescents with these medi-
cations.

The question of whether or not SSRIs should be used
in the treatment of children also sheds light into the range
of opinions of clinicians based both on experience and
training. As a graduate student in clinical psychology, I
have attempted to address the topic of the controversy sur-
rounding the treatment of children and adolescents with
SSRIs. In contrast, in his review of TADS (2004), which
provided support for the role of psychotherapy in the treat-
ment of depressed adolescents, Glass (2004) suggests that
an “area of lingering controversy is the role of psychother-
apy in the treatment of psychiatric disorders, including
major depression” (p. 863). The depiction of child and
adolescent depression as either a psychiatric or a psycho-
logical disorder, with different points of view and treatment
implications of each, should not pose a threat to finding the
most effective help for depressed children and adolescents.
If anything, the early studies appear to suggest that the
combination of psychotherapeutic and psychopharmacolo-
gic treatment may offer the most hope to patients.

Wilens, Spencer, Frazier, and Biederman (1998) offer a
six-step framework for evaluating the treatment of children
and adolescents with psychotropic medication. First, psy-
chotropics should only be prescribed following a thorough
diagnostic evaluation. Second, when used, pharmacother-
apy should be integrated with other forms of treatment,

such as psychotherapy, rather than suggested as an alterna-
tive form of treatment. Third, the severity and type of
symptoms and the age of the child should be considered.
Fourth, both the family and the child should be educated
about treatment alternatives and the risks and benefits asso-
ciated with the medication. Fifth, the child or adolescents’
dosage should be kept as low as possible and treatment
should be tapered if not effective and reevaluated after the
child or adolescent has improved. Sixth, multiple practitio-
ners (e.g., psychologists and psychiatrists or pediatricians)
should work collaboratively in managing the psychophar-
macologic treatment. Such a framework should guide the
treatment of children and adolescents with SSRIs.

For now, a primary goal should be collaborative, inter-
disciplinary research to assess the true safety and efficacy
of SSRIs in pediatric patients and to identify effective
forms of psychotherapy. Until more research has clarified
the safety of SSRI mediation for use with children and
adolescents, they should continue to be prescribed only in
severe cases of depression and after the parents, child, and
clinician have learned about, understood, and considered
other alternatives. Ideally, such medication would be pre-
scribed and patients closely monitored by psychiatrists with
specialization in the treatment of children and adolescents.
However, as Won Tesoriero (2004) pointed out, there are
simply too few of such professionals (with some 7,000
child and adolescent psychiatrists in the U.S. currently, ver-
sus an estimated need in 1990 for 33,000 such profession-
als). Won Tesoriero suggests that this shortage is associated
with the limited federal funding for hospitals to offer the
training this specialty requires. Because of the heightened
concerns over the safety of antidepressant treatment of chil-
dren and adolescents, it seems critical to address this short-
age of child and adolescent psychiatrists. Perhaps this could
be addressed by increasing the opportunities for psychia-
trists to specialize, by offering training to the pediatricians
who prescribe the medication, or by increasing collabora-
tion between child and adolescent psychologists and those
writing the prescriptions in an attempt to improve diagno-
sis, treatment plans, and monitoring of young patients.

Furthermore, when treating children and adolescents
with SSRIs, concurrent psychotherapy should be strongly
encouraged for several reasons. First, psychotherapy be-
comes critical to monitor risks related to suicidality and
impulsivity. Second, psychotherapy can offer depressed
children and adolescents support as they wait for the inhi-
bition of enough serotonin-reuptake to occur and an im-
provement in mood to result. The support and development
of coping skills offered by psychotherapy can be equally
important throughout psychopharmacological treatment,
during the tapering and removal of medication, and in the
future as children and adolescents face other Major Depres-
sive Episodes and cope with everyday life stressors.

For proponents of SSRI use in children who are exclu-
sively focused on examining depression and treatment on
the neurobiological level, the potential role of psychother-
apy in treatment remains a powerful one. Studies compar-



ERICA SAYPOL

36

ing interpersonal therapy and SSRIs have demonstrated that
psychotherapy produces similar (and possibly longer-
lasting) brain changes to those produced by SSRI treatment
(Friedman, 2002). Finally, the research so far on the treat-
ment of child and adolescent depression reveals the benefits
of psychotherapy both directly and indirectly. TADS (2004)
demonstrated significant improvement among depressed
adolescents only from the combination of an SSRI and psy-
chotherapy, and a possible protective effect of psychother-
apy related to impulsivity and suicidality. Wagner et al’s
(2003) work revealed the more subtle possibility that even
in a study limited to psychopharmacological treatment, the
informal, frequent psychotherapeutic interactions between
investigators and pediatric patients may have led to sub-
stantial improvement. Together, such findings offer power-
ful evidence of the importance of psychotherapy in the
treatment of depressed children and adolescents.

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