# 07 - After prescribing

# After prescribing

Prescribing in children and adolescents
CHAPTER 5
are approved for use in adults with treatment-­resistant depression, but there is no 
substantial evidence in children and adolescents.31 With regard to ketamine, or its 
enantiomer esketamine, emerging evidence suggests that it may be effective and adequately tolerated in adolescents with treatment-­resistant depression based on a small 
number of studies, including two small RCTs.­36–­38 Considering rTMS, initial evidence 
suggested that it may be effective, again based on a small number of studies and a 
small RCT, but a larger RCT found no evidence of effectiveness.39 Electroconvulsive 
therapy (ECT) has limited evidence of effectiveness in young people, although one 
randomised trial in adolescents showed good effect against both depression and suicide.40 Therefore, these treatments’ unknown potential effects on the developing brain 
need to be considered carefully and weighed up against the risks of not attempting 
these treatments.41 Further research is greatly needed to inform clinical decisions.42
■
■NICE warns against prescribing paroxetine, venlafaxine, tricyclic antidepressants or 
St John’s wort for depression in young people, because of potential adverse effects 
and interactions.4
Table 5.2 summarises medication treatment for depression in children and adolescents.
After prescribing
Acute phase
■
■Monitor for adverse effects regularly, for example weekly for the first 4  weeks. 
Children and adolescents generally tolerate SSRIs well. Potential adverse effects 
include those experienced by adults, described in Chapter 3. Additionally, young people taking SSRIs have a small increased risk of suicidality and switch to mania, as well 
as activation effects (see ‘Specific issues’ later in this chapter). Therefore, risk of harm, 
mood and behaviour should be monitored closely and addressed.3,4,6,31
■
■After 4  weeks of SSRI treatment at a therapeutic dose, assess response including 
depression severity using the measures completed at baseline. Most therapeutic effects 
appear by 4 weeks.43
■
■If partial or non-­response, consider the possibility of poor treatment adherence, inaccurate diagnosis, comorbidity or modifiable maintaining factors.
Table 5.2  Summary of pharmacotherapy for depression in children and adolescents.3,4,6,31
Medication
Starting dose
Therapeutic dose range
First line
Fluoxetine
10mg/day
­20–­60mg/day
Second line
Sertraline
Escitalopram
Citalopram*
­25–­50mg/day
­5–­10mg/day
10mg/day
­50–­200mg/day
­10–­20mg/day
­20–­40mg/day
Subsequently
Consider augmentation of antidepressant with second-­generation antipsychotic 
or lithium.†
Consider switching to an antidepressant from a different class, such as mirtazapine.
*Caution advised in cardiac or hepatic disease.
†No randomised controlled trials available in young people (but there is evidence from adult trials).