Tricyclic antidepressants and selective serotonin reuptake inhibitors: use during pregnancy, in children/adolescents and in the elderly

OBJECTIVE

Depressive disorders can occur at any point in the lifespan. One way of differentiating antidepressants is by examining their efficacy and safety in the special patient populations that exist along the lifespan. Thus, we examine clinical data that is available regarding the use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) at three distinct points in the lifespan: childhood and adolescence, pregnancy and late adulthood.

METHOD

Literature regarding the use of antidepressants in children and adolescents, pregnancy and the elderly was reviewed.

RESULTS

Clinical data suggest that SSRIs should be first line treatment in children and adolescents as TCAs have questionable efficacy and definite safety issues. Similarly, although TCAs and SSRIs show equivalent efficacy in elderly patients, the safety profile of the SSRIs makes them a more prudent choice in this population. Finally, although there is no definitive data that contraindicates the use of a particular antidepressant in pregnancy, the bulk of reassuring pregnancy outcome data exists for the SSRIs, specifically for fluoxetine.

CONCLUSION

Although no single antidepressant can ever be recommended for every patient, SSRIs should be considered the first-line choice in the treatment of depression in special patient populations.

Clinician, parent, and child prediction of medication or placebo in double-blind depression study

To evaluate how well a blind is maintained in a double-blind study. Clinicians (n = 66), parents (n = 62), and depressed child/adolescent subjects (n = 62) predicted whether the patient had been on either placebo or active medication at the end of an eight-week double-blind placebo versus fluoxetine trial. Clinician, patient and parents' guesses as to which treatment they had received were at a chance level based on an overall analysis. However, when clinical response and condition assignment were controlled, all were correctly predicting placebo treatment but not medication treatment. The finding that subjects, parents and clinicians predict at a chance level is important for double-blind study design integrity. However, clinicians, parents and subjects were accurately predicting placebo treatment when clinical response and the assigned condition were taken into account but not medication. Since they do not know condition however, all remain essentially blinded, and this is an important finding for design and analysis integrity for double-blind studies.

The effect of fluoxetine on sleep EEG in childhood depression: a preliminary report

Fluoxetine is associated with substantial objective and subjective sleep disturbance in adults with major depressive disorders. In this preliminary report, the effects of fluoxetine on sleep electroencephologram (EEG) are described in 6 children and adolescents with nonpsychotic major depression. Fluoxetine increased light Stage 1 sleep, the number of arousals and rapid eye movement (REM) density. REM latency was largely unaffected. Oculomotor abnormalities were also evident on treatment, accompanied by an increase in myoclonic activity. Subjective sleep was also disturbed on treatment. These results are in keeping with those observed in depressed adults treated with fluoxetine.

Recognizing and managing the adolescent with Kleine-Levin syndrome

This report calls attention to the Kleine-Levin Syndrome, a sleep disorder which predominantly occurs in adolescent males. It can easily be mistaken for other psychiatric or neurologic illness. Differential diagnosis and treatment are discussed.

Acute psychosis complicating induction therapy for acute lymphoblastic leukemia

Two adolescents with acute lymphoblastic leukemia developed acute psychotic episodes shortly after induction therapy, which included prednisone, was begun. Symptoms included regressive behavior, incontinence, fluctuating levels of activity, and delusions. Both patients regained normal mental status after a number of weeks. Treatment included tapering of steroid dosage, introduction of a highly structured environment, and early use of chlorpromazine. Psychosis persisted beyond discontinuation of steroid therapy, but both patients subsequently received steroids after return of normal mentation, and in neither did psychosis recur.