Major depressive disorder and bipolar disorder can occur in quite young children. However, since both conditions are more common in adolescence than in childhood, and there is a greater evidence base for medication use in this age group, we focus here primarily on adolescents. Mood disorders in children and adolescents are diagnosed using adult criteria, although this is controversial, particularly in paediatric bipolar disorder. The advent of DSM-5 (American Psychiatric Association, 2013) has brought about few changes in the classification of mood disorders: grief is no longer an exclusion criterion for depression, and increased energy/activity is now regarded as a core symptom of mania and hypomania. A new category, disruptive mood dysregulation disorder (DMDD), has been introduced with the aim of reducing inappropriate diagnosis of bipolar disorder in children and adolescents who have non-cyclical, frequent severe temper outbursts along with a persistent irritable mood. Currently, there is little research regarding the diagnosis and treatment of DMDD, but early studies suggest that it is unlikely to be a precursor of bipolar disorder, so it will not be considered further in this chapter.

Prescribing in depression

Background

The prescribing of newer-generation antidepressants to children and adolescents with depression has been controversial in the UK since the publication of the Committee on Safety of Medicines (CSM) report on selective serotonin reuptake inhibitors (SSRIs) (Committee on Safety of Medicines, 2003). This report highlighted the important matter of the nonpublication of negative trial results and questioned both the effectiveness and safety of these medications, particularly an increased risk of suicidality. Before discussing the practicalities of prescribing, we will first review the evidence for the CSM findings. The tricyclic antidepressants will not be discussed here, as the risks associated with these drugs outweigh the relatively small benefits of using them.

Evidence base for pharmacological treatment

The CSM report concluded that, of the new-generation antidepressants (a group which includes the SSRIs and antidepressants such as venlafaxine, a serotonin–noradrenaline reuptake inhibitor or SNRI), only fluoxetine showed a positive risk–benefit ratio in treating depression in young people when compared with a drug placebo (Committee on Safety of Medicines, 2003).