Psychological therapy is recommended as the first line of defense against depression. However, the use of antidepressants keeps going up. The increase comes in spite of the U.S. Food and Drug Administration’s 2004 black box warning against the use of antidepressants among people under the age of 24 due to an increased suicide risk.

In a recent study, published in The Lancet, researchers analyzed both the efficiency and the risks associated with 14 antidepressants commonly prescribed to children suffering from depression. Their findings show that the benefits associated with these medications do not outweigh the potential risks.

"The balance of risks and benefits of antidepressants for the treatment of major depression does not seem to offer a clear advantage in children and teenagers, with probably only the exception of fluoxetine,” said Professor Peng Xie, from The First Affiliated Hospital of Chongqing Medical University in China, in a statement. “We recommend that children and adolescents taking antidepressants should be monitored closely, regardless of the antidepressant chosen, particularly at the beginning of treatment."

Xie and his colleagues conducted a systematic review of all studies that compared the effects of 14 antidepressants prescribed to young people with major depression up to the end of May 2015. This data included 34 trials with 5,260 participants between the ages of 9 and 18. Each type of antidepressant was ranked by its ability to change depressive symptoms, the patient’s response to treatment, discontinuation due to side effects, discontinuation due to any other cause, and suicide thoughts or attempts.

The 14 antidepressants considered were amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, venlafaxine, as well as a placebo. Only fluoxetine, sold under the brand name Prozac, was more effective at relieving symptoms of depression when compared to the placebo effect. Venlafaxine, on the other hand, was linked to a higher risk for suicidal thoughts and attempts when compared to the placebo and five other antidepressant drugs.

This is far from the first study to show the potential pitfalls of prescribing antidepressants to children and teenagers. Research published in JAMA Internal Medicine included data on over 160,000 participants between the ages of 10 and 64 who suffered from depression and were treated with antidepressants such as Prozac and Seroxat. Children prescribed high doses of these medications were twice as likely to exhibit suicidal behavior compared to those who took average doses.

According to the Anxiety and Depression Association of America, two out of every 100 young children and eight out of every 100 teenagers experience severe depression. Health care professionals recommend using cognitive behavioral therapy as the first treatment option for depression, especially for children. The goal of this form of psychotherapy is to turn negative thought patterns about the world and oneself into positive ones. All forms of psychological therapy used to treat anxiety or depression among children should include their parents as much as possible.

If behavioral therapy has failed to reduce depressive symptoms and medications are a patient’s only remaining option, then it’s important to note that all antidepressants affect people differently. There are a variety of different antidepressants that work in different ways and have different side effects. Before prescribing these medications, a doctor may consider which symptoms of depression the patient is experiencing, which side effects are associated with particular medications, whether a parent or sibling has used it, what other medications the patient is taking, whether the patient is pregnant or breast-feeding, and if they suffer from any other type of physical or mental health conditions.

Source: Zhou X, Xie P, Cipriani A, et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet . 2016.