SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder. However, there are certain clinical settings where the use of a tricyclic antidepressant, like imipramine, may be preferred.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
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Imipramine hydrochloride inhibits reuptake of norepinephrine or serotonin at the presynaptic neuron. This agent is an antagonist at histamine H1 and alpha1 adrenoceptors, as well as at M2 muscarinic acetylcholine receptors.
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Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. It may be beneficial in the treatment of pain, morning stiffness, functional status, sleep, and global well-being.
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Sertraline selectively inhibits presynaptic serotonin reuptake. It may be beneficial and well tolerated in the treatment of generalized anxiety disorder.
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Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. It may be useful in the treatment of somatic symptoms associated with generalized anxiety disorder.
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Escitalopram is the S-enantiomer of citalopram. It is used for the treatment of depression. The mechanism of action is thought to be potentiation of serotonergic activity in the CNS resulting from inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief is typically after 1-2 weeks, which is sooner than that noted with other antidepressants.
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Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do. In the treatment of body dysmorphic disorder (BDD), higher doses than those used for depression generally are needed. It may improve depression, anxiety, anger, and somatic symptoms.
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Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is approved for obsessive-compulsive disorder.
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Mirtazapine is an alpha-2 antagonist. Mirtazapine exhibits both noradrenergic and serotonergic activity. In some cases of depression associated with severe insomnia and anxiety, it is superior to SSRIs.
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Duloxetine is a potent inhibitor of neuronal serotonin and norepinephrine reuptake. Its antidepressive action is theorized to be due to serotonergic and noradrenergic potentiation in the CNS. It is approved for the treatment of somatic symptoms in patients with generalized anxiecy disorder and chronic musculoskeletal pain.
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Venlafaxine is structurally unrelated to other available antidepressants. It inhibits serotonin reuptake at select receptors, as well as the reuptake of norepinephrine. Venlafaxine has been shown to be effective in the improvement of core psychic anxiety symptoms and associated somatic symptoms in patients with with generalized anxiety disorder.
Medically Reviewed by Smitha Bhandari, MD on November 17, 2020
Somatic symptom disorder (SSD formerly known as "somatization disorder" or "somatoform disorder") is a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause including general medical conditions, other mental illnesses, or substance abuse. But regardless, they cause excessive and disproportionate levels of distress. The symptoms can involve one or more different organs and body systems, such as: Many people who have SSD will also have an anxiety disorder. People with SSD are not faking their symptoms. The distress they experience from pain and other problems they experience are real, regardless of whether or not a physical explanation can be found. And the distress from symptoms significantly affects daily functioning. Doctors need to perform many tests to rule out other possible causes before diagnosing SSD. The diagnosis of SSD can create a lot of stress and frustration for patients. They may feel unsatisfied if there's no better physical explanation for their symptoms or if they are told their level of distress about a physical illness is excessive. Stress often leads patients to become more worried about their health, and this creates a vicious cycle that can persist for years. Several conditions related to SSD are now described in psychiatry. These include: Stress usually makes symptoms of conversion disorder worse.
Patients who experience SSD may cling to the belief that their symptoms have an underlying physical cause despite a lack of evidence for a physical explanation. Or if there is a medical condition causing their symptoms, they may not recognize that the amount of distress they are experiencing or displaying is excessive. Patients may also dismiss any suggestion that psychiatric factors are playing a role in their symptoms.
A strong doctor-patient relationship is key to getting help with SSD. Seeing a single health care provider with experience managing SSD can help cut down on unnecessary tests and treatments.
The focus of treatment is on improving daily functioning, not on managing symptoms. Stress reduction is often an important part of getting better. Counseling for family and friends may also be useful.
Cognitive behavioral therapy may help relieve symptoms associated with SSD. The therapy focuses on correcting:
- Distorted thoughts
- Unrealistic beliefs
- Behaviors that feed the anxiety