Do antidepressants work differently in teen brains?
We know teen brains are different, that has be proven time and again through neuroresearch. In fact, brains are different until they fully “mature” at around age 25 years.
I have been working with teenagers my whole career, and I started out following the standards of psychiatry without much questioning: put teens on the same medications you might prescribe adults, and dose them similarly. But it didn’t take long before I grew to question standard practice. I was prescribing antidepressants to teens, and too many of them would get better for a couple of weeks, and then spiral into a crisis. Not only would they spiral, but they would all go into basically the same type of spiral, a spiral full of pent up energy bursting to come out as troubled behavior. The pent-up-badness would burst out as aggression toward the parents, drug experimentation, lying, running away in the middle of the night, or in kids who were too cooperative and well-behaved for any of the behaviors above, the behavior bursting forth would be self-harm or a suicide attempt.
At first, I decided I must be seeing a large number of Bipolar teens. The symptoms above are often side effects of antidepressants in Bipolar spectrum illness. But that didn’t make sense. Bipolar Disorders exist at rates in the low single digits (less than 5%), and almost every teen was reacting badly to antidepressants.
I started to veer away from using antidepressants in teens, at the least the standard ones. I tried non-serotonin alternatives like bupropion (Wellbutrin) wherever I could, and treated anxiety with drugs like buspirone and hydroxyzine. I was offering individual and family therapy as an alternative to medications for every patient family who was willing to try it. I was making fewer referrals to the hospital, and trying to find answers in the medical literature to explain what I was seeing, but I didn’t find clear answers, only occasional competing theories that needed to be investigated further.
And then something very important happened in my practice. My youngest child got injured, and I was suddenly away from practice for almost 6 weeks. My psychiatric colleagues generously covered my practice without question; they took over and treated my patients for me while I sat in the ICU with my child and I was unable to offer any insights to the practice. My colleagues must have stared at my handwritten chart notes in confusion, wondering why these patients weren’t receiving the antidepressants they so desperately deserved. The doctor colleagues changed my patients’ care plans, and one by one prescribed the teens antidepressants.
Even though I was on leave, I hadn’t inactivated my emergency call service. I had a pretty stable group of patients, and I didn’t receive frequent enough calls to worry about it. I remember when the calls started coming in: a teen found unresponsive, another had made a serious attempt on her life, another had run away. These were teens I knew well, and their crisis behaviors were a shocking break from normal.
Having already struggled with questions about antidepressants in teens, this 6-week window functioned as a small-scale experiment. I was convinced that antidepressants were acting differently in teen brains. I spoke with colleagues who mostly shrugged and said, “I haven’t seen that.” Only one, Dr. Randall Sellers, a psychiatrist who also treated mostly teens and young adults, passionately agreed. He thought we needed to conduct a research study, but before we put together that study, Dr. Sellers died suddenly from metastatic melanoma.
In the intervening years, research is catching up. Black box warnings for suicidal ideations have been issued for all antidepressants used in teens, and increasingly research articles are recommending cautiously low dosing of antidepressants in teen and young adult brains. Unfortunately, the wheels of change turn slowly, and while we wait for change, another teen was admitted to the hospital yesterday for downing a bottle of pills prescribed by her primary care physician.
Maybe this piece will start a conversation, spark a closer look, or persuade a parent to request caution from a doctor. Antidepressants are often predictable in their effects on adult brains, but teen brains are different and so are their responses to these medications.
