According to that study, Dr. Wagner said, “If by week 4, they haven't had a 58% improvement–if they're not more than 50% improved–they're unlikely to go on to remit. It's time to up the dose or switch.”
A successful therapy should be maintained for at least a year before attempting to cease treatment, Dr. Wagner said (J. Child. Adolesc. Psychopharmacol. 2008;18:389-94). “A year from the time you start treatment would be a bare minimum. I know a lot of parents want it short, but then it's important that they understand and assume the risk,” she said.
As to the box warnings on suicide risk that were issued by the FDA in 2004 and 2007, she referred to findings that showed a 44% decrease in primary care providers' diagnoses of depression after the warnings were issued and a 10% reduction in prescriptions of SSRIs (Arch. Gen. Psychiatry 2009;66:633-9).
“Where did those children who were previously being diagnosed with depression go?” Dr. Wagner asked. “The suicide rate is now 5% higher than it has been in the previous 20 years. It's worrisome that diagnosis … and treatment has dropped. There's increasing evidence that those trends could be an unintended consequence of the FDA's box warning.”
She concluded by citing another study that showed that the number of children needed to treat with antidepressants to achieve one remission is 10, while the comparable number needed to harm due to suicidal ideation or attempts is 112 (JAMA 2007;297:1683-96).
“That's not committing suicide but having suicidal attempts or ideation,” she emphasized. “They are 11 times more likely to get benefit than to develop suicidality. From my perspective, that's an excellent ratio.”
Dr. Wagner disclosed that she has received honorarium and travel support from AACAP, research support from National Institute of Mental Health, and other support from the American Society of Clinical Pharmacology.