With our emphasis on treatment-refractory depression, one cannot help but think about recent media coverage and regulatory events surrounding antide-pressant therapy. The current debate about the safety of antidepressant therapy for children and adolescents stands out in particular.

Recently, a pediatrician attending a symposium at the University of Pennsylvania asked me whether I thought that primary care pediatricians should continue to prescribe antidepressants for children with depression and anxiety disorder. As is now well known, data have emerged suggesting a link between selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and an increase in suicidal ideation involving children and adolescents during clinical trials. It is important to bear in mind that no actual suicides occurred and that some of the “suicidal acts” were far from lethal and, arguably, not suicidal. Nevertheless, overall ~1 in 50 children on active medication—significantly more than those on placebo—had new-onset suicidal ideation or actions. The effect was most noticeable for venlafaxine and paroxetine and least noticeable for fluoxetine. As all of these drugs block the presynaptic reuptake of serotonin, it is not clear if the differences among these medications are real.