Rapid rise in adolescent antidepressant prescriptions sparks debate on appropriate use and safety

A sharp increase in antidepressant and antipsychotic prescribing among teenagers, particularly girls, prompts concerns over prescribing practices, escalation speeds, and safety safeguards amidst expanding access and off-label use.

A routine question about increasing a teenager’s sertraline dose opens onto a much larger debate: whether antidepressants are being started, escalated and continued more quickly than the evidence warrants. The concern is not that these medicines lack value. For many adolescents, they are essential. The worry is that prescribing has begun to rise in ways that outstrip what changes in diagnosis alone can explain.

Research from Germany’s largest statutory health insurer, covering adolescents aged 12 to 17 between 2015 and 2023, found steep increases in several psychotropic medicines, especially among girls. Sertraline prescribing in girls rose 482%, while escitalopram climbed 194%. Antipsychotic use also increased for girls, led by aripiprazole and quetiapine, with overall antipsychotic prescribing up 26% in that group even as it fell among boys. The authors concluded that the scale and pattern of change suggested earlier drug intervention and more off-label use, rather than simply more illness being recognised.

A similar picture has emerged in the United States. A study published in Pediatrics found that monthly antidepressant dispensing for people aged 12 to 25 increased by 66.3% between 2016 and 2022, with the rate accelerating sharply after March 2020. The rise was especially pronounced among girls and young women. According to the study, dispensing among females aged 12 to 17 rose 129.6% faster after the pandemic began than before it, while the rate for boys and young men fell or remained comparatively flat. Another analysis in JAMA found the same pattern: a broad rise over time, then a much steeper pandemic-era surge driven largely by female adolescents.

That trend is not necessarily evidence of overprescribing on its own. Selective serotonin reuptake inhibitors remain the main drug treatment for adolescent depression and anxiety, and fluoxetine and escitalopram are approved by the US Food and Drug Administration for paediatric depression. The American Academy of Pediatrics has also urged primary care doctors to treat mild to moderate depression and anxiety, including with medication when clinically appropriate, reflecting the reality that many families cannot quickly reach specialist care. But the same expansion in access that allows more young people to be helped can also make it easier to medicate distress that might respond to therapy, time and close follow-up instead.

That is where the caution becomes important. Every antidepressant used in children and teenagers carries a black-box warning about the risk of suicidal thoughts and behaviour, and guidelines recommend starting low, increasing slowly and monitoring closely, particularly during the first weeks of treatment and after dose changes. Yet those safeguards are hard to maintain in short appointments, busy practices and systems that reward quick prescribing over sustained review. US prescribing data also suggest that much of the growth is now happening outside psychiatry: by 2020, nurse practitioners were writing the largest share of antidepressant prescriptions for adolescents and young adults, ahead of psychiatric specialists and family doctors. The practical result is a system that can deliver treatment faster, but not always more carefully.

For parents, the message is not that antidepressants should be feared or avoided. It is that a growing prescription alone is not proof that more treatment is better treatment. A sharp rise in use, particularly among teenage girls, deserves the same scrutiny as any major shift in medical practice. The central question is not whether these medicines work, but whether they are being used at the right time, for the right reasons and with enough follow-up to keep young people safe.