Depression in Children and Adolescents

PHILIP HAZELL

PHILIP HAZELL, Professor, University of Newcastle, New South Wales, Australia

Am Fam Physician. 2003;67(3):577-579

Questions Addressed

What are the effects of treatments for depression in children and adolescents?
Which treatments are effective to improve long-term outcomes?

Beneficial	Unknown effectiveness	Unlikely to be beneficial
Cognitive therapy (in mild to moderate depression)	Intravenous clomipramine (adolescents) Monoamine oxidase inhibitors Lithium St. John's wort Venlafaxine Electroconvulsive therapy Family therapy Group treatments other than cognitive behavior therapy Long-term effects of different treatments	Oral tricyclic antidepressants (adolescents)
Cognitive therapy (in mild to moderate depression)		Ineffective or harmful
Likely to be beneficial		Oral tricyclic antidepressants (children)
Interpersonal therapy in adolescents (in mild to moderate depression)
Trade off
Selective serotonin reuptake inhibitors

Definition	Compared with adult depression, depression in children (six to 12 years of age) and adolescents (13 to 18 years of age) may have a more insidious onset, may be characterized more by irritability than sadness, and occurs more often in association with other conditions such as anxiety, conduct disorder, hyperkinesis, and learning problems.¹
Incidence/Prevalence	Estimates of prevalence of depression among children and adolescents in the community range from 2 to 6 percent.^2,3 Prevalence tends to increase with age, with a sharp rise around onset of puberty. Preadolescent boys and girls are affected equally, but depression is seen more frequently among adolescent girls than boys.⁴
Etiology/Risk Factors	The etiology is uncertain, but may include childhood events and current psychosocial adversity.
Prognosis	In children and adolescents, the recurrence rate of depressive episodes first occurring in childhood or adolescence is 70 percent by five years, which is similar to the recurrence rate in adults, but it is not clear if this is related to severity of depression.⁴ Young people experiencing a moderate to severe depressive episode may be more likely than adults to have a manic episode within the next few years.^4,5 Trials of treatment for child and adolescent depression have found high rates of spontaneous remission (as much as two thirds of people in some inpatient studies).
Clinical Aim	To improve mood, social and occupational functioning, and quality of life; to reduce morbidity and mortality; to prevent recurrence of depressive disorder; and to minimize adverse effects of treatment.
Clinical Outcomes	In children and adolescents, there are developmentally specific pseudocontinuous self-report measures such as the Children's Depression Rating Scale and the Children's Depression Inventory, although some studies of adolescents use scales developed for use in adults such as the Hamilton Rating Scale for Depression. Parent-report pseudocontinuous measures such as the Children's Depression Inventory for Parents are also used. Categorical outcomes are sometimes expressed as people no longer meeting specified criteria for depression on a structured psychiatric interview such as the Kiddie-Shipman Anxiety Depression Scale, which combines data from children and their parents. Global improvement in symptoms as judged by an investigator is sometimes reported using the Clinical Global Impressions scale or the Clinical Global Assessment scale. Severity of depression is defined in some studies using cut-off scores on pseudocontinuous measures, such as the Children's Depression Rating Scale and the Children's Depression Inventory, but is often not stated.

Evidence-Based Medicine Findings

SEARCH DATE:Clinical Evidence update search and appraisal January 2002; Additional references identified by contributor.

Tricyclic Antidepressants

One systematic review found no significant difference with oral tricyclic antidepressants (amitriptyline, desipramine, imipramine, nortriptyline) versus placebo in depression scores in children and adolescents with depression. Subgroup analyses found that oral tricyclic antidepressants versus placebo significantly reduced symptoms in adolescents but not in children. The review also found that oral tricyclic antidepressants were associated with adverse effects. One small, randomized controlled trial (RCT) found that in nonsuicidal adolescents, intravenous clomipramine versus placebo significantly reduced depression scores at six days.

Monoamine Oxidase Inhibitors

One RCT found insufficient evidence on moclobemide versus placebo in children nine to 15 years of age with major depression and some with a comorbid disorder. We found no RCTs on use of nonreversible monoamine oxidase inhibitors in children or adolescents.

Selective Serotonin Reuptake Inhibitors

One RCT found no significant difference with fluoxetine versus placebo in depression symptoms or psychologic functioning in adolescents with depression after eight weeks. Another RCT found that in children and adolescents with major depression, fluoxetine versus placebo significantly improved depressive symptoms after eight weeks. One RCT found that in adolescents with major depression, paroxetine versus placebo significantly improved remission after eight weeks. Fluoxetine and paroxetine were associated with adverse effects. We found no RCTs on other selective serotonin reuptake inhibitors.

Venlafaxine

One RCT found no significant difference with venlafaxine versus placebo in improvement of depressive symptoms in children and adolescents with major depression after six weeks.

Lithium

One RCT found no significant difference with lithium versus placebo in global assessment or depression scores after six weeks in children with depression and family history of bipolar affective disorder. Lithium was associated with adverse effects.

St. John's Wort (Hypericum perforatum)

We found no RCTs on St. John's wort (H. perforatum) in children or adolescents with depression.

Electroconvulsive Therapy

We found no RCTs on electroconvulsive therapy in children and adolescents with depression.

Specific Psychologic Treatments

One systematic review has found that cognitive behavior therapy increases the rate of resolution of the symptoms of depression compared with nonspecific supportive therapies for children and adolescents with mild to moderate depression. We found limited evidence from two small RCTs that interpersonal therapy versus clinical monitoring alone or placement on a waiting list increases recovery in adolescents with mild to moderate depression. We found insufficient evidence that family therapy or group treatments other than cognitive behavior therapy are effective treatments for depression in children and adolescents.

Long-Term Outcomes

We found no systematic review or RCTs looking at long-term outcomes of interventions for depression in children and adolescents.

Costello EJ, Angold A, Burns BJ, et al. The Great Smoky Mountains Study of Youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry. 1996;53:1129-36.

Costello EJ. Developments in child psychiatric epidemiology. J Am Acad Child Adolesc Psychiatry. 1989;28:836-41.

Lewinsohn PM, Rohde P, Seely JR. Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clin Psychol Rev. 1998;18:765-94.

Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years, Part I. J Am Acad Child Adolesc Psychiatry. 1996;35:1427-39.

Geller B, Fox LW, Fletcher M. Effect of tricyclic antidepressants on switching to mania and on the onset of bipolarity in depressed 6- to 12-year-olds. J Am Acad Child Adolesc Psychiatry. 1993;32:43-50.