Depression in Children and Adolescents: Evaluation and Treatment

 

The prevalence of major unipolar depression in children and adolescents is increasing in the United States. In 2016, approximately 5% of 12-year-olds and 17% of 17-year-olds reported experiencing a major depressive episode in the previous 12 months. Screening for depression in adolescents 12 years and older should be conducted annually using a validated instrument, such as the Patient Health Questionnaire-9: Modified for Teens. If the diagnosis is confirmed, treatment should be initiated for persistent, moderate, and severe depression. Active support and monitoring may be sufficient for mild, self-limited depression. For more severe depression, evidence indicates greater response to treatment when psychotherapy (e.g., cognitive behavior therapy) and an antidepressant are used concurrently, compared with either treatment alone. Fluoxetine and escitalopram are the only antidepressants approved by the U.S. Food and Drug Administration for treatment of depression in children and adolescents. Fluoxetine may be used in patients older than eight years, and escitalopram may be used in patients 12 years and older. Monitoring for suicidality is necessary in children and adolescents receiving pharmacotherapy, with frequency of monitoring based on each patient's individual risk. The decision to modify treatment (add, increase, change the medication or add psychotherapy) should be made after about four to eight weeks. Consultation with or referral to a mental health subspecialist is warranted if symptoms worsen or do not improve despite treatment and for those who become a risk to themselves or others.

The prevalence of depression is increasing among youth in the United States. The 2005 to 2014 National Surveys on Drug Use and Health, which included 172,495 adolescents 12 to 17 years of age, found that the percentage of adolescents who experienced one or more major depressive episodes in the previous 12 months increased from 9% in 2005 to 11% in 2014.1 In 2016, this percentage was approximately 13% (5% in 12-year-olds, 13% in 14-year-olds, and 17% in 17-year-olds), and although 70% of youths experienced severe impairment from depression, only about 40% received treatment.1 Treatment rates have changed little since 2005, raising concern that adolescents are not receiving needed care for depression.1

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SORT: KEY CLINICAL RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Adolescents should be screened annually for depression.36,38

B

Recommendation from evidence-based guidelines

For children and adolescents with mild depression, consider delaying pharmacotherapy and psychotherapy for six to eight weeks while providing supportive care and close monitoring, because patients may improve without further treatment.4650

A

Evidence from response in placebo arms of trials and recommendation from consensus guidelines

Children and adolescents with moderate or severe depression or persistent mild depression should be treated with fluoxetine (Prozac) or escitalopram (Lexapro) in conjunction with cognitive behavior therapy or other talk therapy.47,5759

A

Consistent evidence from several randomized trials

For those who do not initiate combination therapy, monotherapy with an antidepressant or psychotherapy is recommended, although the likelihood of benefit is lower.46,5256

A

Evidence from several randomized trials and systematic reviews


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY CLINICAL RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Adolescents should be screened annually for depression.36,38

B

Recommendation from evidence-based guidelines

For children and adolescents with mild depression, consider delaying pharmacotherapy and psychotherapy for six to eight weeks while providing supportive care and close monitoring, because patients may improve without further treatment.4650

A

Evidence from response in placebo arms of trials and recommendation from consensus guidelines

Children and adolescents with moderate or severe depression or persistent mild depression should be treated with fluoxetine (Prozac) or escitalopram (Lexapro) in conjunction with cognitive behavior therapy or other talk therapy.47,5759

A

Consistent evidence from several randomized trials

For those who do not initiate combination therapy, monotherapy with an antidepressant or psychotherapy is recommended, although the likelihood of benefit is lower.46,5256

A

Evidence from several randomized trials and systematic reviews


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented

The Authors

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SHELLEY S. SELPH, MD, MPH, is a core investigator at the Pacific Northwest Evidence-based Practice Center, Portland, Ore. She is also an assistant professor in the Department of Medical Informatics and Clinical Epidemiology and the Department of Family Medicine at Oregon Health and Science University, Portland....

MARIAN S. MCDONAGH, PharmD, is the associate director of the Pacific Northwest Evidence-based Practice Center and a professor in the Department of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University.

Address correspondence to Shelley S. Selph, MD, MPH (email: selphs@ohsu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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