Treatment of Depression in Children and Adolescents

What are the benefits and harms of nonpharmacologic and pharmacologic treatments for depressive disorders in children and adolescents?

Cognitive behavior therapy (CBT), family therapy, exercise, and spirituality reduce depressive symptoms in adolescents with no evidence of harms. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Selective serotonin reuptake inhibitors (SSRIs) improve depressive symptoms and response in adolescents with major depressive disorder. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Serious adverse events and withdrawal because of adverse events are more common with SSRIs compared with placebo. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Paroxetine may cause increased suicidal ideation or behavior in adolescents and children. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is no symptom improvement with serotonin-norepinephrine reuptake inhibitors compared with placebo in adolescents with major depressive disorder. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) CBT combined with fluoxetine improves depressive symptoms, remission, and functional status more than CBT alone.¹ (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

Nearly one in five adolescents has a depressive disorder at some point before adulthood.² Primary care physicians cite many barriers to treating depression in adolescents and children. One of those barriers is a concern about increased suicidality after the U.S. Food and Drug Administration placed a boxed warning on antidepressants for children and adolescents in 2004 and expanded that warning in 2018.^3,4

This Agency for Healthcare Research and Quality (AHRQ) review assessed the benefits and harms of nonpharmacologic and pharmacologic treatment of depressive disorders in children and adolescents. The review identified 60 relevant studies (including 43 in the United States) that treated participants for at least six weeks and reported both benefits and harms.¹

The AHRQ review found limited evidence of benefit for depressive symptoms from CBT, family therapy, exercise, and spirituality, although none of these treatments showed evidence of harm. Family therapy focuses on the family and interpersonal relationships, as opposed to other forms of therapy, which are child focused.^5,6 The spirituality intervention was an eight-week online program based on principles of spirituality such as gratitude and forgiveness.⁷ When pharmacotherapy was added to nonpharmacologic therapy, there was a benefit for symptoms and functional status compared with nonpharmacologic therapies alone.¹

Depressive symptoms and function were improved with SSRIs but not serotoninnorepinephrine reuptake inhibitors. Patients taking SSRIs were more likely to withdraw from treatment because of serious adverse events. Paroxetine may be associated with increased suicidal ideation. This was evident only when all studies were included. When the analysis excluded two studies with a high risk of bias, there was insufficient evidence to suggest an increased risk of suicidal ideation. When CBT was added to fluoxetine, depressive symptoms and remission improved compared with fluoxetine alone.¹

Family physicians play a critical role in identifying and treating depressive disorders in children and adolescents. Physicians following the U.S. Preventive Services Task Force recommendation to screen all adolescents from 12 to 18 years of age for major depressive disorder may feel less comfortable managing treatment.⁸ To support physicians, the American Academy of Pediatrics has published guidelines for treating adolescent depression in primary care.² These guidelines recommend considering active support and monitoring for six to eight weeks before beginning treatment and monitoring patients monthly for up to two years after remission because symptom recurrence is common. The guidelines emphasize evidence-based treatments such as CBT and SSRIs.²

Physicians may consider initiating SSRIs for children and adolescents with major depressive disorder. Only fluoxetine and escitalopram are approved by the U.S. Food and Drug Administration for the treatment of depression in this age group.⁹ Options such as CBT or family therapy with or without SSRIs should be considered. Exercise and spirituality may also be incorporated into the treatment of adolescents with depression because they improve symptoms with no known harms.¹

Editor's Note: American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings.