Implementing AHRQ Effective Health Care Reviews
Helping Clinicians Make Better Treatment Choices
Treatment of Depression in Children and Adolescents
Am Fam Physician. 2020 Nov 1;102(9):558-561.
Author disclosure: No relevant financial affiliations.
Key Clinical Issue
What are the benefits and harms of nonpharmacologic and pharmacologic treatments for depressive disorders in children and adolescents?
Evidence-Based Answer
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.)
CLINICAL BOTTOM LINE
Outcomes of Nonpharmacologic Treatments for Depression in Children and Adolescents
| Intervention (duration of treatment) | Population | No. of studies (No. of participants) | Findings | Strength of evidence |
|---|---|---|---|---|
Cognitive behavior therapy vs. wait-list control (8 weeks) | Adolescents with major depressive disorder or dysthymic disorder | 1 RCT (n = 64) | Benefit for depressive symptoms (self-reported) and functional status (clinician-reported) | ●○○ |
Cognitive behavior therapy plus treatment as usual vs. treatment as usual (12 to 16 weeks) | Adolescents with major depressive disorder | 1 RCT (n = 212) | Benefit for depressive symptoms (clinician-reported), weeks to recovery, recovery duration, response, functional status | ●○○ |
Relapse prevention with cognitive behavior therapy plus continued antidepressant medication vs. continued antidepressant medication (30 weeks) | Adolescents and children with major depressive disorder | 1 RCT (n = 121) | Benefit for relapse after 78 weeks | ●○○ |
Family-based interpersonal therapy vs. child-centered therapy (14 weeks) | Children with major depressive disorder, dysthymic disorder, or depressive disorder not otherwise specified | 1 RCT (n = 38) | Benefit for depressive symptoms (clinician-, parent-, and self-reported) | ●○○ |
Family therapy vs. active control (22 weeks) | Adolescents or children with major depressive disorder, dysthymic disorder, or depressive disorder not otherwise specified | 1 RCT (n = 99) | Benefit for response | ●○○ |
Exercise vs. active control (12 weeks) | Adolescents with major depressive disorder | 1 RCT (n = 26) | Benefit for response | ●○○ |
Spirituality vs. wait-list control (8 weeks) | Adolescents with major depressive disorder | 1 RCT (n = 25) | Benefit for depressive symptoms (clinician-reported) | ●○○ |
Strength of evidence scale
●●● High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.
●●○ Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.
●○○ Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
○○○ Insufficient: Evidence either is unavailable or does not permit a conclusion
RCT = randomized controlled trial
Adapted from Viswanathan M, Kennedy SM, McKeeman J, et al. Treatment of depression in children and adolescents: a systematic review. Comparative Effectiveness Review No. 224. (Prepared by the RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center under contract No. 290-2015-00011-I.) AHRQ publication no. 19(20)-EHC024-EF. Rockville, Md.: Agency for Healthcare Research and Quality; April 2020. Accessed May 14, 2020. https://effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_0.pdf
CLINICAL BOTTOM LINE
Outcomes of Nonpharmacologic Treatments for Depression in Children and Adolescents
| Intervention (duration of treatment) | Population | No. of studies (No. of participants) | Findings | Strength of evidence |
|---|---|---|---|---|
Cognitive behavior therapy vs. wait-list control (8 weeks) | Adolescents with major depressive disorder or dysthymic disorder | 1 RCT (n = 64) | Benefit for depressive symptoms (self-reported) and functional status (clinician-reported) | ●○○ |
Cognitive behavior therapy |
References
show all references1. Viswanathan M, Kennedy SM, McKeeman J, et al. Treatment of depression in children and adolescents: a systematic review. Comparative Effectiveness Review No. 224. (Prepared by the RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center under contract No. 290-2015-00011-I.) AHRQ publication no. 19(20)-EHC024-EF. Rockville, Md.: Agency for Healthcare Research and Quality; April 2020. Accessed May 14, 2020. https://effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_0.pdf...
2. Cheung AH, Zuckerbrot RA, Jensen PS, et al.; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics. 2018;141(3):e20174082.
3. Cheung AH, Kozloff N, Sacks D. Pediatric depression: an evidence-based update on treatment interventions. Curr Psychiatry Rep. 2013;15(8):381.
4. U.S. Food and Drug Administration. Suicidality in children and adolescents being treated with antidepressant medications. 2018. Accessed May 14, 2020. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications
5. Dietz LJ, Weinberg RJ, Brent DA, et al. Family-based interpersonal psychotherapy for depressed preadolescents: examining efficacy and potential treatment mechanisms. J Am Acad Child Adolesc Psychiatry. 2015;54(3):191–199.
6. Tompson MC, Sugar CA, Langer DA, et al. A randomized clinical trial comparing family-focused treatment and individual supportive therapy for depression in childhood and early adolescence. J Am Acad Child Adolesc Psychiatry. 2017;56(6):515–523.
7. Rickhi B, Kania-Richmond A, Moritz S, et al. Evaluation of a spirituality informed e-mental health tool as an intervention for major depressive disorder in adolescents and young adults – a randomized controlled pilot trial. BMC Complement Altern Med. 2015;15:450.
8. U.S. Preventive Services Task Force. Depression in children and adolescents: screening. 2016. Accessed May 14, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-in-children-and-adolescents-screening
9. U.S. Food and Drug Administration. Depression medicines. 2019. Accessed May 14, 2020. https://www.fda.gov/consumers/free-publications-women/depression-medicines
The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer and an interpretation that will help guide clinicians in making treatment decisions.
This series is coordinated by Kenny Lin, MD, MPH, deputy editor.
A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.
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