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Depression - Treatment & Management
Overview
The major available treatments for children and adolescents with depressive disorders include medication and psychotherapy. Depression is generally episodic with episodes lasting from months to years. Most episodes are 6 to 12 months in duration, so it is recommended that treatment be continued for at least one year from symptom improvement. The goal of this section is to give a rational and evidence-based overview of widely used treatments.Primary Care Roles
Primary care pediatric providers are often the first line in evaluation AND treatment of depressive disorders. The majority of children and adolescents with depressive disorders can be treated successfully in a primary care setting. Failure to improve with adequate treatment trials is a criterion for consultation with, or referral to, a qualified Child and Adolescent Psychiatrist.Pearls And Alerts
An independent review of available data by the AMA (American Medical Association Report 2005: Safety and Efficacy of Selective Serotonin Reuptake Inhibitors (SSRIs) in Children and Adolescents) indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established. ...Concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” There is also recent data demonstrating a correlation between higher rates of SSRI prescriptions and reduction in child and adolescent suicide rates [Gibbons: 2006]. See the issue Medications for Depressive Disorders for more information.
Practice Guidelines
Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H,
Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry.
2007;46(11):1503-26.
PubMed abstract
Systems
Mental Health/Behavior
Antidepressant medications include selective serotonin re-uptake inhibitors (SSRI), such as fluoxetine, sertraline, paroxetine, citalopram, and escitalopram and non-SSRI antidepressants, such as tricyclic antidepressants (TCA), bupropion, venlafaxine, mirtazapine, and duloxetine. Only fluoxetine has FDA approval for treatment of Major Depressive Disorder in children and adolescents aged 7 to 17 years. Escitalopram recently received FDA approval for treatment of Major Depressive Disorder in adolescents aged 12 to 17 years. Use of all other antidepressants is considered “off label” in children and adolescents.
For more details on specific medications as well as a discussion of antidepressants and suicidal adverse events, see Medications for Depressive Disorders.
General considerations for medication treatment with any antidepressant include: [Boylan: 2007]
- Start at low doses and titrate up over several days as tolerated.
- Patients should have frequent follow up, preferably weekly until dose is stable and medication is tolerated.
- Trial at an adequate dose should go on 2 to 4 weeks before any further dose increase as it may take that long to see any benefit. If three is no beneficial effect after 2 to 4 weeks, dose may be increased.
- Antidepressants work best when taken daily at the same time.
- Most antidepressants with once a day dosing can be taken in the morning or evening based upon patient preference and observed side effects.
- Total trial time should be at least 6 to 8 weeks. A medication trial should not be considered a failure until maximal tolerated dose has been used for this long without improvement.
- Family history of response to particular medication may be used as an approximate guide for medication selection.
- The FDA approval of fluoxetine and escitalopram may make those medications appealing choices for clinicians, however, clinical judgment may lead to the use of other medications.
The other major treatment modality is psychotherapy, which refers to any psychology-based treatment directed by a trained mental health professional and delivered by means of communication or behavioral techniques. Psychotherapy is often referred to as ”counseling“ or “talk therapy.” Several types of psychotherapy exist but the only two with significant research evidence for efficacy in the treatment of depressive disorders in children and adolescents are cognitive behavior therapy (CBT) and interpersonal therapy (IPT). See Treatment of Depressive Disorders in Youth: Psychotherapy for further discussion of the different psychotherapy modalities used in children and adolescents.
Subspecialist Collaborations and Other Resources
Child Psychiatry (see Services below for relevant providers)
May aid in providing and managing treatment and ongoing care. Due to chronic shortages in the US, these subspecialists often primarily see patients with the most severe mental illnesses or those with complicating biological, psychological, or social factors. Consider referral for depression for patients who:
- Have no improvement after 6 to 8 weeks of medications or therapy
- Require more than two psychotropic medications to control symptoms
- Require psychiatric hospitalization
- Have parents with significant emotional impairment or substance use issues
- Have complex psychosocial issues (e.g. history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
- Have family history suggesting adverse reactions to therapy (e.g. planned antidepressant therapy in a patient with family history of bipolar disorder)
- Are young (6 years or under)
- Have chronic medical illness
See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.
Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features.
Child Psychology (see Services below for relevant providers)
A clinical child psychologist will have a PhD or PsyD. Individuals with bachelors or masters degrees in psychology are generally not trained or qualified to diagnose or treat mental illness. All states have licensing requirements for psychologists. Psychologists may be trained in various fields – clinical psychologists or counseling psychologists are the most apt to evaluate or treat depression. Psychologists may perform diagnostic interviewing or specific testing, such as intelligence or personality testing. Psychologists may provide psychotherapy but are not generally trained nor permitted to prescribe medications (although two states, Louisiana and New Mexico, allow clinical psychologists with special training to prescribe some medications). Many psychologists will, however, consult with prescribers, such as physicians, to help coordinate diagnosis and treatment.
Social Work (see Services below for relevant providers)
There are varying levels of academic degrees and fields of expertise in Social Work. All states have specific licensing requirements for social workers. Independently practicing social workers or those working in a hospital or healthcare setting should have a minimum of a master’s degree. Mental Health and Substance Abuse Social Workers are the most apt to be involved in evaluating or treating depression. Social workers may interview for assessment but usually are not qualified to make a formal mental health diagnosis. Social workers may provide psychotherapy and may consult with other specialists to coordinate treatment.
Counseling (see Services below for relevant providers)
Aside from psychologists, and social workers, there are a number of disciplines that may provide psychotherapy. Most often, these counselors hold a masters degree in Clinical Mental Health Counseling, Marriage and Family Therapy, or Substance Abuse and Behavior Counseling. Counselors, like social workers, may do interviewing for assessment purposes but they usually are not qualified to make a formal mental health diagnosis. Most states have specific licensing requirements for governing counselors in practice.
Resources
Information & Support
For Professionals
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, information on brochures (“Facts for Families”), books, videos, practice
parameters, research, and getting help for depression; from the American Academy of Child & Adolescent Psychiatry.
Guidelines for Management of Depressive Disorders, Texas Department of State Health Services
These guidelines reflect the state of knowledge, current at the time of publication, on effective and appropriate care, as
well as clinical consensus judgements when knowledge is lacking. These guidelines (algorithms) do not apply to all patients,
and each must be adapted and tailored to each individual patient. Proper use, adaptation modifications or decisions to disregard
these or other guidelines, in whole or in part, are entirely the responsibility of the clinician who uses the guidelines.
Youth Depression in the Primary Care Setting
Depression in children and adolescents is a debilitating, serious illness with acute and chronic mortality and morbidity which
most often presents in the primary care setting. This presentation by Lisa L. Giles, M.D. will review evidence-based guidelines
for the effective assessment, diagnosis and treatment of youth depressive disorders in the primary care setting.
For Parents and Patients
Support
NAMI Utah
Utah Chapter of the National Alliance on Mental Illness; provides advocacy, and information about mental illnesses.
National Alliance on Mental Illness
Provides information about mental illnesses, links to state chapters, information about conferences, and links to additional
resources.
Practice Guidelines
Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H,
Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry.
2007;46(11):1503-26.
PubMed abstract
The most recent practice parameter on the diagnosis and treatment of depressive disorders in children and adolescents.
Tools
Depression Scale for Children (Bright Futures)
(
37 KB)
free depression screening tool for ages 12-18 (Center for Epidemiologic Studies - Depression Scale for Children); 6th grade
reading level; 20 items; 5-10 minutes to complete.
Beck Depression Inventory-II (Pearson Assessments)
ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete.
Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care)
Designed for primary care practices to help in the diagnosis and management of maternal depression; contains screening tools,
patient handouts, medication information, resources, and references and includes the 9-question Public Health Questionnaire
(PHQ-9). Available for download upon agreement to terms.
Patient Health Questionnaire 9
This is a validated, quick, and free screening tool for depression to be used by primary care providers.
Services
For other services related to this condition, browse our Services categories or search our database.
Page Bibliography
Boylan K, Romero S, Birmaher B.
Psychopharmacologic treatment of pediatric major depressive disorder.
Psychopharmacology (Berl).
2007;191(1):27-38.
PubMed abstract
Gibbons RD, Hur K, Bhaumik DK, Mann JJ.
The relationship between antidepressant prescription rates and rate of early adolescent suicide.
Am J Psychiatry.
2006;163(11):1898-904.
PubMed abstract
March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents
With Depression Study (TADS) randomized controlled trial.
JAMA.
2004;292(7):807-20.
PubMed abstract