Effects of psychotherapy for depression in children and adolescents: a meta-analysis

Evidence-based psychosocial treatments for child and adolescent depression

The evidence-base of psychosocial treatment outcome studies for depressed youth conducted since 1998 is examined. All studies for depressed children meet Nathan and Gorman's (2002) criteria for Type 2 studies whereas the adolescent protocols meet criteria for both Type 1 and Type 2 studies. Based on the Task Force on the Promotion and Dissemination of Psychological Procedures guidelines, the cognitive-behavioral therapy (CBT) based specific programs of Penn Prevention Program, Self-Control Therapy, and Coping with Depression-Adolescent are probably efficacious. Interpersonal Therapy-Adolescent, which falls under the theoretical category of interpersonal therapy (IPT), also is a probably efficacious treatment. CBT provided through the modalities of child group only and child group plus parent components are well-established intervention approaches for depressed children. For adolescents, two modalities are well-established (CBT adolescent only group, IPT individual), and three are probably efficacious (CBT adolescent group plus parent component, CBT individual, CBT individual plus parent/family component). From the broad theoretical level, CBT has well-established efficacy and behavior therapy meets criteria for a probably efficacious intervention for childhood depression. For adolescent depression, both CBT and IPT have well-established efficacy. Future research directions and best practices are offered.

Family-based interpersonal psychotherapy for depressed preadolescents: an open-treatment trial

AIM

To conduct an open-treatment trial to evaluate the feasibility, acceptability and clinical outcomes of using a family-based adaptation of Interpersonal Psychotherapy for Depressed Adolescents with a sample of preadolescents (ages 9-12) presenting for outpatient treatment for depression.

METHODS

Sixteen preadolescents who met criteria for a depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition participated in this open-treatment trial of family-based interpersonal psychotherapy (FB-IPT). Parents chose whether their preadolescents should receive FB-IPT only (n = 10) or FB-IPT with antidepressant medication (n = 6). Pre- and post-treatment assessments included clinician-administered measures of depression and global functioning, and parent- and child-reported anxiety symptoms.

RESULTS

FB-IPT was associated with high treatment compliance rates (88%) and was associated with significant decreases in preadolescents' depressive and anxiety symptoms. Preadolescents who received FB-IPT only were as likely as those receiving FB-IPT and medication to have significant reductions in depressive symptoms and anxiety symptoms, and to experience significant improvement in global functioning. Parents were more likely to choose combination treatment when their depressed preadolescents had a comorbid anxiety disorder.

CONCLUSIONS

Further research on FB-IPT is needed to establish its efficacy as compared with usual outpatient treatment, its ability to be disseminated to child clinicians with varying levels of training and in adequately powered randomized controlled trials that can detect group differences.

Modifications à la psychothérapie focalisée sur le transfert (PFT) pour le traitement des adolescents avec une identité diffuse

Cet article présente une version modifiée de la psychothérapie focalisée sur le transfert (PFT) appliquée aux adolescents démontrant une identité diffuse. Cette méthode a déjà démontré son efficacité auprès d’adultes souffrant d’importants problèmes de diffusion de l’identité. Nous signalons l’importance de distinguer la crise identitaire normale à l’adolescence de la diffusion de l’identité, afin de bien repérer les adolescents qui pourraient bénéficier de ce traitement. Les principales modifications apportées à la PFT pour s’adapter aux adolescents impliquent divers changements : des changements quant à la fréquence et à la durée de certaines techniques particulières (par exemple une clarification accrue ; une plus grande attention aux relations extra-transférentielles avant d’aborder directement le transfert), des changements quant aux tactiques (par exemple l’inclusion de la famille à l’étape de l’évaluation et dans le contrat qui établit les phases de traitement, l’inclusion d’interventions de soutien dans le milieu tout en gardant la position analytique au cours des séances), des changements quant aux stratégies (par exemple tenter de lever les blocages qui nuisent au développement normal de l’intégration de l’identité, plutôt que de « forcer la maturation »). Le traitement vise à améliorer les relations de l’adolescent avec ses amis, ses parents et ses professeurs ; à clarifier ses objectifs dans la vie ; à acquérir une estime de lui-même et à être mieux préparé à s’investir dans les relations amoureuses.

Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency

The present study examined possible predictors of youth client retention in therapy in a large community-based sample. We used several conceptualizations of retention, including (a) "intake retention" (i.e., returned to treatment after intake session); (b) "mutual termination" (i.e., termination agreed upon by family and therapist), (c) "mean treatment duration" (i.e., completing the mean number of sessions in the agency), and (d) "total treatment duration" (i.e., total number of sessions). Archival data from over 400 children and adolescents who sought treatment at a large public mental health clinic were analyzed using regression analyses. Although different predictors were identified across the various conceptualizations, a few robust predictors emerged including ethnicity and client symptom severity. Clinical implications and future research directions are discussed.

Evidence-Based Psychotherapy for Children and Adolescents: Data from the Present and a Model for the Future

What is the best way to help children cope with behavioural and emotional problems? This question has been a focus of concern - to children and the adults who care for them - across many centuries and in cultures around the world. In this article we examine the current state of efforts to help children by means of an array of non-medical interventions designed to alleviate psychological distress, reduce maladaptive behaviour, and/or increase adaptive behaviour. We refer to these interventions, collectively, as 'psychotherapy'. In the article, we will note some accomplishments of the effort to develop effective interventions through clinical research. Then we will note some concerns about these efforts, and suggest ways to address the concerns through an alternate model of intervention development and testing.

Disorder-specific effects of CBT for anxious and depressed youth: a meta-analysis of candidate mediators of change

The commonalities between anxiety and depression have been discussed before, but few have delineated the potentially different mechanisms through which treatments work for these populations. The current study conducted a comprehensive review of child and adolescent randomized clinical trials that tested cognitive-behavioral therapy (CBT) for anxiety or depression. All studies were required to have assessed both treatment outcomes and at least one theory-specific process target, including behavioral, physiological, cognitive, and coping variables. Using a meta-analytic approach, CBT demonstrated positive treatment gains across anxiety, depression, and general functioning outcomes. CBT for anxiety also produced moderate to large effects across behavioral, physiological, cognitive, and coping processes, with behavioral targets demonstrating potentially the greatest change. CBT for depression produced small effects for cognitive processes but nonsignificant effects for behavioral and coping variables. Findings were generally consistent with CB theory but suggest potentially different mediators in the treatment of anxiety and depression. Results are discussed in terms of implications for mechanisms research, theories of change, and treatment development.

Psychiatric diagnosis - is it universal or relative to culture?

BACKGROUND

There is little consensus on the extent to which psychiatric disorders or syndromes are universal or the extent to which they differ on their core definitions and constellation of symptoms as a result of cultural or contextual factors. This controversy continues due to the lack of biological markers, imprecise measurement and the lack of a gold standard for validating most psychiatric conditions.

METHOD

Empirical studies were used to present evidence in favor of or against a universalist or relativistic view of child psychiatric disorders using a model developed by Robins and Guze to determine the validity of psychiatric disorders.

RESULTS

The prevalence of some of the most common specific disorders and syndromes as well as its risk and protective factors vary across cultures, yet comorbid patterns and response to treatments vary little across cultures. Cross-cultural longitudinal data on outcomes is equivocal.

CONCLUSIONS

The cross-cultural validity of child disorders may vary drastically depending on the disorder, but empirical evidence that attests for the cross-cultural validity of diagnostic criteria for each child disorder is lacking. There is a need for studies that investigate the extent to which gene-environment interactions are related to specific disorders across cultures. Clinicians are urged to consider culture and context in determining the way in which children's psychopathology may be manifested independent of their views. Recommendations for the upcoming classificatory system are provided so that practical or theoretical considerations are addressed about how culture and ethnic issues affect the assessment or treatment of specific disorders in children.

Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial

CONTEXT

Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy.

OBJECTIVE

To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006.

INTERVENTIONS

Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy.

MAIN OUTCOME MEASURES

Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Children's Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time.

RESULTS

Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment.

CONCLUSIONS

For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00018902.

Screening of depression in adolescents through the Internet : sensitivity and specificity of two screening questionnaires

The Internet may offer new opportunities for treating depressed adolescents. However, before such treatments are possible, well-validated screening instruments are needed. In the current study, we validate two Internet-based screening instruments for depression among adolescents, the major depression inventory (MDI), and the Center for Epidemiological Studies-Depression scale (CES-D). A total of 1,392 adolescents, recruited through high schools and the Internet, filled in the online questionnaires. Of these, 243 (17%) were interviewed with the MINI diagnostic interview to assess the presence of a mood disorder. Cronbach's alpha was high for both the CES-D (0.93) and the MDI (0.88), and both correlated highly with each other (0.88; P < .001). The scores on both instruments were significantly increased in all subjects with a mood disorder, whether current or lifetime, except for lifetime minor depression. In the ROC analyses, high areas under the curve were found for the MDI (0.89) and CES-D (0.90). The best cut-off point for the MDI was 19 (sensitivity: 90.48; specificity: 71.53), and for the CES-D it was 22 (sensitivity: 90.48; specificity: 74.31). We conclude that the MDI and CES-D are reliable and valid instruments that can be used for this screening.

The effects of cognitive-behavioural therapy on mood-related ruminative response style in depressed adolescents

BACKGROUND

A mood-related ruminative response style increases the risk of onset and persistence of depression. This preliminary study investigated whether, in depressed adolescents, cognitive-behaviour therapy reduces mood-related ruminative response style. Whether specific factors within the rumination scale were differentially affected by CBT is also reported.

METHODS

26 depressed adolescents were randomised to receiving serotonin-specific reuptake inhibitor antidepressants (SSRI) plus psychosocial treatment as usual or SSRI and psychosocial treatment as usual plus CBT. Ruminative response style and depressive symptoms were measured at baseline and after 30 weeks of treatment, with the Responses to Depression Questionnaire and Mood and Feelings Questionnaire.

RESULTS

There were significantly greater reductions in ruminations in the CBT group compared to the non-CBT group (p = .002). There was no significant difference in the reduction in self-reported depressive symptoms between the groups. Rumination was reduced to levels of never-depressed controls in adolescents who had recovered from depression and received CBT. There were greater falls in the CBT group in the more pathological 'brooding' factor of rumination.

CONCLUSION

These findings suggest that adding CBT to SSRI medication in the presence of active clinical care causes a greater reduction in mood-related ruminative response style in depressed adolescents. This may reduce the risk of future relapse.

TRIAL REGISTRATION

Current Controlled Trials ISRCNT83809224.

Depression in children

PURPOSE OF REVIEW

This summary of literature published during the past year focuses on research into factors that may contribute to development of childhood-onset depression and on appropriate assessment and treatment.

RECENT FINDINGS

The recent literature suggests that investigating risk factors and gene-environment interactions could be fruitful in elucidating the aetiology of childhood-onset depression and could have implications for developing preventive (selective or targeted programmes) and therapeutic strategies. These strategies clearly should involve interventions to improve parent-child relationships and parenting style, especially in children at high risk early in their lives. Cognitive-behavioural therapy, interpersonal therapy and (in the case of severe depression) selective serotonin reuptake inhibitor medications (fluoxetine as the first-line option, with close monitoring for adverse effects during treatment) appear to be effective in the management of depression in children. However, recent reports on psychotherapies yield a less clear picture about their effectiveness in childhood depression than was previously indicated.

SUMMARY

Controlled trial data and evidence-based guidelines for management of depressed children are limited with respect to pharmacological and psychotherapeutic options, especially in prepubertal and preschool children. Further research in this area is therefore warranted.

Depression in young people: description, assessment and evidence-based treatment

OBJECTIVE

The literature on depression in children and adolescents was reviewed to provide an update for clinicians.

REVIEW PROCESS

Literature of particular relevance to evidence-based practice was selected for critical review. Meta-analyses and controlled trials were prioritized for review along with key assessment instruments.

OUTCOMES

An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was provided.

CONCLUSIONS

Depression in children and adolescence is a relatively common, multifactorially determined and recurring problem which often persists into adulthood. Psychometrically robust screening questionnaires and structured interviews facilitate reliable assessment. There is growing evidence for the effectiveness of cognitive behaviour therapy, psychodynamic therapy, interpersonal therapy and family therapy in the treatment of paediatric depression. There is also evidence that SSRIs may be particularly effective for severe depression, although they may carry the risk of increased suicidality.

Depressive symptoms and SSRI use in pediatric oncology patients

This review of depressive symptoms in pediatric cancer patients describes the challenge of recognizing depression in this group, prevalence, risk factors, and treatment, primarily with the selective serotonin reuptake inhibitors (SSRIs). Pediatric oncologists prescribe SSRIs, but there is limited data regarding their use in this setting. Adverse effects, pharmacokinetics and metabolism of SSRIs are reviewed to provide a reference for physicians and inform choices for SSRI prescription. Ongoing research includes incorporation of routine screening measures for depression and future studies might focus on physician recognition and prospectively evaluating treatment for children with cancer and depressive symptoms.

Comorbid adolescent substance use and major depressive disorders: a review

Psychiatric comorbidity is the rule rather than the exception in adolescents diagnosed with substance use disorders (SUD). The aim of this evidence-based review is to enhance practitioners' understanding of the relationship between the commonly concomitant SUD and comorbid unipolar depression as well as increase the knowledge of treatment of adolescents with these comorbid disorders.

Bias in Meta-Analytic Estimates of the Absolute Efficacy of Psychotherapy

Meta-analytic estimates of the absolute efficacy of psychotherapy indicate an effect size of approximately 0.80. However, various biases in primary and meta-analytic studies may have influenced this estimate. This study examines 4 nonsystematic biases that increase error variance (i.e., nonrandomized designs, methodological deficiencies, failure to use the study as the unit of analysis, and violations of homogeneity), 4 underestimation biases that primarily concern psychometric issues (i.e., unreliability of outcome measures, failure to report nonsignificant effect sizes, nonoptimal composite outcome measures, and nonstandardized outcome measures), and 8 overestimation biases (i.e., excluding nonsignificant effects from calculations of effect size estimates, failure to adjust for small sample bias, failure to separate studies using single-group pre–post designs vs. control group designs, using unweighted average effect sizes, analyzing biased partial samples that reflect treatment dropout and research attrition, researcher allegiance bias, publication bias, and wait-list control group bias). Wherever possible, evidence regarding the magnitude of these biases is presented, and methods for addressing these biases separately and collectively are discussed. Implications of the meta-analytic evidence on psychotherapy for the effect sizes of other psychological interventions are also considered.

Cognitive-behavioral therapy for adolescent depression: a meta-analytic investigation of changes in effect-size estimates

OBJECTIVE

To explicate differences between early and recent meta-analytic estimates of the effects of cognitive-behavioral therapy (CBT) for adolescent depression.

METHOD

Meta-analytic procedures were used to investigate whether methodological characteristics moderated mean effect sizes among 11 randomized, controlled trials of CBT focusing on adolescents meeting diagnostic criteria for unipolar depression.

RESULTS

Cumulative meta-analyses indicated that effects of CBT have decreased from large effects in early trials, and confidence intervals have become narrower. Effect sizes were significantly smaller among studies that used intent-to-treat analytic strategies, compared CBT to active treatments, were conducted in clinical settings, and featured greater methodological rigor based on CONSORT (Consolidated Standards of Reporting Trials) criteria. The mean posttreatment effect size of 0.53 was statistically significant.

CONCLUSIONS

Differences in estimates of the efficacy of CBT for depressed adolescents may stem from methodological differences between early and more recent investigations. Overall, results support the effectiveness of CBT for the treatment of adolescent depression.

Depressive Störungen im Kindes- und Jugendalter - Eine Übersicht

Zusammenfassung: Depressive Störungen im Kindes- und Jugendalter sind ein ernstzunehmendes Gesundheitsrisiko, das eine große Anzahl von Komplikationen und Spätfolgen haben kann. Eine Literaturrecherche in PubMed, Psycontent und Psyndex gibt die gegenwärtige Datenlage wieder und die Ergebnisse werden kritisch diskutiert. Auffällig war die geringe Anzahl an Studien für Kinder und die wenige Beachtung möglicher geschlechterbezogener Unterschiede. Nicht nur im Bezug auf die Epidemiologie, Erkrankungsdauer, Symptomatik, Komorbidität, Entwicklungspsychopathologie werden weitere Untersuchungen notwendig sein, sondern gerade bezüglich einer adäquaten Pharmako- und Psychotherapie sind unumgänglich, um auf die Prognose, Progredienz und Persistenz der Erkrankung erfolgreich Einfluß nehmen zu können.

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders

This practice parameter describes the epidemiology, clinical picture, differential diagnosis, course, risk factors, and pharmacological and psychotherapy treatments of children and adolescents with major depressive or dysthymic disorders. Side effects of the antidepressants, particularly the risk of suicidal ideation and behaviors are discussed. Recommendations regarding the assessment and the acute, continuation, and maintenance treatment of these disorders are based on the existent scientific evidence as well as the current clinical practice.

Depression and anxiety in children at the end of life

A significant component of palliative care is the prompt diagnosis and management of distress, anxiety, and depression. This article reviews the symptoms and treatment of anxiety and depressive disorders in children at the end of life. Distinguishing between symptoms and disorders, the importance of open communication, consideration of the child's understanding of death, diagnostic challenges in chronically ill children, and suicidality are discussed. Because treatment options are available, it is imperative that symptoms are recognized and addressed. Understanding the issues involved in screening and diagnosis and the risks and benefits of available treatments can lead to an informed approach to the management of these disorders in the palliative care setting.

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression

OBJECTIVE

To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis.

METHOD

Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children.

RESULTS

The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group.

CONCLUSIONS

Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI.

CLINICAL TRIAL REGISTRATION INFORMATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

A psychometric evaluation of the CDRS and MADRS in assessing depressive symptoms in children

OBJECTIVE

This study compared the psychometric properties of the Children's Depression Rating Scale-Revised (CDRS-R) and the Montgomery-Asberg Depression Rating Scale (MADRS) in children with major depressive disorder.

METHOD

Children (N = 96; ages 8 to 11 years inclusive) with nonpsychotic major depressive disorder were enrolled. Participants were part of a multisite, outpatient, randomized, placebo-controlled, 9-week trial of fluoxetine (10 mg/day for the first week and 20 mg/day thereafter). The CDRS-R and MADRS were completed based on clinician interviews with both parents and children. Classic test theory and item response theory analyses were conducted.

RESULTS

The MADRS and CDRS-R total scores were correlated at baseline (r = 0.51) and at study exit (r = 0.85). Cronbach's alpha was .86 (CDRS-R) and .82 (MADRS) at exit. The effect sizes for change from baseline to exit between the fluoxetine and placebo groups were 0.78 (CDRS-R) and 0.61 (MADRS). There was agreement between the CDRS-R and MADRS in the declaration of treatment response (50% improvement from baseline to exit) in 84.2% of children. Test information function favored the CDRS-R.

CONCLUSIONS

The CDRS-R showed greater effect size for differentiating drug and placebo and better test information than the MADRS in this study of depressed children.

Psychotherapy for depression among children and adolescents: a systematic review

OBJECTIVE

To examine the clinical benefit, the harm and the cost-effectiveness of psychotherapies in comparison with no treatment, waiting-list controls, attention-placebos, and treatment as usual in depressed youths.

METHOD

Meta-analyses were undertaken by using data from all relevant randomized-controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

RESULTS

We identified 27 studies containing 35 comparisons and 1,744 participants. At post-treatment, psychotherapy was significantly superior (RR = 1.39, 95% CI 1.18-1.65, P = 0.0001, number-needed to treat 4.3). There was an evidence of the existence of small study effects, including a publication bias (P < 0.001). The superiority of psychotherapy was no longer statistically significant (1.18 [0.94-1.47], P = 0.15) at 6-month follow-up. None of the studies reported adverse effects or cost-effectiveness outcomes.

CONCLUSION

Although the findings were biased by some small positive trials, psychotherapies appear to help depressed youths for the short term, but are no longer significantly favourable at 6-month follow-up.

Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents

BACKGROUND

Depressive disorders are common in young people and are associated with significant negative impacts. Selective serotonin reuptake inhibitors (SSRIs) are often used, however, evidence of their effectiveness in children and adolescents is not clear. Furthermore, there have been warnings against their use in this population due to concerns about increased risk of suicidal ideation and behaviour.

OBJECTIVES

To determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of SSRIs compared to placebo in the treatment of depressive disorders in children and adolescents.

SEARCH STRATEGY

We searched the CCDAN Trials Register, MEDLINE, PSYCHINFO and CENTRAL. Reference lists were checked, letters were sent to key researchers and internet databases searched.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two or three review authors selected the trials, assessed the quality and extracted trial and outcome data. We used a fixed-effect meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference to summarise continuous measures.

MAIN RESULTS

Twelve trials were eligible for inclusion, with ten providing usable data. At 8-12 weeks, there was evidence that children and adolescents 'responded' to treatment with SSRIs (RR 1.28, 95% CI 1.17 to 1.41). There was also evidence of an increased risk of suicidal ideation and behaviour for those prescribed SSRIs (RR 1.80, 95% CI 1.19 to 2.72). Fluoxetine was the only SSRI where there was consistent evidence from three trials that it was effective in reducing depression symptoms in both children and adolescents (CDRS-R treatment effect -5.63, 95% CI -7.38 to -3.88), and 'response' to treatment (RR 1.86, 95% CI 1.49 to 2.32). Where rates of adverse events were reported, this was higher for those prescribed SSRIs.

AUTHORS' CONCLUSIONS

Caution is required to interpret the results. First, there were methodological issues, including high attrition, issues regarding measurement instruments and clinical usefulness of outcomes, often variously defined across trials. Second, patients seen in clinical practice are likely to be more unwell, and at greater risk of suicide, compared to those in the trials, and it is unclear how this group would respond to SSRIs. This needs to be considered, along with the evidence of an increased risk of suicide related outcomes in those treated with SSRIs. It is unclear what the effect of SSRIs is on suicide completion. While untreated depression is associated with the risk of completed suicide and impacts on functioning, it is unclear whether SSRIs would modify this risk in a clinically meaningful way.

Effects of psychotherapy for depression in children and adolescents: what we can (and can't) learn from meta-analysis and component profiling

In this column, we comment on the state of the science regarding psychotherapy for youths (including children and adolescents) with depression. We begin by discussing our recent meta-analysis of the youth depression clinical trials literature to illustrate how meta-analysis can be of use to clinicians. We consider how to interpret measures of effect size, introduce some cautionary notes, and discuss the Treatment of Adolescent Depression Study (TADS; TADS Team, 2004 ) as an example of factors that may contribute to effect size. Then, using a component profile, we describe the techniques most often used in the most successful treatments for youth depression. When combined, we suggest, meta-analysis and component profiling can shed light on the magnitude of treatment benefit and on the treatment techniques associated with that benefit.

[Depression in children and adolescents: prevalence, diagnosis, etiology, gender differences and therapeutic approaches]

Prevalence rates of the different forms of depression (depressive mood, depressive syndromes and Major Depression) have increased during recent years. Similarily, gender differences have augmented. Stress, dysfunctional coping styles, a negative body image, and an insecure attachment style have been identified as factors contributing to the etiology of depression. Different therapeutic approaches were presented with psychonanalytic treatment being the most comprehensive.

Examining the association between parenting and childhood depression: a meta-analysis

Theoretical models posit that parenting plays a causal role in the development and maintenance of child psychological problems, yet meta-analytic findings indicate that parenting accounts for less than 6% of the variance in child externalizing problems and less than 4% of the variance in childhood anxiety. Extending the analysis to childhood depression, we conducted a meta-analysis of 45 studies testing the association between parenting and childhood depression. We found that parenting accounted for 8% of the variance in child depression. Parental rejection was more strongly related to childhood depression than was parental control. Moreover, various subdimensions of parenting were differentially associated with childhood depression, with parental hostility toward the child most strongly related to child depression. Analyses also revealed that methodological factors (i.e., how parenting and child depression was conceptualized and assessed) moderated the parenting-childhood depression association. Inconsistent findings within the literature are partially attributable to variations from study to study in measurement quality. Closer attention to the precise measurement of these two constructs in future studies may lead to a more accurate estimate of the association between parenting and child depression. In all, the modest association between parenting and childhood depression indicates that factors other than parenting may account for the preponderance of variance in childhood depression.

Psychopharmacologic treatment of pediatric major depressive disorder

RATIONALE

The role of pharmacotherapy in the treatment of major depressive disorder (MDD) in youth has received much attention in recent years due to concerns of efficacy and safety of the antidepressants for the treatment of MDD in youth.

OBJECTIVES

This review describes the existing published and unpublished literature regarding the efficacy and short-term safety of the antidepressants and decision-making process required for the use of these medications for youth with MDD. In addition, current continuation and maintenance treatments are discussed.

RESULTS

In general, nine depressed youth must be treated with an antidepressant to obtain one clinical response above that achieved with placebo. To date, fluoxetine has showed the most consistent positive treatment effects. Depressed youth had also acutely responded to other antidepressants, but the response to placebo has also been high. Overall, the antidepressants are well tolerated, but 1-3 children and adolescents of 100 taking antidepressants showed onset or worsening of suicidal ideation and, more rarely, suicide attempts.

CONCLUSIONS

There is a positive risk-benefit ratio for the use of antidepressants in the acute treatment of depressed youth. First-line antidepressant treatment with-or without-specific types of psychotherapy is indicated for youth with MDD of at least moderate severity. All youth taking antidepressants must be closely monitored for suicidality and medication side effects. Many youth will likely require psychotherapy or additional medication treatments to address comorbid disorders. Treatments to prevent relapses and recurrences require further study.

Psychosocial treatment of depression and suicidality in adolescents

Depression is a common disorder among adolescents and is associated with a high risk of suicide. Suicide is the third leading cause of death among adolescents in the United States. Currently, there are only two evidence-based psychotherapies for adolescence depression: cognitive-behavioral therapy and interpersonal psychotherapy. Furthermore, psychosocial interventions that specifically target suicidal behavior in adolescents are even fewer in number than treatments for depression. This article will review the psychosocial interventions for depression and suicidality in adolescents and will describe a recently developed treatment that is under study for depressed suicidal adolescents.

The Treatment for Adolescents with Depression Study (TADS): methods and message at 12 weeks

Funded by the National Institute of Mental Health, the Treatment for Adolescents With Depression Study (TADS) is intended to evaluate the short-term (12 weeks) and longer-term (36 weeks) effectiveness of four treatments for adolescents with DSM-IV major depressive disorder: clinical management with fluoxetine (FLX), cognitive-behavioral therapy (CBT), FLX and CBT combined (COMB), and clinical management with placebo (PBO). We previously reported that COMB and FLX were more effective in reducing depression than CBT or PBO after 12 weeks of acute treatment. In this special section of the Journal, separate articles extend these findings to the impact of TADS treatments on remission, speed of response, function and quality of life, predictors of outcome, and safety during the first 12 weeks of treatment. To set the stage for the special section, we briefly review the rationale, design, and methods of the TADS; describe the TADS sample to which the TADS findings generalize; using all of the currently available data, summarize the intent-to-treat outcomes across multiple endpoints at 12 weeks; and consider the public health value of the TADS findings in the context of design decisions and methodological limitations of the TADS, including some that may have advantaged the combined treatment condition. Reflecting the ordering of effect sizes at week 12--COMB (0.98) > FLX (0.68) > CBT (-0.03)--combined treatment proved superior to PBO on 15 of 16 endpoints, to CBT on 14 of 16 endpoints, and to FLX on 8 of 16 endpoints, whereas FLX was superior to CBT on 8 of 14 and to PBO on 7 of 16 measures. CBT did not differ from PBO on any measure. Despite the fact that suicidality improved markedly across all of the treatment conditions, suicidal events were twice as common in patients treated with FLX alone than with COMB or CBT alone, perhaps indicating that CBT protects against suicidal events. Thus, combined treatment appears to accelerate recovery relative to CBT and, for some outcomes, FLX alone, while minimizing the risk of suicidality relative to FLX alone. Taking benefit and risk into account, we conclude that the combination of FLX and CBT appears superior to either monotherapy as a treatment for moderate to severe major depressive disorder in adolescents.

Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials

BACKGROUND

Older meta-analyses of the effects of psychological treatments for depression in older adults have found that these treatments have large effects. However, these earlier meta-analyses also included non-randomized studies, and did not include newer high-quality randomized controlled trials.

METHODS

We conducted a meta-analysis of randomized studies on psychological treatments for depression in older adults.

RESULTS

Twenty-five studies were included, of which 17 compared a psychological intervention to a control condition (mainly waiting list and care-as-usual control groups). The quality of the included studies varied. Psychological treatments have moderate to large effects on depression in older adults (standardized mean effect size d = 0.72). Heterogeneity was very low. No differences were found between individual, group or bibliotherapy format, or between cognitive behavioral therapy and other types of psychological treatment. The effects were comparable in studies where depression was defined according to diagnostic criteria, and those in which depression was measured with self-rating questionnaires.

CONCLUSION

Although the quality of many studies was not optimal, the results of this meta-analysis support the results of earlier meta-analyses, which also included non-randomized studies. Psychological treatments are effective in the treatment of depression in older adults.

Effectiveness of complementary and self‐help treatments for depression in children and adolescents

OBJECTIVE

To review the evidence for the effectiveness of complementary and self-help treatments for depression in children and adolescents.

DATA SOURCES

Systematic literature search using PubMed, PsycINFO and the Cochrane Library for 131 treatments up to February 2006.

STUDY SELECTION

There were 13 treatments that had been evaluated in intervention studies.

DATA EXTRACTION

Studies on each treatment were reviewed by one author and checked by a second. A consensus was reached for level of evidence.

DATA SYNTHESIS

Relevant evidence was available for glutamine, S-adenosylmethionine, St John's wort, vitamin C, omega-3 fatty acids, light therapy, massage, art therapy, bibliotherapy, distraction techniques, exercise, relaxation therapy and sleep deprivation. However, the evidence was limited and generally of poor quality. The only treatment with reasonable supporting evidence was light therapy for winter depression.

CONCLUSIONS

Given that antidepressant medication is not recommended as a first line treatment for children and adolescents with mild to moderate depression, and that the effects of psychological treatments are modest, there is a pressing need to extend the range of treatments available for this age group.

Treatment-resistant depression in adolescents: recognition and management

Approximately 20% of adolescents experience at least one depressive episode by the time they enter their adult years. For most adolescents, depression, although serious, either remits spontaneously or responds to treatment. For a smaller but significant proportion of adolescents, however, depression can be long-lasting and relatively unresponsive to initial treatment. In this article the authors provide an operational definition of treatment-resistant depression, identify factors associated with treatment nonresponse, describe an approach to the management of treatment-resistant depression, and advance suggestions for promising avenues of research.

Cognitive behavioral therapy for depression in youth

Without question, cognitive behavioral therapy (CBT) is the most studied non-pharmacological intervention for the treatment of depression in youth, with over 80% of published psychotherapy trials testing the effects of CBT protocols. Until quite recently, CBT also was widely proclaimed to be a highly effective intervention for youth depression, albeit with stronger data for adolescent than for child samples. However, within the past two years, a series of new findings have complicated this previously rosy picture of CBT. The most well-known results come from the Treatment of Adolescents with Depression Study (TADS, 2004). In the TADS investigation, CBT failed to outperform a pill placebo, while active medication treatments (fluoxetine alone and fluoxetine-plus-CBT) produced strong and consistent effects. In this article, the authors strive to make sense of these seemingly conflicting findings, provide direction for the appropriate use of CBT in practice given the current evidence base, and suggest areas of additional investigation that may help to clarify the current confusion on the effects of CBT.