Childhood and adolescent depression: a review of the past 10 years. Part II

How effective are treatments for child and adolescent depression? A meta-analytic review

We located a comprehensive sample of studies (1980-1999) on the psychosocial and pharmacological treatment of child and adolescent depression through an extensive literature search. Articles that met the inclusionary criteria were subsequently analyzed. The outcome data from 38 studies were extracted and converted into effect sizes (ESs). Comparisons of main effects, demographic, and quality of study variables were conducted. The overall findings of this meta-analysis indicate that several different psychosocial interventions for child and adolescent depression produced moderate to large treatment gains that were clinically meaningful for many afflicted youth. However, in general, the vast majority of pharmacological interventions were not effective in treating depressed children and adolescents. Nonetheless, there is recent evidence that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are efficacious, and will likely play an increased role in the management of affective illness in youngsters. The clinical implications and limitations of these data are discussed and suggestions for future research are provided.

Child psychiatric skills in primary healthcare--self-evaluation of Finnish health centre doctors

OBJECTIVE

To study Finnish general practitioners' (GP's) perceptions of their child psychiatric skills.

METHODS

The study sample consisted of physicians (n=755) working in health centres situated in the special response area of the Tampere University Hospital, Finland. They were requested to assess their competence in 16 areas on a four-step Likert scale. The response rate was 66.1% (n=499).

RESULTS

Physicians evaluated their child psychiatric skills as inadequate on many issues. The ability to identify depression was poorer the younger the child in question. Only a minority (14%) felt they were well able to identify a depressed infant. Many physicians considered themselves poorly skilled in assessing the relationship between infant and parents (39.8%), in assessing a child's need for psychiatric treatment (42.7%) and in identifying a child with attention-deficit disorder (40.7%). A majority (75.9%) rated their skills poor in co-operating with daycare personnel or school staff in matters concerning a child with conduct disturbance. Only 26.8% could assess the necessity of taking a child into custody. Women gave higher ratings of their skills in identifying depressed infants and in assessing the infant-parent relationship than men, whereas men assessed their skills as better in cases in which there were problems in co-operation with parents.

CONCLUSIONS

In order to provide good psychiatric services for children, attention should be paid to the GPs' child psychiatric skills.

Developmental factors in the treatment of adolescents

Most empirically supported interventions for adolescent mental health problems are either downward adaptations of adult treatments or upward adaptations of child treatments. Although these treatments show respectable effects with teens, a review of the outcome research reveals significant gaps. both in coverage of adolescent conditions and problems (e.g., eating disorders, suicidality) and in attention to the biological, psychological, and social dimensions of adolescent development. The authors critique the field, propose a biopsychosocial framework for the development of dysfunction and intervention, and discuss ways the developmental literature can and cannot inform intervention and research. A long-term goal is an array of developmentally tailored treatments that are effective with clinically referred teens and an enriched understanding of when, how, and why the treatments work.

Management of Depression in Children and Adolescents

Depression is increasingly recognized as an illness that causes functional impairment and diminished quality of life for all age groups, including children. One to two percent of children and between 4% and 8% of adolescents meet Diagnostic Statistical Manual of Mental Disorders(4th ed.) (DSM-IV-TR) criteria for major depression. Psychotherapy, particularly cognitive-behavioral therapy, is effective, with 70% response rates. Antidepressants are effective according to limited controlled trials; however, concern exists over the gap between research and clinical practice, as most antidepressants are not well-studied in youth. Nevertheless, pharmacotherapy has gained greater acceptance in pediatric psychiatry, and prescriptions for antidepressants in youth have increased dramatically over the past 5 to 10 years. In 1995, 1.08 million selective serotonin reuptake inhibitor prescriptions were written for children and adolescents. Scientific evidence for the safety and effectiveness of antidepressants in youth is reviewed along with data on nondrug interventions such as cognitive-behavioral therapy. Recommendations for promoting the safe and effective management of depression in children and adolescents is provided.

Diagnosing pediatric depression

This review examines current instrumentation for making clinical and research diagnoses of depressive disorders in children and adolescents. Reliable assessment of depression in children requires gathering information from both the parent and child, as well as from all other available information. The methodology for obtaining information from the child must be adapted to reword and better obtain information in those domains that are inherently difficult for children, including questions about internal affect state and questions requiring judgment. Because child depression is highly comorbid with other psychiatric disorders, including anxiety, attention-deficit/hyperactivity disorder (ADHD), and conduct disorder (CD), it is imperative that these and other psychiatric disorders be simultaneously assessed. A number of structured and semistructured instruments address this task well. More work is needed to decrease the time burden and cost of reliable assessment of child depression.

Specific psychotherapies for childhood and adolescent depression

Specific psychotherapies for childhood or adolescent depression have been tested against control or comparative conditions. In school-age children with elevated depressive symptoms, cognitive behavioral therapies (CBT) administered in school settings have proven superior to no treatment or to waiting-list controls in almost all studies. One child study suggests that CBT is superior to alternative psychosocial intervention during acute treatment but not at longer term follow-up. No one type of CBT for children has proven more efficacious than others. Studies with adolescents have included subjects with diagnosed depressive disorders, primarily major depression. Seven of nine efficacy studies indicate that CBT is more efficacious than a waiting-list condition or than a non-CBT alternative psychotherapy at the end of acute intervention. Longer term follow-up indicates high rates of remission or recovery among depressed adolescents and no superiority of CBT over other psychotherapies in this regard; however, CBT is associated with more rapid remission of symptoms than is family or supportive therapy. Interpersonal psychotherapy has been demonstrated to be more efficacious than a waiting-list condition or minimal contact clinical management in two acute treatment studies. Research is needed to assess the comparative efficacy of psychotherapeutic interventions, antidepressant medication, and their combination and to develop optimal strategies for facilitating remission and preventing relapse.

Bupropion sustained release in adolescents with comorbid attention-deficit/hyperactivity disorder and depression

OBJECTIVE

To determine whether bupropion sustained release (SR) is effective and well-tolerated in adolescents with comorbid attention-deficit/hyperactivity disorder (ADHD) and depression.

METHOD

Subjects were 24 adolescents (aged 11-16 years old) with ADHD and either major depressive disorder or dysthymic disorder. After a 2-week, single-blind placebo lead-in, subjects were treated for 8+ weeks with bupropion SR at doses flexibly titrated up to 3 mg/kg b.i.d. (mean final doses: 2.2 mg/kg q A.M. and 1.7 mg/kg q P.M.). Outcomes were global improvement in ADHD and depression (clinician-rated), along with changes in depressive symptomatology (parent- and child-rated), ADHD symptomatology (parent- and teacher-rated), and functional impairment (parent-rated).

RESULTS

Clinicians rated 14 subjects (58%) responders in both depression and ADHD, 7 (29%) responders in depression only, and 1 (4%) a responder in ADHD only. Compared with post-placebo ratings, final parents' (p < .0005) and children's (p = .016) ratings of depressive symptomatology improved significantly, as did parents' (p < .0005) but not teachers' (p = .080) ratings of ADHD symptomatology. Final ratings of functional impairment improved significantly from enrollment (p < .0005). No subject discontinued medication because of side effects.

CONCLUSIONS

Bupropion SR may be effective and well-tolerated in adolescents with comorbid ADHD and depressive disorders. However, randomized, placebo-controlled studies are needed.

Affect regulation, brain development, and behavioral/emotional health in adolescence

This paper addresses the importance of affect regulation (AR) in relation to a broad range of behavioral and emotional health problems that emerge during adolescence. AR is defined as the adaptive modulation of emotional experience to serve a goal or purpose. This conceptualization of AR emphasizes the use of cognitive skills to guide, inhibit, or modify emotion and behavior, including the expression of emotional responses, in learned, strategic ways-skills that ultimately underpin adult levels of social maturity and the ability to show "responsible" behavior across a range of emotional situations. Neurobehavioral systems that subserve these AR skills include areas of the inferior and orbital prefrontal cortex (PFC), with rich interconnections to several limbic structures and other cortical areas, including the dorsolateral PFC. Adolescence represents an important developmental period in the functional maturation of adult AR skills; it is also a critical time in the development of clinical disorders of AR (eg, rates of depression increase dramatically and gender differences in depression emerge). Maturational changes in AR that occur during adolescence-particularly with respect to the role of emotions influencing responsible decision making-are also relevant to understanding key aspects of the developmental pathways of some behavioral health problems, such as alcohol use and nicotine dependence. A strong case is made for developmental research in affective neuroscience aimed at this important maturational period, particularly the kind of transdisciplinary research leading toward mechanistic understanding of the development of adolescent-onset disorders. Improving understanding in these areas could ultimately lead to the development of early interventions in targeted high-risk populations, and has enormous clinical and social policy relevance.

Low growth hormone response to growth hormone-releasing hormone in child depression

BACKGROUND

This study examined growth hormone (GH) response to growth hormone-releasing hormone (GHRH) in a large sample of depressed children compared with normal control children. Within-subject comparisons were also performed in control subjects to examine test-retest reliability and in depressed children comparing episode versus clinical recovery.

METHODS

The sample included depressed children (n = 82) and normal control children (n = 55) group-matched for age, gender, and pubertal status; the mean ages were 11.2 +/- 1.7 and 11.2 +/- 1.8 years, respectively. We gave GHRH (0.1 mcg/Kg) at 9 AM, and serum GH levels were determined every 15 min from -30 min through +90 min of the GHRH infusion. A subgroup of normal control subjects (n = 11) repeated the protocol for test-retest reliability within a 2-month interval. A subgroup of depressed children (n = 20) were restudied off all medications following full clinical remission from depression.

RESULTS

The mean GH response to GHRH was significantly lower in the depressed group (8.7 ng/mL +/- SEM 0.9) compared with normal control children [12.2 ng/mL +/- SEM 1.3; t(135) = 2.59, p =.01 effect size 0.44]. The test-retest reliability of GH response to GHRH was stable (intraclass correlation =.93 for mean post-GH). The GH response to GHRH remained low in subjects restudied during clinical remission from depression.

CONCLUSIONS

Depressed children show low GH response to GHRH. The measure appears to be reliable, and the low GH response continues following clinical remission. Further studies are needed to explore the mechanism and relative specificity of this finding.

Depressive symptoms and cigarette smoking among teens

CONTEXT

Although several risk factors for tobacco use have been implicated in the development of depression, smoking progression has typically been viewed as a consequence of depression. The results of limited longitudinal studies are controversial.

OBJECTIVE

To assess the nature and direction of the relationship between cigarette smoking and depression among teens.

DESIGN

Prospective analysis of baseline and 1-year follow-up data from the National Longitudinal Study of Adolescent Health.

SETTING

In-home teen and parent interviews.

PARTICIPANTS

Two samples were identified. For the first sample, 8704 adolescents who were not depressed at baseline based on CES-D scores were identified for analyses of the effects of cigarette smoking on development of high depressive symptomatology. Baseline smoking status, which could vary in this group, was the predictor of interest in these analyses. For the second sample, 6947 teens who had not smoked cigarettes in the 30 days before the baseline survey (noncurrent smokers) were identified for analyses on the effect of high depressive symptoms on subsequent moderate to heavy cigarette use at 1 year of follow-up. Baseline high depressive symptomatology based on CES-D score was the predictor of interest in this sample.

MAIN OUTCOME MEASURES

Among the nondepressed, developing high depressive symptoms at 1 year of follow-up. Among noncurrent smokers, smoking at least 1 pack per week at 1 year of follow-up.

RESULTS

For the nondepressed, multivariate modeling revealed that current cigarette smoking was the strongest predictor of developing high depressive symptoms in all models (final model odds ratio [OR]: 3.90; 95% confidence interval [CI]: 1.85,8.20). For noncurrent smokers, although in bivariate analyses, baseline high depressive symptoms increased the risk of heavy smoking nearly threefold, multivariate modeling revealed that baseline high depressive symptoms were not predictive of heavy smoking when controlling for other determinants of smoking in teens. Previous experimentation with smoking was the strongest predictor of becoming a heavy smoker (OR: 3.04; 95% CI: 1.93,4.88).

CONCLUSIONS

In contrast to common dictum, depression does not seem to be an antecedent to heavy cigarette use among teens. However, current cigarette use is a powerful determinant of developing high depressive symptoms.

Depression and asthma in children

Genetic vulnerability, allergic sensitivity, immunological compromise, and psychological stressors all contribute to the onset and severity of asthma. When depression decreases compliance and worsens prognosis, caring for an asthmatic child becomes even more problematic. Early intervention to address comorbid depressive disorders increases compliance, improves outcome, and allows a child to continue to appropriately to meet developmental expectations. In cases of severe asthma, treatment of depression may also decrease mortality.

Selective serotonin reuptake inhibitors for children and adolescents

The controlled studies of selective serotonin reuptake inhibitors (SSRIs) in pediatric psychopharmacology research lag behind the controlled studies of SSRIs in adults. As a result, widespread use of SSRIs in the treatment of child and adolescent psychiatric disorders is in stark contrast to the paucity of research data. Recent changes in the research climate (including support from the National Institute of Mental Health, the Food and Drug Administration, and industry) have encouraged well-designed SSRI studies in pediatric psychopharmacology, and will ultimately provide needed information to guide treatment. This paper reviews the best available data from pediatric SSRI trials, including 10 double-blind placebo-controlled trials, and two abstracts of open-label continuation studies of SSRIs associated with large pediatric efficacy studies. Adverse events (AEs) of SSRIs in children and adolescents are discussed in reference to available pediatric studies. Recent pharmacokinetic studies of SSRIs in children and adolescents are reviewed. Future SSRI research strategies are also discussed.

Depression: a comparison study between blind and sighted adolescents

An exploratory study was conducted to identify whether the incidence of depression was greater among blind adolescents than among a sighted comparison group. A convenience sample of 22 adolescents, legally blind since birth, and 29 sighted adolescents participated in the study. The adolescents in both samples were between the ages of 12 and 18. The Beck Depression Inventory (BDI) was used to measure depression. The findings indicated that the incidence of depression among the blind adolescents was significantly higher than the incidence of depression among the sighted adolescents (t = 2.937, df = 50, p < .005). Mean BDI score was 7.103 for the sighted group and 13.652 for the blind group. There were no significant relationships between demographic variables and depression. This study serves as a pilot for more extensive research that can expand the empirical base for understanding depression and its relationship to visual impairment among adolescents.

Relative size of the literatures for psychopathological disorders: number of articles pertaining to DSM-IV diagnostic categories

A computerized search of the 1991-1997 PsycLIT database was used to quantify the size of the literature for each of the DSM-IV mental disorders. The search included DSM-IV/IIIR diagnoses and alternative terms for the disorders to provide a complete assessment. Generally it was found that major disorders and those with neurophysiological components were investigated a great deal (there were over 10,000 articles for both major depression and schizophrenia) while there were few articles concerning rare or newly introduced disorders. Within diagnostic groups certain disorders received the preponderance of research attention. Factors related to the degree to which a mental disorder is investigated are discussed. These findings should stimulate consideration of whether clinical research is directing its efforts in a way that best promotes understanding of the nature and treatment of mental disorders.

Effective treatment for mental disorders in children and adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

The Texas Children's Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVES

To develop consensus guidelines for medication treatment algorithms for childhood major depressive disorder (MDD) based on scientific evidence and clinical opinion when science is lacking. The ultimate goal of this approach is to synthesize research and clinical experience for the practitioner and to increase the uniformity of preferred treatment for childhood MDD. A final goal is to develop an approach that can be tested as to whether it improves clinical outcomes for children and adolescents with MDD.

METHOD

A consensus conference was held. Participants included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review and use clinical evidence to recommend specific pharmacological approaches for treatment of MDD in children and adolescents. After a series of presentations of current research evidence and panel discussion, the consensus panel met, agreed on assumptions, and drafted the algorithms. The process initially addressed strategies of treatment and then tactics to implement the strategies.

RESULTS

Consensually agreed-upon algorithms for major depressions (with and without psychosis) and comorbid attention deficit disorders were developed. Treatment strategies emphasized the use of selective serotonin reuptake inhibitors. The algorithm consists of systematic strategies for treatment interventions and recommended tactics for implementation of the strategies, including medication augmentation and medication combinations. Participants recommended prospective evaluation of the algorithms in various public sector settings, and many volunteered as sites for such an evaluation.

CONCLUSIONS

Using scientific and clinical experience, consensus-derived algorithms for children and adolescents with MDD can be developed.

Psychotropic medication use among children in foster care: relationship to severe psychiatric disorders

OBJECTIVES

This study sought to describe the level of psychotropic medication use and its relationship to severe psychiatric disorders among school-aged children in foster care.

METHODS

Home interviews with 302 foster parents and children aged 6 to 12 years and 266 follow-up clinical evaluations were conducted.

RESULTS

Thirteen percent of the children had taken psychotropic medication in the previous year, and 52% of those whose clinical status merited a medication evaluation had not received medication in the previous year.

CONCLUSIONS

As the efficacy of psychotropic medication treatment for severe child psychiatric disorders becomes more established, research on the appropriateness of such care can begin.

Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: clinical outcomes

OBJECTIVE

The primary purpose of this study was to determine whether multisystemic therapy (MST), modified for use with youths presenting psychiatric emergencies, can serve as a clinically viable alternative to inpatient psychiatric hospitalization.

METHOD

One hundred sixteen children and adolescents approved for emergency psychiatric hospitalization were randomly assigned to home-based MST or inpatient hospitalization. Assessments examining symptomatology, antisocial behavior, self-esteem, family relations, peer relations, school attendance, and consumer satisfaction were conducted at 3 times: within 24 hours of recruitment into the project, shortly after the hospitalized youth was released from the hospital (1-2 weeks after recruitment), and at the completion of MST home-based services (average of 4 months postrecruitment).

RESULTS

MST was more effective than emergency hospitalization at decreasing youths' externalizing symptoms and improving their family functioning and school attendance. Hospitalization was more effective than MST at improving youths' self-esteem. Consumer satisfaction scores were higher in the MST condition.

CONCLUSIONS

The findings support the view that an intensive, well-specified, and empirically supported treatment model, with judicious access to placement, can effectively serve as a family- and community-based alternative to the emergency psychiatric hospitalization of children and adolescents.

Including children and adolescents with schizophrenia in medication-free research

OBJECTIVE

There has been an increasing focus on the ethical issues raised by studies requiring the withdrawal of effective medication in schizophrenic adults. This article examines the risks and benefits of a medication-free period for pediatric patients with treatment-refractory schizophrenia who are participating in an ongoing study.

METHOD

Between April 1993 and March 1998, 31 children and adolescents were admitted with a diagnosis of treatment-resistant, childhood-onset schizophrenia. Parental consent was obtained so that patients could participate in a medication-free research period. Patients were evaluated at screening, at the end of a 4-week washout, at the completion of a 6- to 8-week atypical neuroleptic trial, and at a 2- to 4-year follow-up.

RESULTS

At the completion of a 4-week drug-free period, seven patients (23%) were diagnosed with another disorder on the basis of data gained from the drug-free period and their lack of schizophrenic symptoms. Their revised diagnoses were posttraumatic stress disorder (N = 1), an atypical psychosis labeled "multidimensionally impaired" (N = 4), and personality disorder (N = 2). At follow-up, three of these patients remained free of neuroleptic therapy. For eight patients (26%), the washout was curtailed because of rapid and severe deterioration of their schizophrenic symptoms.

CONCLUSIONS

For children and adolescents with treatment-refractory schizophrenia, a medication-free period can be conducted safely for at least 4 weeks for inpatients. Such trials are useful on clinical grounds and for providing homogeneous patient groups for research. This study also highlights the necessity of having access to hospitalization to observe children and adolescents with psychotic symptoms while medication free.

Mood stabilizers in children and adolescents

OBJECTIVE

The efficacy of mood stabilizers in children and adolescents has not been studied adequately. This article will review existing studies and highlight some important issues in designing future studies on these agents.

METHOD

Electronic databases including Medline, Psycholnfo, and CRISP were searched for data in children receiving compounds that have mood-stabilizing properties in adults.

RESULTS

Some open clinical data and an extremely modest amount of controlled research data suggest lithium, carbamazepine, and valproate may be effective mood stabilizers in children and adolescents. There are no controlled data on other potential mood stabilizers in children.

CONCLUSIONS

The disorders that may be responsive to mood stabilizers are among the most morbid in child psychiatry. More studies are needed to clarify the efficacy of these compounds in children and adolescents and to provide a rational basis for choosing among them.

Personality disorder comorbidity in early-onset versus late-onset major depression in Japan

This study explored the comorbidity of DSM-III-R personality disorders in early-onset versus late-onset major depression in Japan. The subjects were 117 consecutive outpatients with major depression, with 26 classified as having an early onset (first depressive episode at age 22 or earlier) and 91 classified as having a late onset (first depressive episode at age 23 or later). Personality disorders were assessed using the Structured Clinical Interview for DSM-III-R Personality Disorders after a 2-month antidepressant treatment. The results indicated that early-onset major depression was characterized by greater personality disorder comorbidity than late-onset major depression in Japan. Subjects with any one cluster A or B personality disorder were more prevalent in the early-onset group. In terms of each personality disorder, histrionic, narcissistic, and borderline patients were more prevalent, and the number of criteria met for schizotypal and cluster B personality disorders was significantly larger in early-onset major depression after corrections for age and gender. The results suggested that the higher prevalence of personality pathologies in early-onset major depression may reflect a higher likelihood to convert into bipolar disorders or a stronger impact of having experienced depressive episodes in young individuals. The possibility that the predisposing personality pathology may be different in early-onset and late-onset major depression is also discussed.

Influence of parental concordance for psychiatric disorders on psychopathology in offspring

OBJECTIVE

To examine the influence of parental mating types for substance abuse and anxiety/affective disorders on the risk of psychopathology among child and adolescent offspring.

METHOD

Emotional and behavioral disorders were assessed in offspring, aged 7 to 17 years, of male and female parents who served as probands from a family study of comorbidity of substance abuse and anxiety disorders.

RESULTS

The findings indicated that (1) patterns of psychopathology among offspring were similar for mothers and fathers; (2) spouse concordance for psychopathology was greater among parents with substance abuse than among those with anxiety, particularly among female substance abusers; (3) there was a direct relationship between the number of affected parents and the magnitude of psychopathology in children, particularly with respect to the anxiety disorders; and (4) by contrast, rates of conduct disorder were elevated only among offspring of dually affected parents, irrespective of the specific parental disorders.

CONCLUSIONS

These findings underscore the importance of the contribution of both mothers and fathers, particularly those with concordance for psychiatric disorders, to the development of psychopathology in offspring.

The context of depression in clinic-referred youth: neglected areas in treatment

OBJECTIVE

To review the empirical, methodological, and conceptual limitations of psychotherapy and pharmacotherapy for childhood and adolescent depression and to present descriptive data on key characteristics of a depressed sample to illustrate gaps in treatment.

METHOD

Interview-based assessment of psychiatric features and psychosocial functioning, family psychopathology and marital adjustment, and child and parent stressful life events was performed in a sample of 43 depressed youngsters seeking outpatient treatment.

RESULTS

The empirical and conceptual review indicated that treatments based on downward extensions of adult procedures are limited in number and success. Also, the treatments generally neglect the following characteristics revealed in the descriptive data: depressed youngsters have high rates of recurrent depression and comorbid conditions, impaired academic and social functioning, exposure to high rates of parental psychopathology, parental assortative mating, severe marital dysfunction, and high rates of severe stressors.

CONCLUSIONS

Treatments need to be informed by and address the actual characteristics of depressed youngsters and their environments, which are highly dysfunctional.

A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents

Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.

Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP

Child and adolescent major depressive disorder and dysthymic disorder are common, chronic, familial, and recurrent conditions that usually persist into adulthood. These disorders appear to be manifesting at an earlier age in successive cohorts and are usually accompanied by comorbid psychiatric disorders, increased risk for suicide, substance abuse, and behavior problems. In addition, depressed youth frequently have poor psychosocial, academic, and family functioning, which highlights the importance of early identification and prompt treatment. Both psychotherapy and pharmacotherapy have been found to be beneficial for the acute treatment of youth with depressive disorders. Opinions vary regarding which of these treatments should be offered first and whether they should be offered in combination. In general, the choice of initial therapy depends on clinical and psychosocial factors and therapist's expertise. Based on the current literature and clinical experience, psychotherapy may be the first treatment for most depressed youth. However, antidepressants must be considered for those patients with psychosis, bipolar depression, severe depressions, and those who do not respond to an adequate trial of psychotherapy. All patients need continuation therapy and some patients may require maintenance treatment. Further research is needed on the etiology of depression; the efficacy of different types of psychotherapy; the differential effects of psychotherapy, pharmacotherapy, and integrated therapies; the continuation and maintenance treatment phases; treatment for dysthymia, treatment-resistant depression, and other subtypes of major depressive disorder; and preventive strategies for high-risk children and adolescents.

Newer antidepressants. Beyond selective serotonin reuptake inhibitor antidepressants

This article outlines the use of alternative agents to TCAs and SSRIs. Features of the more commonly used alternative antidepressant agents are outlined. In addition, antidepressant agents that are currently either under development or used in other countries are indicated for completeness because it seems likely that many of these will be introduced in the United States within the next few years. Many of these agents will be used by pediatricians and child psychiatrists for treatment of depression in children, and although much further research is needed, the future for alternative antidepressants and augmenting strategies is extremely promising.

Pharmacologic treatment for children and adolescents with anxiety disorders

Pediatric anxiety disorders are common illnesses that, if left untreated, may induce academic, family, and interpersonal problems. Cognitive-behavioral techniques and other psychotherapeutic interventions may be adequate for the treatment of most anxiety disorders. For patients with severe symptoms or for whom psychotherapeutic approaches are not adequate, medications are indicated. Among the available medications, the SSRIs are currently the first choice; however, other medications, such as the benzodiazepines and the TCAs, may be used alone or sometimes in combination with the SSRIs. Caution with respect to medication interactions and side effects is indicated. In particular, long-term side effects in these medications have not been well studied.

Child and adolescent mood disorders--experience with serotonin-based therapies

By most measures, child and adolescent depression is much like and continuous with adult depression. Aggregating all available data, much of which is relatively new, it seems most likely that noradrenergic and mixed serotonergic/noradrenergic tricyclic antidepressants are ineffective in child and adolescent depression, whereas serotonergic antidepressants (e.g., selective serotonin reuptake inhibitors) are probably effective).

Randomized, controlled trial of amitriptyline versus placebo for adolescents with "treatment-resistant" major depression

OBJECTIVE

To assess the response to a serotonergic/noradrenergic tricyclic antidepressant, amitriptyline (AMI), in a group of adolescents with treatment-resistant major depressive disorder (MDD).

METHOD

Twenty-seven depressed adolescents admitted to a state hospital underwent a 10-week randomized, controlled trial with a flexible dose of AMI or placebo.

RESULTS

There were no differences between patients taking AMI (n = 13) and placebo (n = 14). Both treatment groups showed approximately 70% to 80% improvement on the clinical outcome measurements, and 65% to 70% showed functional improvement. At the end of the protocol, 30% of patients still fulfilled criteria for MDD and had impaired functioning. Patients taking AMI experienced significantly more dry mouth and tachycardia. The final AMI dose was 173.1 mg/day +/- 56.3 mg/day; blood levels were 226.2 ng/mL +/- 80.8 ng/mL.

CONCLUSIONS

No significant differences were found between AMI and placebo, in part because of the high placebo response rate. Although both treatment groups showed substantial response, at the end of treatment a substantial proportion of patients still had MDD of subsyndromal symptoms of depression. This and other studies of tricyclic antidepressants question the use of this medication as first-line treatment for youths with MDD.

Child and learning disability psychopharmacology

In January 1997, the British Association for Psychopharmacology convened a Round Table meeting to look at issues surrounding the prescription of psychotropic drugs to children or individuals with learning disabilities. This followed reports in the UK media about increasing rates of prescription to children with attention deficit hyperactivity disorder (ADHD) and children who are depressed as well as concerns regarding the prescription of psychotropic drugs to both children and adults with learning disabilities. The participants included both clinical and basic scientists, psychiatrists and psychologists, as well as regulators and representatives of the pharmaceutical industry and they were drawn from the UK, the United States, Canada, Holland, France and Germany. The brief was to consider the evidence in favour of prescribing for individuals with learning disabilities or children with obsessive-compulsive disorder, schizophrenia, depression or ADHD and the basis on which prescribing could take place in the absence of clinical trial evidence of efficacy drawn from the populations in question, where prescribing is effectively off label or outside the remit of a medicine's product licence or sometimes must take place in the face of data sheet disclaimers that it is contraindicated.