Treatment approach to and response of children and adolescents with depression may vary with severity, duration, and comorbidity of the presenting illness. Treatment should always include an acute and a continuation phase, with the availability of maintenance treatment. Psycho-education, support, and involvement of family and school are fundamental to any treatment plan, and in cases of very mild depression, may be adequate. In cases of more severe depression, use of psychotherapy, pharmacotherapy, or a combination is indicated.
In the consideration of psychopharmacologic treatment of depressed children and adolescents, it is important to note a high-placebo response rate of 30–60%. Nevertheless, there is evidence of efficacy of selective serotonin reuptake inhibitors (SSRIs) with response rates of 50–70%. Fluoxetine is the only medication approved by the FDA for the treatment of child and adolescent depression. It is the best studied and has demonstrated the greatest difference between medication and placebo. Moreover, there is evidence that fluoxetine has greater efficacy than cognitive–behavioral therapy (CBT), though combined treatment was found to have the greatest rate of response except in more severe cases, when it was equivalent to medication alone.
There are published studies demonstrating efficacy for citalopram and sertraline, though there are also unpublished negative studies. A meta-analysis of all available clinical trials, both published and unpublished, revealed that SSRIs are more efficacious than placebo, with response rates of 60% versus 49%. In some studies there are significant effects for adolescents but not for children. In addition, while tricyclic antidepressants show excellent response rates in adults, evidence does not support their use for the treatment of depression in children and adolescents.
Dosing recommendations for children and adolescents are to start at half the usual adult starting dose for 1 week (i.e., the equivalent of 10 mg of fluoxetine) and to then increase the dose to 20 mg of fluoxetine or equivalent for another 3 weeks. Dosing increases should occur at no less than 4-week intervals to allow the medication to reach steady state. Children and adolescents may require relatively higher doses of citalopram, sertraline, or fluvoxamine, based on pharmacokinetic studies. There is evidence that, in order to prevent relapse, treatment should be continued for at least 6 months after complete symptom remission, in the case of a first episode of MDD, and for at least 12 months after a recurrent episode.
In view of its more extensive efficacy data, fluoxetine should be used as a first-line agent. In depression that has been refractory to monotherapy with adequate doses of at least two SSRIs, augmentation strategies can include buproprion, lithium, or lamotrigine. Undiagnosed comorbid conditions or misdiagnosis should first be ruled out. Psychotherapy, if not started previously, is also indicated. Other considerations in the pharmacotherapeutic treatment of depression include the management of contributing comorbidity. Milder cases may respond to psychoeducation alone or in combination with brief psychotherapy.
CBT has been shown to be one of the most efficacious psychotherapies for the management of child and adolescent depression, with or without concomitant use of pharmacotherapy. CBT is based on the premise that depressed individuals have distorted information processing, thoughts, and core beliefs. Distortion manifests itself in a negative attributional style and beliefs that lead to, exacerbate, or perpetuate depression, particularly during times of stress. CBT uses cognitive techniques and skills building to attenuate cognitive distortions and maladaptive processing. The content of various CBT treatments varies widely, ranging from the highly structured CWD-A (Coping with Depression for Adolescents), to much less structured treatments like those based on Beck's CBT, to hybrids like that used in the Treatment of Adolescent Depression Study (TADS).
Based upon TADS, CBT alone or in combination with pharmacotherapy may be best for less severe cases of depression. Predictors of poorer response to CBT, from TADS and other studies, include greater severity, history of sexual abuse, parental depression, older age of onset, and greater hopelessness.
Interpersonal Therapy (IPT) is predicated on the exploration and recognition of precipitants of depression including interpersonal loss, role disputes and transitions, social isolation, and social skills deficits. IPT for adolescents (IPT-A) is an adaptation of IPT. It begins with an “interpersonal inventory” that includes the patient's interpersonal relationships. This inventory allows therapist and patient to make collaborative decisions about goals for treatment. IPT-A may be successful because it addresses role transitions, interpersonal difficulties with peers and family, and the development of social skills—all important developmental tasks of adolescence.
In some measures of depression and functional impairment, IPT has been shown to be superior to CBT. IPT-A has been shown to be superior to “care as usual” in treatment of depression, as in regard to improvement in social adjustment, and functional status.
Family therapy is often used as an adjunct to other treatments for depression. There have been both positive and negative studies regarding the use of family therapy. Interventions such as the management of parental depression, improvement of family communication, the reduction of criticism, and the enhancement of support, are likely to be of benefit.
Light therapy has been shown to be beneficial for seasonal affective disorder and as an adjunct for MDD with a seasonal component. Light therapy involves the daily use of full spectrum light in the early morning hours to help with potential abnormality of the hypothalamic–pituitary axis. Light therapy is initiated in fall and winter months to counteract reduced daylight.
Although there is little controlled evidence about the use of electroconvulsive therapy (ECT) in adolescent depression, documented clinical experience supports a role for ECT in depression that is refractory to pharmacological and psychosocial management, as well as in severe psychotic depression, and life-threatening depression. There is evidence that ECT may not be effective in the case of comorbid Axis II personality disorders. It may be most efficacious in bipolar depression.