pediatrics
Depressive Disorders in Children and Adolescents
Treatment
Concurrent measures directed at the family and school For adolescents, usually antidepressants plus psychotherapy For preadolescents, psychotherapy followed, if needed, by antidepressants Appropriate measures directed at the family and school must accompany direct treatment of the child to enhance continued functioning and provide appropriate educational accommodations. Brief hospitalization may be necessary in acute crises, especially when suicidal behavior is identified. For adolescents (as for adults), a combination of psychotherapy and antidepressants usually greatly outperforms either modality used alone ( Treatment references: General ). For preadolescents, the situation is much less clear. Most clinicians opt for psychotherapy in younger children; however, medications can be used in younger children ( Usually, a selective serotonin reuptake inhibitor (SSRI; see table Drugs for Long-Term Treatment of Depression, Anxiety, and Related Disorders ) is the first choice when an antidepressant is indicated ( may also be used with a selective serotonin reuptake inhibitor (SSRI) to enhance efficacy. In very severe depression, psychotic and/or manic symptoms may require treatment with an Antipsychotic Drugs ( Transcranial magnetic stimulation—although not yet approved by the Food and Drug Administration (FDA) for use in youths—has been used, particularly when patients do not respond to or tolerate medications ( Treatment references: General ). Preliminary studies of transcranial magnetic stimulation in adolescents show similar clinical effects and tolerability as in adults ( As in adults, relapse and recurrence are common. Children and adolescents should remain in treatment for at least 1 year after symptoms have remitted. Most experts recommend that children who have experienced≥2 episodes of major depression be treated indefinitely. 1.Kennard BD, Silva SG, Tonev S, et al: Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): Acute and long-term outcomes.J Am Acad Child Adolesc Psychiatry48(2):186-195, 1009. doi: 10.1097/CHI.0b013e31819176f9 2.Dwyer JB, Bloch MH: Antidepressants for pediatric patients.Curr Psychiatr8(9):26-42F, 2019. 3.Kendall T, Morriss R, Mayo-Wilson E, et al: Assessment and management of bipolar disorder: Summary of updated NICE guidance.BMJ349:g5673, 2014. doi: 10.1136/bmj.g5673 4.Yatham LN, Kennedy SH, Parikh SV, et al: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: Update 2013.Bipolar Disord15(1):1-44, 2013. doi: 10.1111/bdi.12025 5.Allen CG, Kluger BM, Buard I: Safety of transcranial magnetic stimulation in children: A systematic review of the literature.Pediatr Neurol68:3-17, 2017. doi.org/10.1016/j.pediatrneurol.2016.12.009 6.Donaldson AE, Gordon MS, Melvin GA, et al: Addressing the needs of adolescents with treatment resistant depressive disorders: A systematic review of rTMS.Brain Stimul7(1):7-12. 2014. doi: 10.1016/j.brs.2013.09.012 7.Krishnan C, Santos L, Peterson MD, et al: Safety of noninvasive brain stimulation in children and adolescents.Brain Stimul8:76-87, 2015. doi: 10.1016/j.brs.2014.10.012 8.Croarkin PE, MacMaster FP: Transcranial magnetic stimulation for adolescent depression.Child Adolesc Psychiatry Clin N Am28(1):33-43, 2019. 10.1016/j.chc.2018.07.003 Suicide risk and treatment with antidepressants have been topics of debate and research ( Treatment references: Suicide risk and antidepressants ). In 2004, the US FDA did a meta-analysis of 23 previously conducted trials of 9 different antidepressants ( In 2006, a meta-analysis (from the United Kingdom) of children and adolescents being treated for depression ( Treatment references: Suicide risk and antidepressants ) found that compared with patients taking a placebo, those taking an antidepressant had a small increase in self-harm or suicide-related events (4.8% vs 3.0% of those treated with placebo). However, whether the difference was statistically significant or not varied depending on the type of analysis (fixed-effects analysis or random-effects analysis). There was a nonsignificant trend toward an increase in suicidal ideation (1.2% vs 0.8%), self-harm (3.3% vs 2.6%), and suicide attempts (1.9% vs 1.2%). There appear to have been some differences in risk between different medications; however, no direct head-to-head studies have been done, and it is difficult to control for severity of depression and other confounding risk factors. Observational and epidemiologic studies ( Treatment references: Suicide risk and antidepressants ) have found no increase in the rate of suicide attempts or completed suicide in patients taking antidepressants. Also, despite a decrease in prescriptions for antidepressants following the black-box warning, the adolescent suicide rate increased by 14% ( In general, although antidepressants have limited efficacy in children and adolescents, the benefits appear to outweigh risks. The best approach seems to be combining treatment with medications with psychotherapy and minimizing risk by closely monitoring treatment. Whether or not medications are used, suicide is always a concern in a child or adolescent with depression. The following should be done to reduce risk: Parents and mental health care practitioners should discuss the issues in depth. The child or adolescent should be supervised at an appropriate level. Psychotherapy with regularly scheduled appointments should be included in the treatment plan. Suicide risk is always a concern in children or adolescents with depression whether they are taking antidepressants or not. 1.Hetrick SE, McKenzie JE, Merry SN: Newer generation antidepressants for depressive disorders in children and adolescents.Cochrane Database Syst RevNov 11 2012. 2.US FDA: Review and evaluation of clinical data: Relationship between psychotropic drugs and pediatric suicidality. 2004. Accessed January 9, 2023. 3.Dubicka B, Hadley S, Roberts C: Suicidal behaviour in youths with depression treated with new-generation antidepressants: Meta-analysis.Br J PsychiatryNov 189:393–398, 2006. 4.Adegbite-Adeniyi C, et al: An update on antidepressant use and suicidality in pediatric depression.Expert Opin Pharmacother13 (15):2119–2130, 2012. 5.Gibbons RD, Brown CH, Hur K, et al: Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents.Am J Psychiatry164 (9);1356–1363, 2007. 6.Garland JE, Kutcher S, Virani A, et al: Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice.J Can Acad Child Adolesc Psychiatry25(1):4-10. 7.Dwyer JB, Bloch MH: Antidepressants for pediatric patients.Curr Psychiatr8(9):26-42F, 2019. 8.Gibbons R, Hur K, Lavigne J, et al: Medications and suicide: High dimensional empirical Bayes screening (iDEAS).Harvard Data Sci Rev2019. doi: 10.1162/99608f92.6fdaa9de 9.Lagerberg T, Fazel S, Sjölander A, et al: Selective serotonin reuptake inhibitors and suicidal behaviour: A population-based cohort study.Neuropsychoparmacol47:817-823, 2022. https://doi.org/10.1038/s41386-021-01179-z 