Treatment of depression in children and adolescents

Depression occurs in children and adolescents, although it may appear differently in younger patients. Research suggests juvenile depression may respond to psychotherapy and to pharmacologic agents, and that antidepressants remain a valuable treatment for juveniles with depression. Diagnostic considerations in juveniles with mood symptoms are discussed. A brief overview is provided of the evidence supporting psychotherapy for juveniles with depression. Controlled antidepressant trials in juveniles with depression provide some support for the use of some selective serotonin reuptake inhibitors and little support for atypical antidepressants, tricyclic antidepressants, or monoamine oxidase inhibitors. Evidence from suicide rates over time, autopsy findings among juvenile suicides, and impacts of antidepressant prescribing trends are related to the current controversy over suicidality and antidepressant use in juvenile patients. Based on this evidence, practical guidelines for treatment of juvenile depression are provided.     

Atypical depression in children and adolescents

Major depressive disorder (MDD) with atypical features has been described in adults. Furthermore, several studies have suggested that tricyclic antidepressants were less effective for MDD with atypical features than for MDD without atypical features. Thus, it may be important to determine whether atypical features are present in MDD. To date, only one study has examined the diagnosis of depression with atypical features in children and adolescents by using the DSM-IV criteria. Current knowledge suggests the DSM-IV criteria for depression with atypical features in children and adolescents may need to be reconsidered, as biological, hormonal, developmental, and psychological factors in this age group may be different from those of adults with atypical depression.     

Refractory depression in children and adolescents

Refractory or treatments resistant depression in child and adolescent populations is a difficult construct to operationalize currently. To date, only one of the small number of completed double-blind placebo-controlled treatment investigations have not demonstrated a significant effect of antidepressants in comparison to placebo. However, it has been established that child and adolescent MDD is a serious disorder that appears to have clinical continuity with adult affective disorders and is generally of long duration with high rates of recurrence and eventual progression to mania, substance abuse, or other serious psychopathology. In addition, families of children with affective disorders evidence substantial genetic loading with high rates of affective disorders contributing both genetic vulnerability and potential environmental risk as well. There have been no empirically identified treatments that alter the long-term course of the illness. Thus treatment resistance is a significant issue for this population. This review will focus on controlled treatment trials and will examine the potential relevance of psychosocial impairment, genetic-familial risk, and neuromorphometric brain differences to treatment resistance in children and adolescents with major depression. Depression and Anxiety 5:212–223, 1997. © 1997 Wiley-Liss, Inc.     

Neurobiology of depression in children and adolescents

This article reviews classical and updated studies of the neurobiology of depressive disorders in children and adolescents. Most studies of childhood and adolescent depression and suicide have followed up the observations and methods used in studies in adults. These studies include neuroendocrine studies, which particularly look at the hypothalamic-pituitary-adrenal axis, the serotonergic system, peripheral blood and cerebrospinal fluid biologic markers, genetics, gene-environment interactions and sleep studies, and neuroimaging and postmortem studies, although in these areas the number of studies is limited.     

Assessment of depression in children and adolescents

Depression assessment instruments are valuable tools in the treatment of children and adolescents. Available instruments include diagnostic interviews, self-administered rating scales, and observer-rated scales. To select an appropriate instrument, the user must define the goal of the assessment and then identify instruments with the properties that match this goal. This article discusses how to choose an assessment instrument and gives an overview of currently available depression assessment instruments. Important considerations include how and by whom an instrument is administered, what kind of data are obtained by the instrument, and the validity and reliability of the instrument. Standardized instruments can greatly improve the assessment process, but the user must not overinterpret or misinterpret the results.     

Treatment of children and adolescents with multiple sclerosis

The onset of multiple sclerosis is being increasingly recognized in children and adolescents. There are now approved immunomodulatory therapies for adults with multiple sclerosis. Treatment early in the disease course appears to have a greater impact on disease outcome, an issue of particular importance for children who face decades of multiple sclerosis disease activity. This review summarizes the multiple sclerosis therapies currently available, efficacy data available from studies of these medications in adults and limited information on the use of these medications in children. Future directions in multiple sclerosis therapeutics and specific issues relating to pediatric multiple sclerosis are discussed.     

Medical treatment of depression in children and adolescents

Pharmacological treatment of depression in minors is contested after some published warnings about suicide related behaviour among youths treated with SSRI. This paper examines the last developments concerning antidepressant use in minors, prescrition patterns and evidence of antidepressants used in minors. Reviewing the guidelines and practise parameters, metaanalyses and the TADS-study a recommendation for an evidence based use in minors can only be given for Fluoxetine. Safety aspects should be taken into consideration during the treatment and patients should be kept in close contact to their therapists to observe suicidal related behaviour and adherence.     

Efficacy of psychodynamic short-term psychotherapy for children and adolescents with depression

Depression is highly prevalent in children and adolescents. Psychodynamic therapies are only insufficiently evaluated in this field although many children and adolescents suffering from depression are treated using this approach. Therefore, the aim of our study was to evaluate the efficacy of psychodynamic short-term psychotherapy (PSTP) for the treatment of depression in children and adolescents. In a waiting-list controlled study, 20 children and adolescents fulfilling diagnosis of major depression or dysthymia were included. The treatment group received 25 sessions of psychodynamic psychotherapy. Main outcome criterion was the Impairment-Score for Children and Adolescents (IS-CA) as well as the Psychic and Social-Communicative Findings Sheet for Children and Adolescents (PSCFS-CA) and the Child Behavior Checklist (CBCL), which were assessed at the beginning and the end of treatment. The statistical and clinical significance of changes in these measures were evaluated. There was a significant advantage of the treatment group compared to the waiting group for the IS-CA. The effect size of the IS-CA total score was 1,3. In contrast to the treatment group, where 20% of the children showed clinically significant and reliable improvement, no subject in the waiting-list control group met this criterion. Comparable results were found for the PSCFS-CA and for the internalising score assessed with the CBCL. The results show that psychodynamic short-term psychotherapy (PSTP) is an effective treatment for depressed children and adolescents. Still, some of the children surely require more intensive treatment.     

An open trial of citalopram in children and adolescents with depression

OBJECTIVE: The aim of this study was to collect pilot data on the magnitude of effect and tolerability of citalopram in early-onset major depressive disorder (MDD). METHOD: This study was performed in two academic child and adolescent psychiatric clinics (2000 through 2002). Thirty children and adolescents, 8-17 years of age (mean age, 13.57 +/- 2.5), of both sexes (53.3% girls; 46.7% boys) and diagnosed with MDD by means of clinical psychiatric evaluation, Diagnostic Interview for Children and Adolescents (DICA) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, were studied in an open-label clinical trial with 10-40 mg/day of citalopram for 6 weeks. The outcome measures were the Hamilton Depression Rating Scale (HDRS), the Children Global Assessment Scale (CGAS), and the New York State Psychiatric Institute side-effect form. RESULTS: Moderate (50%-70% change in HDRS and CGAS) to large (> 70% change in HDRS and CGAS) effect were seen in 91.7% of children (22/24). There were significant changes on HDRS (X = 22.78; t = -14.12; p < 0.000) and CGAS (X = 26.02; t = 9.68; p < 0.000) between baseline and the 6th week. Mild side effects were reported in 2 patients (8.3%). Adverse effects that contributed to discontinuation were nausea and vomiting in 3.3% (n = 1) of patients and unexpectedly switching to mania in 16.7% (n = 5) of patients. CONCLUSION: Citalopram may be an efficatious treatment in early-onset MDD. However, the high switch rate to mania warrants further investigations, as well as cautions, in using it.     

Anxiety and depression in children and adolescents with sickle cell disease

A growing body of evidence suggests that depressive disorders and anxiety disorders are much more prevalent among medically ill children and adolescents when compared with the general population, and that the presence of comorbidity may adversely affect medical outcomes and quality of life. Whereas the prevalence and impact of anxiety and depressive disorders have been described in chronic conditions such as asthma, diabetes, and epilepsy, much less is known about sickle cell disease (SCD), a disorder that affects more than 70,000 Americans, primarily those of African and Mediterranean descent. A hallmark of this disorder is recurrent, acute, and chronic pain that often requires emergency management and hospitalization. Medical advances in the treatment of this illness have transformed SCD from a condition associated with very early morbidity and mortality into a chronic condition of adulthood. This article reviews the evidence describing our knowledge of anxiety and depression in children and adolescents with SCD, its clinical impact, and effectiveness of interventions.     

Anxiety and depression in children and adolescents with spinal cord injuries

Aim  To determine the levels of anxiety and depression in young people with spinal cord injuries (SCI) and their associated factors and outcomes.
Method  Children and adolescents aged 7 to 17 years at interview who had sustained SCI at least 1 year before the study were assessed using the Children's Depression Inventory, the Revised Children's Manifest Anxiety Scale, the Pediatric Quality of Life Inventory, the Children's Assessment of Participation and Enjoyment, and a demographic questionnaire designed for the study.
Results  The 118 participants (61 males, 57 females) had a mean age of 12 years 4 months, SD 3y 1mo, range 7-17y. Mean age at injury was 5 years 11 months, SD 4y 11m, range 0-16y; 89 participants (75%) had paraplegia and 29 (25%) had tetraplegia. Fifty-seven (52%) had complete injuries and 52 (48%) had incomplete injuries according to the American Spinal Injury Association impairment scale. Thirteen participants (13%) reported significant symptoms of anxiety, and seven (6%) reported significant levels of depression, which were comparable to the normative population. Age, race, and sex were not associated with anxiety or depression, but participants with shorter duration of injury were more likely to be anxious, and those with less functional independence were more likely to be depressed. Only one dimension of participation was associated with anxiety and depression, but all aspects of quality of life were decreased among those with anxiety or depression.
Interpretation  The levels of anxiety and depression in young people with SCI are comparable to the normative range. When anxiety and depression occur they are associated with reduced levels of quality of life.     

Measurement of anxiety and depression in children and adolescents

In summary, symptom checklists and rating scales are a cost-effective means of deriving an extensive amount of clinical information in a relatively short period of time. Measures designed to assess affect in children have primarily been self-report inventories owing to the subjective nature of the constructs being assessed. However, subscales for the assessment of anxiety and depression by significant others (parent, teacher, clinician) can be found on more general measures of behavior such as the Conners' Parent and Teacher Rating Scales, the Achenbach Parent and Teacher Forms of the Child Behavior Checklist, and the Brief Psychiatric Rating Scale for Children. In choosing from the array of available measures, emphasis should be placed on an examination of the psychometric properties of the scales. Inventories with demonstrated reliability and validity will provide the clinician with a much more useful profile of a patient's symptoms than will instruments with undocumented or poor psychometric properties. A major concern for all structured interviews is the relative lack of detailed reliability or validity studies. In addition, there are important caveats for such research. A high internal reliability may only demonstrate that one narrow aspect of depression has been measured or a high test-retest reliability may indicate that the interview is measuring a stable trait rather than a current state. Research on the validity and efficiency of the interviews requires careful consideration and consensus regarding acceptable comparison standards. At this time, variants of the "best estimate diagnosis" methodology appear to have gained widest acceptance. In general, there remains much work to be done before the distinct capabilities of the structured interviews are established. It should be noted that in all cases these interviews are evolving instruments and continue to undergo revision and refinement. However, one difference has evolved and may be relevant to the choice of instrument in specific studies. The highly structured interviews, such as the DICA and the DISC, are amenable to epidemiologic screening. They cover a wide range of disorders and have a relatively low threshold for disorder or high sensitivity. In application, these instruments will tend to overdiagnose. It will be necessary to use good clinical judgment in ruling out those disorders that do not apply. In contrast the semistructured interviews, such as the K-SADS and the ISC, have a relatively high diagnostic threshold or relatively high specificity for a few disorders. These instruments are probably best used for the purpose for which they were designed; that is, the selection of depressed and or anxious subjects for research studies.(ABSTRACT TRUNCATED AT 400 WORDS)     

Pharmacotherapy for major depression in children and adolescents

Major depression is a serious illness in children which adversely effects their social, academic, and emotional development. It is essential to identify safe and effective medication for the treatment of this disorder in youths. Only some selective serotonin reuptake inhibitors (citalopram, fluoxetine, sertraline) have demonstrated superiority to placebo on primary outcome measures in acute controlled treatment trials. This article will review acute efficacy studies as well as long-term studies of antidepressants for the treatment of childhood depression. Treatment recommendations are discussed and the issue of suicidality and antidepressants are addressed.     

Treatment of children and adolescents with tics and Tourette syndrome

Tics, patterned movements distinct from stereotypies, myoclonus, and other hyperkinetic movements, are quite common in children, particularly among those with developmental and psychiatric disorders. Thus, tics can indicate the presence of atypical neurodevelopment or broader difficulties with cognition or mood. Tics are also the cardinal feature of Tourette syndrome, a childhood-onset neurobehavioral disorder characterized by a chronic inability to suppress or an urge to perform patterned, repetitive movements. Patients with Tourette syndrome most commonly have, in addition to tics, symptoms of inattention, hyperactivity, obsessiveness, or anxiety. Achieving the most effective treatment of a child with tics is contingent on proper diagnosis of the movement disorder and thorough assessment for other problems, followed by consideration of both nonpharmacologic and pharmacologic interventions for any and all symptoms interfering with the child's function and quality of life. This review focuses primarily on the diagnosis and medical treatment of tics in children and adolescents with Tourette syndrome.     

Diagnosis and management of depression and psychosis in children and adolescents with epilepsy

The neurologic dysfunction underlying epilepsy can predispose patients to psychiatric disorders, and the incidence of both depression and psychosis is increased in people with epilepsy. Depressive disorders are the most frequently recognized psychiatric comorbidities in people with epilepsy, but depression in children can be particularly difficult to recognize. Clinicians need to inquire about not only classic symptoms of depression such as anhedonia but also less obvious symptoms such as unprovoked irritability, unsubstantiated complaints of lack of love from family members, somatic complaints, and problems with concentration and poor school performance. The diagnosis of depressive disorders in children with epilepsy and mental retardation is even more difficult. Physicians need to be alert for the presence of iatrogenic depression, which may result from antiepileptic drugs or epilepsy surgery. People with epilepsy are also at increased risk for psychosis, which can be interictal, postictal, or (rarely) an expression of ictal activity. This psychosis can be related to seizure remission (ie, alternative psychosis) or iatrogenic (eg, related to antiepileptic drugs or following temporal lobectomy). Although both antidepressants and antipsychotic drugs have the potential to lower the seizure threshold and increase seizures, careful drug selection, dosing, and slow titration can minimize this risk, allowing treatment to proceed.     

Treatment guidelines for children and adolescents with bipolar disorder

Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines. These guidelines were developed by expert consensus and a review of the extant literature about the diagnosis and treatment of pediatric bipolar disorders. The four sections of these guidelines include diagnosis, comorbidity, acute treatment, and maintenance treatment. These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder. These guidelines are subject to change as our evidence base increases and practice patterns evolve.