Depressive Disorders (Children and Adolescents) (Treatments)

The most common treatment for depressive disorders in children and adolescents involves psychotherapy and medication, as well as targeted interventions involving the home or school environment.

An NIMH-funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option. Other NIMH-funded researchers are developing and testing ways to prevent suicide in children and adolescents, including early diagnosis and treatment, and a better understanding of suicidal thinking.

Psychotherapy is often used as an initial treatment for milder forms of depression. Many times, psychotherapy accompanied by an early follow-up appointment may help to establish the persistence of depression before a decision is made to try antidepressant medications.

Many forms of psychotherapy, including some short-term (10- to 20-week) therapies, can help depressed individuals. Talking therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with homework assignments between sessions.

Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—have been proven effective in treating depression. CBT helps people change negative styles of thinking and behaving that may contribute to depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings.

Continuing psychotherapy for several months after remission of symptoms may help patients and families consolidate the skills learned during the acute phase of depression, cope with the after-effects of the depression, effectively address environmental stressors, and understand how the young person's thoughts and behaviors could contribute to a relapse.

Antidepressant medications, especially when combined with psychotherapy, can be very effective treatments for depressive disorders in adults. Use of SSRI medications has risen dramatically in the past several years in children and adolescents ages 10 through 19.

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac®), citalopram (Celexa®), sertraline (Zoloft®) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor®) and duloxetine (Cymbalta®).

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In 2005, the FDA adopted a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning, the most serious type of warning on prescription drug labeling, emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. This warning advises additionally that families and caregivers be told of the need for close monitoring and report any changes to the physician.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.

Medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to undergo psychotherapy, those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation of treatment with medication and, or, psychotherapy for at least several months may be recommended by the psychiatrist, given the high risk of relapse and recurrence of depression. Discontinuation of medications, as appropriate, should be done gradually over six weeks or more.