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Depression
in Children—Part II
(This article was first printed in the March
2002 issue of the Harvard Mental Health Letter.
For more information or to order, please go
to http://health.harvard.edu/mental.)
In Part I we discussed the symptoms, causes,
and diagnosis of child and adolescent depression.
In this part we consider medications, psychotherapy,
help for families, and some early efforts at
prevention.
Medications
A few controlled studies have found that the
SSRIs paroxetine (Paxil), fluoxetine (Prozac),
and sertraline (Zoloft) are as effective in children
as they are in adults—about 60% improve,
compared with 35% taking a placebo. The side
effects are similar in children and adults. Some
physicians also use the newer antidepressants
venlafaxine (Effexor), mirtazapine (Remeron),
bupropion (Wellbutrin), and nefazodone (Serzone).
For reasons that are not clear, the older tricyclic
antidepressants have never been shown to be more
effective than a placebo in children. If the
child feels better, drug treatment should usually
continue for at least 4–6 months. Stopping
sooner raises the risk of relapse. [2005 Note:
Lately, highly publicized concerns about the
risk of suicide have led practitioners to exercise
particular caution. To read more, go to the FDA information
on antidepressant use in children, adolescents,
and adults.]
The mood stabilizers prescribed for adults with
bipolar disorder—lithium and anticonvulsants—are
also given to children, although again there
are no controlled studies and the FDA has not
formally approved any drug treatment. Sometimes
antidepressants or antipsychotic drugs are added
(See HMHL , April 2001). After a child’s
mood is reasonably stable, he or she can also
be treated with a stimulant for any symptoms
of attention deficit disorder.
Critics have been concerned about the growing
use of psychiatric drugs by children and adolescents.
They complain that physicians and psychiatrists
are turning too quickly to chemical solutions
rather than psychotherapy, possibly under the
pressure of insurers and HMOs trying to cut expenses.
Some say the drugs are overused because services
are inadequate. They are worried about the effects
of drug combinations, especially those that include
stimulants. They doubt that we know enough about
possible long-term effects on the developing
brain.
At least until recently, though, very few children
had been taking antidepressants and mood stabilizers.
In a study based on data from 1994, investigators
looked at the records of 900,000 young people
in two state Medicaid systems and an HMO. About
2% of children and adolescents in the Medicaid
programs and 1% of children in the HMO were taking
antidepressants (at ages 15–19, the rate
rose to 4% for the group as a whole). But the
rate was three to five times higher in 1994 than
in 1988, the year before Prozac was introduced.
Another study, published in October 2000 and
based on a survey conducted in 1990–1995
by the Bureau of the Census, indicates that 1.5%
of children ages 5–18 who saw a doctor
were given an antidepressant. Only 13% of children
and adolescents diagnosed with depression (and
no other mental illness) received antidepressants
alone as a treatment. Another 32% received psychotherapy
alone, 36% received both, and 20% received neither.
Preschool children are even less likely to be
given psychiatric medications, according to a
study reported at the American Psychological
Association convention in 2001. In 1997–98,
among 40,000 children under 5 served by a large
HMO, 0.4% (about 150) received any medication
at all for emotional or behavior problems. Fourteen
(0.04%) were taking antidepressants, and nine
of them were diagnosed with a mood disorder.
Psychotherapy
Parents can find a child psychiatrist or other
mental health professional for psychotherapy
through a general practitioner, pediatrician,
school psychologist, guidance counselor, or the
department of psychiatry at a university hospital.
Most psychotherapists use the same methods for
children that they use with adults, adapting
them to a child’s understanding and the
needs of the child’s family. Supportive
therapy provides a sympathetic listening ear,
reassurance, and advice to parents and depressed
children. Psychodynamic therapy is often helpful
for older children and adolescents; its aim is
to explore the impact of important relationships
and the effectiveness of a person’s psychological
defenses against uncomfortable emotions.
The most thoroughly tested form of psychotherapy
for children is cognitive behavioral treatment.
On the cognitive side, it takes aim at errors
in thinking, especially self-defeating automatic
thoughts that rule from the fringes of awareness.
These thoughts are associated with sadness and
withdrawal that make all of life’s problems
seem impossible to solve. The psychotherapist
tries to make these unacknowledged thoughts explicit,
and goes on to help the patient examine schemas,
which are defined as pervasive fundamental systems
of belief and ways of interpreting experience.
The schema underlying depression, the so-called
cognitive triad, is sometimes stated as, “I
am worthless, the world is hostile, and there
is no hope for the future.” A depressed
child or adolescent is shown evidence against
these beliefs and helped to substitute new ways
of thinking for pessimistic and self-critical
attitudes. For this purpose, the patient may
be asked to keep a daily record of thoughts and
feelings.
On the behavioral side, children are encouraged
to make a record of their activities and learn
which ones give them pleasure or a sense of accomplishment.
In therapy sessions and homework assignments,
they rehearse new ways of behaving while learning
assertiveness, practicing social skills, and
developing strategies for solving problems.
Another treatment, interpersonal therapy, is
used mainly for adolescents and emphasizes personal
relationships or recent events in the patient’s
life. The therapist usually chooses one of four
problems for special attention: grief and loss,
ongoing disputes and conflicts within the family,
life transitions, and social isolation. The therapist
may help the patient find activities and friendships
to compensate for a loss, explore ways of resolving
conflicts or surviving a transition, or provide
training in the social skills needed to establish
and maintain personal relationships. Some issues
important for adolescents are parental authority,
separation or independence from parents, relations
with the opposite sex, and pressures for conformity.
Psychotherapists who work with depressed children
may also be able to help their parents by improving
family communication and problem-solving. Parents
can be educated about depression, learning how
to respond to the child’s behavior and
avoid situations that cause unnecessary conflict.
In interpersonal therapy for adolescents, the
last session is often a family meeting in which
the therapist tries to help everyone distinguish
between problems arising from depression and
the usual tensions between teenagers and their
parents. When a child has bipolar disorder, rehearsing
what to do in case of a relapse may be useful.
Families can also be taught how to avoid hostile
and otherwise intensely emotional comments that
raise the risk of relapse. Finally, treatment
for a depressed parent is also treatment for
a child who is depressed or at risk of depression.
Suicide is rare before age 12 but almost as
common in late adolescence as it is in adults—even
though adolescent suicide is often concealed
or not acknowledged, and may be disguised in
the form of reckless driving and drug overdoses.
Signs to explore are an apparent lack of interest
in the future (“It’s no use”; “Nothing
matters”), constant thoughts about death
and dying, and, of course, fantasies about suicide
or a suicide plan. Suicidal thoughts and suicide
attempts, even if not highly lethal, should always
be taken seriously, because people who attempt
suicide are at increased risk for completed suicide.
It is safe to ask the adolescent direct questions,
perhaps beginning “Have you ever felt so
low that life seemed to be not worth living?” Teenagers
who are not suicidal will say so. Some who have
suicidal thoughts will not confess them, but
others feel relieved to be able to talk about
it. The therapist may offer solutions to the
problem for which suicide was thought to be the
answer, just to see whether the adolescent acknowledges
that there are alternatives. Therapists may also
convene a family meeting to make sure that the
family understands how to respond to suicidal
impulses.
Hospitalization is sometimes necessary when
the danger of suicide is immediate. Parents should
ask why it is being recommended, what the alternatives
are, whether the admitting physician is a certified
child or adolescent psychiatrist, what the treatment
program at the hospital is, and how long the
child will be in the hospital. Legally, minors
can be committed without their consent on the
authority of a parent, but in practice psychiatrists
will almost always consult their young patients
first.
There are few controlled studies of psychotherapy
for depressed children and adolescents, and most
of them involve cognitive behavioral treatments.
In a 1998 review, five of seven controlled trials
found cognitive behavioral therapy to be more
effective than no treatment (that is, being placed
on a waiting list). The average rate of improvement
was about the same as the rate found in medication
trials. A 1998 meta-analysis (combined analysis)
including six controlled studies of cognitive
behavioral therapy for adolescents indicated
that depressive symptoms were reduced for as
long as two years. The most common control was
a waiting list or relaxation rather than another
form of psychotherapy or medication. Little is
known about the effectiveness of other forms
of psychotherapy.
Despite the uncertainty about causes, mental
health professionals are beginning to work with
schools in an attempt to prevent childhood depression.
In one study, the families of 8- to 14-year-old
children who had a parent with a mood disorder
were divided into two groups. One group was given
only educational lectures attended by many families.
In the second group, therapists met four to eight
times with individual families, including separate
sessions for parents and children as well as
joint meetings with the whole family, to discuss
how the parent’s depression affected the
children. Family communication improved in both
groups, but the response was better in families
given individual attention.
In another study, researchers tested a school-based
program for 10- to 13-year-olds who had symptoms
of depression and conflicts with their parents.
They were divided into four groups and assigned
to cognitive training, social problem solving,
a combination of both, or a control group with
no special treatment. Children in all three treatment
groups had fewer symptoms of depression than
the controls immediately after treatment and
six months later.
We still understand much less about mood disorders
in children than we do about these disorders
in adults. Long-term studies of prevention and
treatment are needed, including more information
about the adult outcome for children with depressive
symptoms and how behavior disorders and attention
deficit disorder are related to childhood depression.
Far too little is known about either the risks
or the therapeutic effects of antidepressants
and mood stabilizers in children. We don’t
know whether the drugs are being overused or
underused. Eventually, genetic and other research
may reveal different kinds of childhood depression
that respond to individualized forms of drug
treatment and psychotherapy.
Resources
- National Depressive and Manic-Depressive
Association (NDMDA)
730 North Franklin St., Suite 501
Chicago , IL 60610-7204
Telephone: (800)826-3632
Web: http://www.ndmda.org
- Child and Adolescent Bipolar Foundation (CABF)
1187 Wilmette Ave. P.M.B. #331
Wilmette , IL 60091
Telephone: (847) 256-8529
Web: http://www.bpkids.org
- American Academy of Child and Adolescent
Psychiatry (AACAP)
3615 Wisconsin Ave., N.W.
Washington , D.C. 20016-3007
Telephone: (202) 966-7300
Web: http://www.aacap.org
FOR FURTHER READING
Goodyear, I.A. et al., eds. The Depressed Child
and Adolescent, second edition. Cambridge University
Press, 2001.
Shamoo, T.K. et al. Helping Your Child Cope
with Depression and Suicidal Thoughts. Jossey-Bass,
1997.
Empfield, M. and Bakalar, N. Understanding Teenage
Depression: A Guide to Diagnosis, Treatment,
and Management. Henry Holt, 2001.
James, A.C. and Javaloyes, A.M. “Practitioner
Review: The Treatment of Bipolar Disorder in
Children and Adolescents,” Jour nal
of Child Psychology and Psychiatry and Allied
Disciplines (2001): Vol. 42, No. 4, pp.
439–49.
Emslie, G.J. et al. “Mood Disorders in
Children and Adolescents: Psychopharmacological
Treatment,” Biological Psychiatry (
June 15, 2000): Vol. 49, No. 12, pp. 1082–90.
Harrington, R. et al. “Systematic Review
of Efficacy of Cognitive Behaviour Therapies
in Childhood and Adolescent Depressive Disorder,” British
Medical Journal (1998): Vol. 316, pp. 1559–63.
Curry, J.F. “Specific Psychotherapies
for Childhood and Adolescent Depression,” Biological
Psychiatry ( June 15, 2001): Vol. 49, No.
12, pp. 1091–1100.
(This article was first printed in the March 2002 issue of the
Harvard Mental Health Letter. For more information or to order,
please go to http://health.harvard.edu/mental.)
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