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Review z Depression in young people

Management of depression in children

and adolescents
Julia Gledhill MD, MRCPsych, Matthew Hodes PhD, FRCPsych
As part of our series on managing neurological and psychiatric conditions in children and
adolescents, Dr Julia Gledhill and Dr Matthew Hodes discuss depression.

T he aim of this article is to briefly describe the fea-

tures of depression in children and adolescents,
including epidemiology and aetiology, and then to
Children in infancy and at primary school age
may develop depression against a background of
poor parental care, which could include neglect,
give an account of the salient aspects of management. abuse and family conflict. Additional adversities
The treatment of bipolar disorder is beyond the remit include parental mental health problems, including
of this article. parental depression. Parental depression is associ-
ated with childhood depression and may occur
Depressive disorders in children and adolescents because of genetic factors.
Depressive disorders in children and adolescents are Interestingly, genetic influences are stronger in ado-
identified using the same diagnostic criteria (ICD-101 lescent depression. Other risk factors for adolescent
and DSM-5 2) as those in adults. They are charac- depression are onset of puberty and hormonal change
terised by core symptoms of mood changes (low in girls, negative life events including bereavement, and
mood/irritability) or loss of enjoyment which lasts at stressors such as family conflict and peer difficulties.
least two weeks and is associated with cognitive and
biological symptoms (see Table 1). Primary care management
Depression can be categorised in terms of severity Only a minority of young people with depressive dis-
by the number of symptoms present (see Table 1), orders present to specialist services,7 but many attend
although in practice depends on a complex clinical primary care services, although not necessarily for
judgement. There may be associated functional depression.
impairment at home, at school or with regard to peer About 75% of registered adolescents attend the
relationships. In contrast to adults, irritability rather general practitioner (GP) each year,8 almost exclu-
than sadness may be the predominant mood change sively presenting with physical health complaints;
and low mood may be less pervasive. about 20% have a concurrent depressive episode,9
often unrecognised by the GP with over 50% still in
Prevalence episode six months later.10
The community prevalence of depressive disorder The primary care service is well placed for provid-
increases from childhood (approximately 1%) to ado- ing intervention. NICE guidelines endorse the need
lescence (3–8%),3,4 and is more common in females.4 for primary care health care professionals to be famil-
Depressive disorders in this age group are associ- iar with screening for mood disorders, to recognise
ated with significant morbidity, such as impaired those with difficulties and provide support.11 NICE
social and academic functioning, substance misuse, recommends watchful waiting initially, and, if the mild
increased risk for other psychiatric disorders as well depression persists, then supportive psychotherapy,
as attempted and completed suicide.5 group cognitive behavioural therapy (CBT) or guided
self-help should be offered.
Causes of depression UK studies have demonstrated the feasibility and
Understanding the causes of depression is useful for effectiveness of interventions to enhance identifica-
considering treatment options. It is recognised that tion and management of depression in primar y
the causes of depressive disorder are multi-factorial, care.12,13 This includes changing the focus of the con-
but evaluating the significance of each is difficult as sultation from the presenting physical complaint(s) to
they tend to be correlated.6 The significance of the a psychological enquiry and screening for depressive
putative risk factors may vary according to age and disorder using diagnostic criteria by enquiring about
developmental phase. depressive symptoms.

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Depression in young people z Review

Key symptoms Associated symptoms Severity

• Depressed mood • Reduced concentration and Mild:

• Loss of interest and enjoyment attention • 2 key symptoms
• Reduced energy leading to • Reduced self-esteem and self- • 2 associated symptoms
increased fatiguability and confidence
diminished activity • Ideas of guilt and unworthiness Moderate:
• Bleak and pessimistic views of the • 2 key symptoms
future • 3–4 associated symptoms
• Ideas or acts of self-harm or suicide
• Disturbed sleep Severe:
• Diminished appetite • 3 key symptoms
• 4 associated symptoms

Table 1. ICD-10 criteria for depression1

Primary care practitioners can be trained to deliver version (http://devepi.duhs.duke.edu/mfq.html).
some components of the evidence-based psychologi- This questionnaire has been validated for the detec-
cal treatments for depressive disorder (CBT and inter- tion of depressive disorder in CAMHS in the UK, and
personal psychotherapy for adolescents [IPT-A]) within is also very useful for monitoring treatment progress.11
the consultation, which may be a sufficient interven- The Children and Young Persons Increasing
tion for some young people with mild depression. In Access to Psychological Treatments (CYP-IAPT) ini-
the United States, a quality improvement intervention tiative began in 2011 in England, and has a target to
included training for primary care clinicians on the work with CAMHS that cover 60% of the 0–19 aged
assessment and treatment of depression, increased population by March 2015. It includes a number of
access to CBT and/or medication. This demonstrated parent and child report questionnaires including the
benefit at six months as compared to ‘usual care’ Revised Children’s Anxiety and Depression Scale
including fewer depressive symptoms and improved (RCADS); see www.cypiapt.org/children-and-young-
quality of life compared with the ‘usual care’ group.14 peoples-project.php.

Management in secondary care: assessment Psychological therapies

Children and young people with persistent mild Cognitive behavioural therapy
depression or moderate to severe depression should Cognitive behavioural therapy, based on social learn-
be referred to specialist Child and Adolescent Mental ing theory, is a collaborative, goal-focused, time-lim-
Health Services (CAMHS). Those suspected to have ited treatment underpinned by the reciprocal
severe depression but not at high risk of suicide should relationship between thoughts (cognitions), feelings
be assessed by CAMHS within a maximum of two weeks and behaviour. It focuses on identifying cognitive dis-
of referral, and, if they have high suicide risk, the assess- tortions linked with depressed mood which are chal-
ment should be carried out within 24 hours.15 lenged in the therapeutic work. CBT also includes
In secondary care, it is appropriate to carry out a psycho-education, self-monitoring, eg diary keeping,
psychiatric interview which is the ‘gold standard’ for enhancing emotional regulation and activity sched-
identification of depressive disorder and other psy- uling. 16 CBT has been evaluated as a therapy for
chiatric disorders.6 Both parents and children should depression both alone and in addition to
be interviewed. Parents are better informants regard- pharmacological treatment.
ing past history and behaviour linked to disruptive The current evidence base supports CBT alone for
behaviours, whereas children are better informants the treatment of mild to moderate depression. The
regarding internal experiences including guilt, anhe- largest meta-analysis of CBT identified 35 studies and
donia and suicidal ideation. found an effect size of 0.34 (small to medium effect).17
Standardised interviews, such as the semi-struc- It is also striking that this review found treatments that
tured Schedule for Affective Disorders and emphasise changing cognitions were not more effec-
Schizophrenia in Children and Adolescents, provide tive than non-cognitive treatments, eg those that
research standard assessments but are too time con- emphasised activity scheduling and other techniques.
suming for routine use by most CAMHS. Screening However, more severe depression is less likely to
for depression can be carried out using the Mood and remit with CBT alone, 18 and the Treatment for
Feelings Questionnaire which has a child and parent Adolescent Depression Study showed no benefit of

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Review z Depression in young people

CBT alone over placebo for moderate to severe However, it is more effective than supportive psy-
depression after 12 weeks of treatment.19 Meta-analy- chotherapy in changing aspects of family interaction,
sis of studies shows that CBT when added to serotonin such as conflict, that are associated with onset and
reuptake inhibitor (SSRI) antidepressants does not perpetuation of depression. These benefits are seen
confer an advantage.20 two years after start of the treatments.26
CBT may have a useful role in preventing recur- Attachment-based family therapy has been inves-
rence of depression after remission and preventing tigated in an RCT of adolescents with depressive
new-onset depressive episodes in at-risk groups, such symptoms and suicidal ideation.27 Among the sub-
as the children of parents who have depression and group of adolescents with depressive disorder, attach-
young people with sub-threshold symptoms.21 ment-based family therapy was significantly more
effective in improving depression than the ‘usual
Interpersonal psychotherapy (IPT) care’ group.
IPT for adolescents with depression (IPT-A) has devel-
oped from adult interpersonal therapy. It is a short- NICE recommendations for psychological treatment in Child
term therapy whose central tenet is the interpersonal & Adolescent Mental Health Services
context in which depressive symptoms occur, and the NICE recommends that, for moderate to severe
reciprocal links between interpersonal relationships, depression, the treatment should be individual CBT,
emotions and affect. This approach may be particu- IPT-A, or shorter-term family therapy.11
larly valuable for this age group where the onset of If the depression continues, then an alternative
depression, response to treatment, and outcomes may psychological therapy, which could include psycho-
be influenced by the relationships between the young dynamic psychotherapy, should be offered. It is sug-
person and significant others such as family members gested that psychological treatment should be at least
and peers. IPT-A focuses on four problem areas: grief, three months’ duration.
interpersonal role disputes, role transitions, and These recommendations have generated contro-
interpersonal deficits. versy28 given the weak evidence base for psychody-
There have been only three randomised con- namic psychotherapy, and the finding that CBT is no
trolled trials (RCTs) of IPT-A and none to date have better than placebo for moderate to severe depres-
compared IPT-A with pharmacological treatments. sion.19 Furthermore, there is no evidence that such
IPT-A has been demonstrated to be superior to clini- treatments should be offered for a three-month trial
cal monitoring (which included brief supportive ther- before commencement of an SSRI antidepressant
apy) at the end of 12 weeks of treatment (75% vs 46% (see below).
recover y respectively), in a sample of 48 clinic-
referred adolescents.22 A small study of 71 Puerto Pharmacotherapy
Rican young people compared three groups: IPT, The decision to use pharmacotherapy for children
CBT and a waiting-list control group. Both the IPT and adolescents with depressive disorder will be
and CBT group did better than the waiting-list con- guided by a number of considerations. This will
trol, but there was no significant difference in out- include the duration and severity of depression,
come between the two therapies.23 A more recent comorbidity, and history of response to other treat-
study trained school-based mental health clinicians ments and antidepressants. In the UK, NICE 11
in IPT-A and compared this to a ‘treatment as usual’ recommends that antidepressant medication for mod-
control group for young people with depressive diag- erate or severe depression should be initiated by child
noses and moderate functional impairment. IPT-A and adolescent psychiatrists.
was superior with regard to reduction in depressive Approximately 20% of patients referred with mod-
symptoms and reduced functional impairment; these erate to severe depressive disorder (ie five symptoms
gains were maintained at 16-week follow up.24 or more) will respond over two to four weeks to initial
Historically in the UK, the paucity of therapists assessment carried out in CAMHS that include
trained in IPT-A limited the availability of this treat- individual child and parent interviews, psycho-edu-
ment, but this is now being changed with the CYP- cation regarding the depressive disorder, and risk
IAPT initiative which includes a module on IPT-A. management.29
Patients who have persistent depression may then
Family therapy be offered an SSRI antidepressant and, given the evi-
Family therapy has been shown to be not as effective dence base supporting fluoxetine, this would be the
as CBT for treatment of depression in adolescents.25 first-line drug. The fluoxetine should be started at

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Depression in young people z Review

10mg daily and increased after one week to 20mg in Other treatments
the absence of significant side effects. Two other treatments will be considered here. Light
For children, 20mg will usually be an adequate therapy is recommended for people with seasonal
dose but, for adolescents, the fluoxetine may be affective disorder. There are a number of studies
increased to 30mg and 40mg if they are not respond- including one RCT that has found light therapy to be
ing adequately.30 Some reports suggest that fluoxe- beneficial for youngsters with seasonal affective dis-
tine 60mg could be used for those not responding to order. 36 However, some commentators have cast
40mg.6,31 Nevertheless, children may respond less doubt on the efficacy of this treatment.
well than adolescents to SSRI antidepressants.32 The other treatment that needs to be mentioned
However, of patients who do not respond to flu- is electroconvulsive therapy (ECT). This treatment is
oxetine, 50% will respond to another SSRI antide- rarely used owing to concern about harmful effects.
pressant.33 In the UK, sertraline and citalopram are Open trials suggest ECT can be beneficial for adoles-
regarded as second-line SSRIs for child and adoles- cents with very severe depression.36 Following the
cent depression11 (see Table 2), and this has some ECT, treatment will then typically be continued with
research support.34 Citalopram is associated with QT pharmacotherapy.
prolongation and so individuals known to have car-
diac abnormalities, or at risk of these, should have an Hospital admission
ECG carried out prior to using this drug. Children and adolescents with depressive disorder may
A third-line drug would be venlafaxine which may require psychiatric admission for ongoing manage-
be beneficial,33 but the side effects result in a high level ment. Indications include high suicidal risk, and depres-
of non-adherence. The antidepressants frequently used sion that results in self-neglect including the inability
in the USA are also included in Table 2 given the mobil- to eat and drink. Admission may also be required to
ity of young people from the USA to Europe. assess the severity of depression and the young person’s
Evidence suggests that the SSRI antidepressant social function when separated from family.
should be continued for six to nine months follow- The admission serves to provide an environment
ing response.35 Most SSRIs should be tapered slowly, where the young person will be safe, and appropriately
but in view of the long half-life of fluoxetine this can cared for.37 The depression may be ameliorated by the
be achieved more rapidly. non-specific elements of the ward milieu including:
There has been a high level of concern about sui- building up a relationship with key workers; groups with
cidality, both suicidal thinking and behaviour, in asso- staff and peers; promoting peer relationships; removal
ciation with SSRI antidepressants. The Treatment for from social difficulties in the external environment;
Adolescent Depression Study suggested the levels and attendance at an appropriate on-site school.
would be lower when fluoxetine was used in combina- Specific treatments for depression might include indi-
tion with CBT.19 Recent reviews have not shown that vidual treatment such as CBT, family therapy and phar-
the levels of suicidal ideation are significantly differ- macotherapy. Admission is associated with great
ent among children and adolescents taking antide- improvement but follow-up studies have shown that a
pressants for depression compared to those having significant minority continue to have ongoing difficul-
other treatments or placebo.32 ties, including depression and suicidal behaviour.38,39

Guideline Minimum age (years) for licensed

prescribing

Drug NICE Texas* UK USA

Fluoxetine First-line First-line ≥8** ≥8

Sertraline Second-line First-line ≥18 ≥18
Citalopram Second-line First-line ≥18 ≥18
Paroxetine Contraindicated by CSM Second-line† ≥18 ≥18
Escitalopram Not discussed Second-line ≥18 ≥12
Venlafaxine Contraindicated by CSM Third-line ≥18 ≥18

*For major depression of sufficient severity to warrant medication. **For moderate to severe depression. †Adolescents only.

Table 2. NICE (UK)11 and Texas (USA)45 guidelines for drug treatments for child and adolescent depression (from Dubicka et al, 2010)30?

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Review z Depression in young people

Outcome adolescent girls. I: estimates of symptom and syndrome prevalence. Br

The natural history of a single depressive episode is J Psychiatry 1993;163:369–74.
4. Ford T, Goodman R, Meltzer H. The British Child and Adolescent
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nity samples40 and 80% by a year in clinic samples.41 Acad Child Adolesc Psychiatry 2003;42(10):1203–11.
5. Thapar A, Collishaw S, Potter R, et al. Managing and preventing
There is also variation between populations with
depression in adolescents. BMJ 2010;340:254–8.
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have shown a median episode duration of 8–12 weeks cence. In: Rutter M, Bishop D, Pine D, et al., eds. Rutter’s Child and
in community samples,40 and 7–24 months in clinic- Adolescent Psychiatry, 5th edn. Blackwells, 2008;587–612.
7. Essau CA. Use of mental health services among adolescents with anx-
referred samples,40–42 probably reflecting greater iety and depressive disorders. Depress Anxiety 2005;22:130–7.
severity and higher comorbidity in the latter group. 8. Kramer T, Iliffe S, Murray E, et al. Which adolescents attend the GP?
After recovery, clinic attenders also have a shorter Br J Gen Pract 1997;47:327.
9. Kramer T, Garralda ME. Psychiatric disorders in adolescents in pri-
time to recurrence (50% within three years)41 as com- mary care. Br J Psychiatry 1998;173:508–13.
pared with community samples (50% within five 10. Gledhill J, Garralda ME. The short-term outcome of depressive dis-
order in adolescents attending primary care: a cohort study. Soc
years).43 Despite persistence, only a minority seek spe-
Psychiatry Psychiatr Epidemiol 2011;46:993–1002.
cialist help. Depression in children and adolescents is 11. National Institute for Health and Clinical Excellence. Depression in
a potentially chronic and relapsing disorder with con- children and young people. Clinical Guideline 28. London: NICE, 2005.
12. Gledhill J, Kramer T, Iliffe S, et al. Brief Report: Training general
tinuity into adulthood, and an increased risk of adult
practitioners in the identification and management of adolescent
psychopathology and impairment.44 depression within the consultation: a feasibility study. J Adolescence
2003;26:245–50.
13. Kramer T, Iliffe S, Bye A, et al. Testing the feasibility of therapeutic
Conclusions
identification of depression in young people in British general prac-
The evidence at the time of writing suggests that tice. J Adolesc Health 2013;52:539–45.
appropriate interventions in primary care settings 14. Asarnow JR, Jaycox LH, Naihua D, et al. Effectiveness of a quality
improvement intervention for adolescent depression in primary care
include watchful waiting, brief problem solving or
clinics: a randomised controlled trial. JAMA 2005;293:311–9.
cognitive behaviour therapies. 15. National Institute for Health and Care Excellence. Depression in chil-
Mild cases of depression in more specialist serv- dren and young people. NICE quality standards (QS48). London: 2013
16. Verduyn C. Cognitive behaviour therapy in childhood depression.
ices should be offered CBT or IPT. Child Adolesc Mental Health 2000;5:176–80.
For moderate to severe depression, following full 17. Weisz JR, McCarty CA, Valeri SM. Effects of psychotherapy for
assessment, fluoxetine should be offered. Non- depression in children and adolescents: a meta-analysis. Psychol Bull
2006;132:132–49.
response may be followed by switching to another 18. Jayson D, Wood A, Kroll L, et al. Which depressed patients respond
SSRI and also addition of CBT, where this is available. to cognitive-behavioural treatment? J Am Acad Child Adolesc Psychiatry
Family therapy may be used for mild, moderate or 1998;37:35–9.
19. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioural
severe depression to address significant family rela- therapy, and their combination for adolescents with depression:
tionship problems. Problems in the external environ- Treatment for Adolescents with Depression (TADS) randomized con-
ment such as learning difficulties or peer difficulties trolled trial. JAMA 2004;292:807–20.
20. Dubicka B, Elvins R, Roberts C, et al. Combined treatment with cog-
should also be addressed. nitive-behavioural therapy in adolescent depression: meta-analysis. Br
J Psychiatry 2010;197:433–40.
Dr Gledhill is Honorary Clinical Senior Lecturer, Imperial 21. Garber J, Clarke GN, Weersing VR, et al. Prevention of depression
in at-risk adolescents: a randomised controlled trial. JAMA
College London, and Consultant Child and Adolescent 2009;301:2215–24.
Psychiatrist, Central and North West London NHS 22. Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal
Foundation Trust; Dr Hodes is Senior Lecturer in Child therapy for depressed adolescents. Arch Gen Psychiatry 1999;56:573–9.
23. Rossello J, Bernal G. The efficacy of cognitive-behavioural and inter-
and Adolescent Psychiatry, Imperial College London, and personal treatments for depression in Puerto-Rican adolescents. J
Honorary Consultant Child and Adolescent Psychiatrist, Consult Clin Psychol 1999;67:734–45.
Central and North West London NHS Foundation Trust 24. Mufson L, Dorta KP, Wickramaratne P, et al. A randomised effec-
tiveness trial of interpersonal psychotherapy for depressed adolescents.
Arch Gen Psychiatry 2004;61:577–84.
Declaration of interests 25. Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for
There are no conflicts of interest declared. adolescent depression comparing cognitive, family and supportive ther-
apy. Arch Gen Psychiatry 1997;54:877–85.
26. Kolko DJ, Brent DA, Baugher M, et al. Cognitive and family thera-
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POEMs
Drug therapy minimally, if at all, effective for PTSD

Clinical Question Synopsis

Is drug therapy effective for posttraumatic stress The authors searched 13 databases, including the
disorder? Cochrane Library, to identify all randomized dou-
ble-blind studies of drug treatment of adults with
Bottom line PTSD. Two reviewers identified suitable studies,
Overall, drug therapy has a minimal effect on the extracted the data and evaluated the studies for
symptoms of posttraumatic stress disorder bias. The authors identified 41 studies that evalu-
(PTSD). Some selective serotonin reuptake ated efficacy and 35 that evaluated acceptability of
inhibitors (SSRIs) show a benefit on symptoms, treatment. Most of the studies evaluated SSRIs,
but the effects are small. (LOE = 1a) though 2 small studies evaluated topiramate
(Topamax) and 2 studies assessed the antipsy-
Reference chotic olanzepine (Zyprexa). In the 21 studies
Hoskins M, Pearce J, Bethell A, et al. that compared an SSRI with placebo (N = 3932),
Pharmacotherapy for post-traumatic stress disor- there was a small effect demonstrated (standard-
der: systematic review and meta-analysis. Br J ized mean difference = –0.23, 95% CI –0.33 to
Psychiatry 2015;206(2):93-100. –0.12), though there was substantial heterogeneity
among the studies. Paroxetine (Paxil) was slightly
Study design: more effective than other drugs on the basis of
Meta-analysis (randomized controlled trials) self-rated and clinician-rated scales; fluoxetine
(Prozac) and venlafaxine (Effexor) were superior
Funding source: Foundation on a clinician-rated scale.

www.progressnp.com Progress in Neurology and Psychiatry March/April 2015 33