Treatment
Treatment of depression includes ensuring safety, establishing a therapeutic relationship, and creating a social support system for the patient. Safety must be addressed first. If the child expresses thoughts of wanting to hurt him- or herself or others, immediate referral to a mental-health professional or the nearest emergency department is mandatory. The same rule applies if a child is acutely psychotic, aggressive toward others, or at risk of being abused or neglected at home. Prompt reporting and referral take precedence over confidentiality in any situation in which there is clear potential for harm to the patient and/or others.
The PCP has the advantage of an established relationship with the child and therefore plays a major role in the therapeutic plan. Family members are a vital component of the child's social support system and need to understand the importance of close supervision. Name a specific person the child should notify if he or she is feeling worse or having thoughts of self-harm. Provide family members with a telephone number they can call at any time if they are worried about changes in the child's mood or behavior. In addition to the immediate and extended family, the social support network can include the school nurse, a school counselor, sports coach, scout leader, member of the clergy, or any caring adult with whom the child has a trusting relationship.
Treatment plans for depression must include professional psychotherapy or counseling plus careful consideration of antidepressant medication.5,6 Research shows that the best treatment response comes from a combination of therapy and antidepressant medications. PCPs often are not trained in psychotherapy but should be able to advise the family about its benefits.
Cognitive-behavioral therapy is used to treat depression in patients of all ages, and there is a large body of research supporting its effectiveness. The cognitive component consists of identifying and changing negative thoughts that can cause or contribute to a depressed mood (e.g., “I am a bad person,” “nobody cares about me,” “my life is all a mess,” etc.). The behavioral component focuses on setting specific goals and following through with such goal-directed actions as doing homework for short periods on school days or participating in one outside activity per week. Interpersonal therapy is another venue that allows the child to talk about troubling life situations and to learn and practice social skills for building better relationships with others.
Unfortunately, accessing professional psychotherapy can be quite difficult. Pediatric therapists are few in number and almost exclusively found in large urban areas. Psychotherapy can be expensive and may not be covered by the family's insurance plan. Support groups, if available, can be very helpful to patients and family members. The Web site of the National Alliance on Mental Illness is a good source of information about support groups. The child's school counselor may also know about groups available locally.
Medications
Antidepressant medication must be seriously considered. The use of psychotropic drugs in children has always been controversial because the long-term effects on developing brains are unknown. Antidepressant therapy became even more controversial in 2004 when the FDA began requiring drug manufacturers to place warning labels on all antidepressants. The FDA ruling was based on research studies indicating a small but statistically significant increased risk of suicidal thoughts and/or attempts in children and adolescents taking antidepressants.7 However, these studies did not show increased suicide completion, nor did they establish the base rate of suicide that would have occurred without treatment. Studies conducted since the ruling indicate that antidepressants are efficacious in the treatment of pediatric depression and that risks of increased suicidality do not outweigh the direct patient benefits of these medications.2,8,9
Suicide in patients treated with antidepressants has been an issue ever since these drugs were first used in adults, and there are a number of potential explanations. Mood improvement typically does not take place for one month or more, while side effects tend to appear immediately. This can worsen the sense of hopelessness in the patient and contribute to the perception that the treatment is worse than the illness. Another possibility is that prior to starting treatment, the patient made —but was unable to implement—a suicide plan. The medication increases the energy level but the feeling of hopelessness does not lift, and the patient finds the strength to carry out the suicide plan. This is commonly referred to as “emergence.” Finally, there is the possibility that the patient who presents with major depression is actually showing the first signs of bipolar illness and will swing toward mania when treated with an antidepressant. Increased energy, irritability, agitation, and impulsiveness create a suicide risk in these patients and must be monitored accordingly.
PCPs must weigh the potential risks and benefits of any prescribed therapy. The risk of suicide is clearly present in a severely depressed person who is not adequately treated. Data compiled by the CDC show an increase in the suicide rates for children aged 10 to 19 years in the year following the FDA ruling on black-box warnings for antidepressants.3 A meta-analysis of studies measuring therapeutic effects and the incidence of suicidal thoughts and/or attempts in pediatric patients treated with antidepressants concluded that the potential benefits outweighed the risks.8
Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs for treatment of depression in children and adolescents (Table 4). Based on studies of safety and efficacy, fluoxetine (Prozac) is the only antidepressant with an official FDA indication for use in pediatric patients.10 Such other medications as sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox) are prescribed off-label. The FDA advises that paroxetine (Paxil) should not be used in the pediatric population. SSRI starting doses should be the lowest possible, with cautious upward titration as indicated. Follow up by telephone within 72 hours, and schedule office visits at least once a week until the child's mood stabilizes. Make certain that neither the child nor the family thinks of the medication as a magic pill that will make things better immediately. Side effects tend to be worse in the first week, and the family needs to observe the child closely for untoward changes in mood or behavior.
