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Tricyclic antidepressants (TCAs) have not been proven to be effective in adolescents and should not be used (9)[A].
Paroxetine (SSRI): Avoid use due to short half-life, associated withdrawal symptoms, and higher association with suicidal ideation.
ISSUES FOR REFERRAL
- Collaborative care interventions between mental health and primary care have a greater improvement in depressive symptoms after 12 months (14)[B].
- Primary care providers should provide initial treatment of pediatric depression. Refer to a child psychiatrist for severe, recurrent, or treatment-resistant depression or if the patient has comorbidities (13)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Physical exercise and light therapy may have a mild to moderate effect (15)[B].
- St. John's wort, acupuncture, S-adenosylmethionine, and 5-hydroxytryptophan have not been shown to have an effect or have inadequate studies to support use in adolescent depression (15)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
If severely depressed, psychotic, suicidal, or homicidal, one-on-one supervision may be needed.
ONGOING CARE
Patient Monitoring
- Systematic and regular tracking of goals and outcomes from treatment should be performed, including assessment of depressive symptoms and functioning in home, school, and peer settings (13)[A].
- Diagnosis and initial treatment should be reassessed if no improvement is noted after 6 to 8 weeks of treatment (13)[A].
- The goal of treatment should be no symptoms or a significant reduction of depressive symptoms for 2 weeks (10)[C].
- Educate patients and family members about the causes, symptoms, course and treatments of depression, risks of treatments, and risk of no treatment.
PROGNOSIS
- 60-90% of episodes remit within 1 year.
- 50-70% of remissions develop subsequent depressive episodes within 5 years.
- Depression in adolescence predicts mental health disorders in adult life, psychosocial difficulties, and ill health (2)[A].
- Baseline symptom severity and comorbid anxiety may impact treatment response (16)[A].
- Parental depression at baseline significantly affects intervention effects (4)[A].
COMPLICATIONS
- Treatment-induced mania, aggression, or lack of improvement in symptoms
- School failure/refusal
- Suicide
REFERENCES
11 Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012;86(5):442-448.22 Thapar A, Collishaw S, Pine DS, et al. Depression in adolescence. Lancet. 2012;379(9820):1056-1067.33 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.44 Beardslee WR, Brent DA, Weersing VR, et al. Prevention of depression in at-risk adolescents: longer-term effects. JAMA Psychiatry. 2013;70(11):1161-1170.55 U.S. Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2009;123(4):1223-1228.66 Thapar A, Collishaw S, Potter R, et al. Managing and preventing depression in adolescents. BMJ. 2010;340:c209.77 Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;(3):CD004691.88 Richardson LP, McCAuley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123.99 Ma D, Zhang Z, Zhang X, et al. Comparative efficacy, acceptability, and safety of medicinal, cognitive-behavioral therapy, and placebo treatments for acute major depressive disorder in children and adolescents: a multiple-treatments meta-analysis. Curr Med Res Opin. 2014;30(6):971-995.1010 Birmaher B, Brent D. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.1111 Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120(5):e1313-e1326.1212 Cox GR, Callahan P, Churchill R, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev. 2014;(11):CD008324.1313 Cheung AH, Kozloff N, Sacks D. Pediatric depression: an evidence-based update on treatment interventions. Curr Psychiatry Rep. 2013;15(8):381.1414 Reeves GM, Riddle MA. A practical and effective primary care intervention for treating adolescent depression. JAMA. 2014;312(8):797-798.1515 Popper CW. Mood disorders in youth: exercise, light therapy, and pharmacologic complementary and integrative approaches. Child Adolesc Psychiatr Clin N Am. 2013;22(3):403-441.1616 Nilsen TS, Eisemann M, Kvernmo S. Predictors and moderators of outcome in child and adolescent anxiety and depression: a systematic review of psychological treatment studies. Eur Child Adolesc Psychiatry. 2013;22(2):69-87.
ADDITIONAL READING
- Emslie GJ, Mayes T, Porta G, et al. Treatment of resistant depression in adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010;167(7):782-791.
- LeFevre ML. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-726.
CODES
ICD10
- F32.9 Major depressive disorder, single episode, unspecified
- F33.9 Major depressive disorder, recurrent, unspecified
- F33.8 Other recurrent depressive disorders
- F32.8 Other depressive episodes
ICD9
- 311 Depressive disorder, not elsewhere classified
- 296.20 Major depressive affective disorder, single episode, unspecified
- 296.30 Major depressive affective disorder, recurrent episode, unspecified
SNOMED
- 35489007 Depressive disorder (disorder)
- 36923009 Major depression, single episode (disorder)
- 66344007 Recurrent major depression (disorder)
CLINICAL PEARLS
- Adolescent depression is underdiagnosed and often presents with irritability and anhedonia.
- Fluoxetine is the most studied FDA approved for treatment of adolescent depression.
- Escitalopram, citalopram, and sertraline are also FDA-approved antidepressants.
- CBT combined with fluoxetine is efficacious for adolescents with major depression.
- Paroxetine and TCAs should not be used to treat adolescent depression.
- Referral to a child psychiatrist is appropriate for complex cases or treatment-resistant depression.
- Monitor all adolescents with depression for suicidality, especially during the 1st month of treatment with an antidepressant.