How should we treat children and youth with depression?
Major depression affects 3 to 5 percent of children and adolescents, and at any one time up to 15% of children have some depressive symptoms. Despite the prevalence of this condition, it is estimated that over 70% of children with depression do not receive appropriate diagnosis or treatment. However, even when diagnosed, there is much debate over how to treat depression in children and adolescents.
Over the past few years there has been a lot of news coverage on increased suicide risk in youth with depression who were prescribed selective serotonin reuptake inhibitors (SSRIs). However, recent evidence published by the American Journal of Psychiatry indicates that youth who are treated with SSRIs have lower rates of suicide. Surrounding this controversy is a growing concern about the health risks of over-medicating, or inappropriately medicating, our youth and prescribing children medications that have only been tested on adults.
Now there is evidence that medication may not even be the best way to treat child depression. The Denmark-based Nordic Campbell Center conducted a meta-analysis of interventions to treat childhood depression and concluded that it is far more effective to provide psychosocial treatment (either cognitive behavioral therapy or social skills group therapy) to children and youth with depression than it is to treat them with medication. According to their findings, psychosocial treatment methods are on average four times more effective than pharmacological treatments for depression in youth. Their results also indicate that psychosocial treatment is more effective in older youth than those aged 6-12 and that psychosocial treatment seems to work better for girls than it does for boys.
There were limitations to this research, however. Most notable is the fact that the studies reviewed for this meta-analysis primarily evaluated the effectiveness of tricyclic antidepressants (TCAs) rather than the more typically prescribed SSRIs of today. The two studies that measured the efficacy of treating depression in youth with SSRIs found them to be equivalent to psychosocial treatment in effectiveness. A later study conducted in the United States found that a combination of medication and psychotherapy is the most effective treatment for adolescents with depression.
Thus, the debate continues over whether it is more beneficial to prescribe medications or psychotherapy to improve the symptoms of depression in younger people. Because outcome studies do not provide clear guidance about best practice, other considerations such as cost, convenience, and adherence to treatment become strong factors in deciding how best to treat this mental health condition.
- What do you think is the best way to treat depression in younger people?
- If more evidence becomes available that indicates SSRIs and psychotherapy work equally well for improving the outcomes of children with depression, which should be prescribed more often? Or how would you decide which?
- Do you have first hand experience with treatments for depression? Does that experience shape how you feel about how treatment guidelines should be designed, particularly regarding medication and/or psychosocial treatments for children and youth?
As always, we look forward to your opinions and perspectives.
Your thoughts…
Comments:
 It never ceases to amaze me how often every discussion about children from a mental health perspective begins with some diagnosis of a child's behavioral actions... and the child suddenly disappears as the theoretical and intellectual discussion of a dog chasing its tail drones on and on...
Nothing within the child could possibly be a matter of discussion. Nothing about the parents could have an impact. And never but never will there be any discussion of the MIND and what it has to do with what is going on with a child?
So in denial and so fearful are mental health workers of the MIND that it has been fully denied and ignored relative to its operation within every child experiencing behavior out of the ordinary.
Drugs are the new religion of mental health... and the stronger they are and the more capable of making zombies of youth the better. Until parents begin to rebel at what is going on... and begin to take some "responsibility" for their own actions relative to their children, children will continue to suffer needlessly. Posted Saturday, January 19, 2008 at 03:40 PM
I aggree with Dr. Huffine that a strength based approach is very important. My 15 year old son has manic depression. As parents, we actively use a strength based approach within our family. We look for our individual strengths as parents. We look for the character, personality, skills strengths in our son. We look for the same strengths in our daughter who does not suffer from depression. Our family takes a holistic approach to coaching our son towards recovery. We do our best to live a positive lifestyle. He is learning, growing from his experiences. Some days are difficult, but overall, we anticipate a productive adulthood for our son.
Our medical team - psychiatrist and psychologist are key to our strength based approach. It has to be a collaborate, trusting team approach.
My son, with our help and psychologist, developed a Wellness Recovery Action Plan (WRAP). It has been a very helpful tool for him to learn self regulation. The WRAP is used in conjunction with Cognitive Behavior Therapy.
Unfortunately, I do not consider our school to be part of our wellness team. They did not support the WRAP. Some teachers understood depression and provided flexibility. The teachers who did not understand, made life so difficult for my son that he often got frustrated, angry and acted out. The principal only esculated matters. After trying our best to help our son cope with middle school, we realized that the school environment triggered his stress so much that it was becoming detrimental to his recovery. We decided to home school him through high school.
Informal community supports are an important addition to home and medical supports. My son attends a Teen Group with other kids with mental illness. He works out at our local boxing club and does pottery at our local arts center. He is accepted and liked. He feels like he belongs.
We participate in local Family Support activities. Friendships from other parents that understand are vital. I am so grateful for them.
However, I am dissappointed that other families seem to harp on the negative. When I ask them, "Well, what is working?", they looked dumbfounded. I feel that many parents expect that medication alone will "fix" their child. Many parents expect that a monthly visit with a psychologist should "get rid of" their behaviors.
I try to explain to them that it takes daily coaching and a total family approach.
In my experience as a Mom and former Parent Partner in a Family Support program, a strength based approach that includes the entire family, child, medical and therapy team, school team and informal community supports are key to leading a youth towards recovery.
Posted Friday, April 20, 2007 by Irene Hall at 08:13 AM
As is true in much of mental health today, there are tens of thousands of "professionals" seeking to "treat' children and adults... and it never occurs to these "professionals" to ask themselves what, precisely causes depression?
Until and unless you know precisely what is causing depression, what in the world is it you are treating? For a century now behaviorism has dominated mental health, and what we see today is the result of this denial of the Whole Humann Being.
If you have not completed a thorough program of personal psychotherapy designed to eliminate your fear of the "unknown" from within yourself... you will unwittenly pass this fear to your client... thus, exacerbating that which is causing the client harm.
James W. Patterson, Ph.D., Esogist Posted Thursday, April 19, 2007 at 01:31 PM
My sister went to her doctor about feeling low some 20 years ago. She was prescribed anti depression drugs and has been taking them ever since. Not once was any alternatives offered. There is a world of alternatives out there. If you have a problem with something it should be specifically treated not just blank numbness accross the board. I have been depressed for a period of time due to drug taking and alcohol dependance in my early twenties but listen up I found hypnosis brilliant, NLP brilliant and also EFT. I feel v v good as a result. My sister is too afraid to come off the drugs but I will persist and help her get off the anti depressant gravy train.
Mayo Ireland Posted Thursday, April 12, 2007 at 03:21 AM
Thank you Dr. Huffine for emphasizing that kids need to feel heard and supported. Posted Wednesday, March 28, 2007 at 05:34 PM
As a psychiatrist closely associated with the System of Care community you can bet that I have thoughts about this issue. I have been deeply troubled by the way data has been interpreted. Most of us in psychiatry were trained to understand that in the process of recovery from depression that individuals get activated before their mood improves - with both medication and psychosocial treatment. Thus the recovery process is frought wiht riskes and demands close attention from any mental health practitioner involved as there is always a risk of a more activated young person acting on their ruminations of suicide early in any treatment. This is old knowledge. I have been surprised that the data only shows "suicidal behavior" increasing in association with SSRI use and not any rise in actual suicides. In fact the new data coming in is that there has been a sharp INCREASE in completed suicides with youth since the Black Box warning was placed on SSRI's as risky for children and teenagers. So in our poor analysis of early data we appear to have done harm.
My point has been that we are looking at the wrong issue. My concern for children and youth vis a vis depression has been that we have neglected core System of Care values both in the delivery of medications and in our approach to psychotherapy. The early comments to this article document good results with psychosocial therapies - even long term generic counseling with no specific CBT content. What was the magic engredient that these kids got? My concern is that way to many kids are sent to a family doc or pediatrician who makes a superficial assessment of depression and gives the mom an antidepressant medication with essentially no relationship to the kid. This is a formual for a poor result. I know of other situations where a kid is sent to a program that is quite enthused about CBT as a cure all for depression in kids and is cheerfully told to join a therapist in following a manual. With many kids this goes over like a lead baloon. More poor results
The delivery of a medication, CBT or even generic supportive therapy demands a relationship be build with a child or youth and that the child be heard. It requires varying engagement with parents depending on the age of the kid. Teens need a high degree of confidentiality and parents of teens need coaching in order to respect that. Once a close working relationship is established an individualize plan can be made based on the preferences of the kid and their parents. Integral to all of this prepratory work is the immediate establishment of a strength based approach to care that invovles listening to the kid and the parents and providing each with good information and a list of options from which a family and/or youth can choose there own starting place. I maintain that it does not mater whether a medication is tried first, a course of CBT is initiated, or supportive counseling is the preference. Active engagement, re-evaluation, close attention and an emphasis on a hopeful vision of recovery is essential. I do this in my half hour med checks with kids when I am asked to provide medications only. I do this with kids I see in psychotherapy who have flately rejected medications. They know that I will support them in designing their own recovery process and will be straight with them about my observations and suggestions.
I cannot emphasize enough how an open respectful strength based approach to caring for a depressed kid is essential for outcomes. This is NOT reflected in the data at all so far as I can tell. Posted Thursday, March 15, 2007 by Charles Huffine MD at 09:34 AM
My experience with my son was approximately 10 years ago and he was prescribed the older meds at the time. He was also seeing a therapist who helped us monitor his suicidal tendencies. About a month after being placed on meds, his depression lifted. It was like a light had been turned on for him. However, for longer term help, the work he was doing with his therapist was invaluable. From this experience, I think that the two fold approach is definitely best. He didn't like takling the meds and was able to transition off of them as his psychotherapy progressed. Posted Wednesday, March 14, 2007 at 05:10 PM
My experience when chatting with youth is that they don't like to take medications, so why do we continue to try this first, why not give the psychosocial treatments a real chance to work first? thanks for asking Posted Wednesday, March 14, 2007 at 08:30 AM
I believe from our experience with childhood depression and/or anxiety that medication alone does not achieve optimal results. I go so far as to think that any child prescribed a psychiatric medication should also be required to work with a psychotherapist for a certain amount of time. Posted Tuesday, March 13, 2007 at 07:33 PM
The finding that psychosocial treatments work so well in comparison to medications (albeit older medications) is certainly news to me. Why isn't this information better known? While the meta-analysis is obviously new, the underlying studies are not, and it makes me wonder why it seems like we all act like medication is the first choice for youth. Hmmm... Posted Monday, March 12, 2007 at 08:53 AM
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