Evidence-Based Reviews

Adolescent depression: Diagnostic skills can differentiate teen angst from psychopathology

Current Psychiatry. 2002 July;1(7):40-50

References

1. Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA. Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school. J Abnorm Psychol 1993;102:133-44.

2. Kessler RC, Avenevoli S, Merikangas KR. Mood disorders in children and adolescents: an epidemiological perspective. Biol Psychiatry 2001;49:1002-14.

3. Jaffee SR, Moffitt TE, Caspi A, et al. Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Arch Gen Psychiatry 2002;58:215-22.

4. Lewinsohn PM, Rohde P, Seeley JR, Klein DN, Gotlib IH. Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. Am J Psychiatry 2000;157:1884-1591.

5. Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grow up. JAMA 2000;281:1707-13.

6. Pfeffer CR. Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention. Biol Psychiatry 2001;49:1055-61.

7. Carlson GA. The challenge of diagnosing depression in childhood and adolescence. J Affect Dis 2000;61(suppl 1):3-8.

8. Emslie GJ, Rush AJ, Weiberg WA, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 1997;54:1031-7.

9. Emslie GJ, Heligenstein JH, Wagner KD, et al. Fluoxetine for acute treatment of depression in children and adolescents (poster presentation). Honolulu, Hawaii: American Academy of Child and Adolescent Psychiatry annual meeting, October 23-28, 2001.

10. Wagner KD, Robb AS, Findling R, Tiseo PJ. Citalopram is effective in the treatment of major depressive disorder in children and adolescents: results of a placebo-controlled (poster presentation). Waikoloa, Hawaii: American College of Neuropsychopharmacology annual meeting, December 9-13, 2001.

11. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 1998;37:63S-83S.

12. Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions. J Am Acad Child Adolesc Psychiatry 1999;38:272-9.

13. Harrington R, Whittaker J, Shoebridge P, Campbell F. Systematic review of efficacy of cognitive behavior therapies in childhood and adolescent depressive disorder. BMJ 1998;316:1559-63.

14. Keller MB, Ryan ND, Birmaher B, et al. Efficacy of paroxetine in the treatment of adolescent major depression: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2001;40:762-72.

15. Donnelly CL, Winokur A, Wholberg CJ. Efficacy and safety of sertraline in the treatment of pediatric major depressive disorder (poster presentation). Waikoloa, Hawaii: American College of Neuropsychopharmacology annual meeting, December 9-13, 2001.

16. Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Arch Gen Psychiatry 1997;54:877-85.

17. Harrington R, Whittaker J, Shoebridge P. Psychological treatment of depression in children and adolescents. A review of treatment research. Br J Psychiatry 1998;173:291-8.

18. Mufson L, Moreau D, Weissman MM, Klerman GL. Interpersonal psychotherapy for depressed adolescents. New York: Guilford Press, 1993.

19. Mufson L, Weissman MM, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry 1999;56:573-9.

Table 2

SSRI DOSAGES FOUND TO BE EFFECTIVE IN ADOLESCENTS WITH MDD

Drug	Dosage (per day)	Reference
Fluoxetine	20 mg	Emslie et al, 1997 and 2001^8,9
Citalopram	20-40 mg	Wagner et al, 2001¹⁰
Paroxetine	20-40 mg	Keller et al, 2001¹⁴
Sertraline	50-200 mg	Donnelly et al, 2001¹⁵

Because of the risks of suicide and social and academic impairment, monitoring alone is acceptable only for a few weeks, and only in cases where depression is mild and uncomplicated. In any case, “monitoring” requires that you periodically reassess the teen and be available for consultation between assessments.

Nonspecific supportive therapy Most psychotherapy provided in the community probably is nonspecific (i.e., not theoretically driven or conducted according to a treatment manual) and supportive (i.e., aimed at providing encouragement). This approach is known to be less effective than specific psychotherapies or antidepressant pharmacotherapy, but we have virtually no data comparing it with lack of treatment.

Nonspecific supportive therapy can be considered a reasonable first-step treatment for depressed teens without complicating risk factors.¹³ Specific treatment is indicated, however, if the adolescent does not improve in a few weeks.

Pharmacotherapy A few placebo-controlled clinical trials have studied the efficacy of selective serotonin reuptake inhibitors (SSRIs) in outpatient adolescents with major depression. It must be noted that practically all the available data relate to major depression, and no systematic studies have been done in dysthymia and other types of depression in this population.

The SSRIs fluoxetine,^8,9 citalopram,¹⁰ paroxetine,¹⁴ and sertraline¹⁵ can decrease symptoms of adolescent depression over 2 to 3 months when given at dosages similar to those used in adults (Table 2). At this time, there are no data that suggest the SSRI dosage must be different in younger (12-year-old) compared with older (18-year-old) adolescents, or in girls compared with boys.

The response rate (adolescents who were substantially improved at end of treatment) ranged from 52 to 65% with SSRI medication and 33 to 48% with a placebo. This means that one would need to treat about six adolescents in order to add one to those who would improve by taking a placebo. Thus, 6 is the number needed to treat (NNT), a common index used to make decisions in evidence-based medicine. As a comparison, the NNT is 1.5 for stimulant treatment of ADHD, indicating that stimulants are more effective in ADHD (i.e., the difference between an active drug and a placebo is greater) than SSRIs are in depression.

It must be noted that receiving a placebo in clinical trials of depression does not equal absence of treatment. Typically, research participants assigned to a placebo have weekly clinical contacts, so placebo treatment could be defined as “nonspecific clinical management.” In any case, the NNT for SSRIs in adolescent depression does not appear to be substantially different from that found in adults.

There is no evidence that tricyclic antidepressants, or TCAs, are more effective than a placebo in adolescents with depression. Considering TCAs’ side effects and potential cardiotoxicity in overdose, their use is not recommended in depressed adolescents. Other antidepressants, such as bupropion and venlafaxine, have been reported to be effective in open studies and clinical observations.

Antidepressants can trigger mania in persons predisposed to bipolar disorder. Before prescribing antidepressant medications, carefully evaluate depressed adolescents for present and past symptoms of mania or hypomania and check family history for possible bipolar disorder. During treatment, monitor the adolescent for signs that suggest emerging mania.

SSRIs and stimulant medications are commonly combined, as depression and ADHD often coexist. Clinical experience indicates that these medications can be safely combined in most cases, although no systematic studies of this combination have been performed in large, representative samples of teens. As with antidepressant monotherapy, adolescent patients must be monitored for signs of mania or hypomania.

Specific psychotherapy Among psychotherapies for depression, the best evidence of efficacy exists for cognitive-behavioral therapy (CBT), which attempts to correct cognitive distortions associated with depression and promotes healthy behaviors. In two clinical studies, CBT was more effective in depressed adolescents than no treatment (i.e., wait list), supportive therapy, or systemic behavior family therapy. About two-thirds of patients treated with CBT achieved remission from depressive symptoms.^16,17

Interpersonal therapy (IPT) has been adapted for use in depressed adolescents.¹⁸ Its efficacy is supported by one controlled study that found greater improvement after 12 weekly IPT sessions than after once-monthly clinical contact.¹⁹ There is no convincing evidence that family therapies are effective in treating depression in adolescents or add much to the benefit of CBT.¹⁷

Combined treatment Research on combined treatments for adolescent depression has been limited. One study found that adding family therapy to CBT does not improve the adolescent’s depressive symptoms.⁸ Although no data are available on the combination of SSRI medication and CBT (or IPT), the National Institute of Mental Health is funding two studies on this important issue: