Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP

Screening and early psychological intervention for depression in schools : systematic review and meta-analysis

Depression in children and adolescents is considerably undertreated, and the school may be a good setting for identifying and treating depression. We conducted a meta-analysis of studies in which students were screened for depression, and those with depressive symptoms were treated with a psychological intervention. Only randomised controlled trials were included. Eight studies met the inclusion criteria. Five studies focused on younger children (7-14 years) and three studies were aimed at adolescents (12-19 years). In total 5803 students were screened, of whom 7.2% were included in the intervention studies (95% CI: 7.1-7.3). The 'numbers-needed-to-screen' was 31 (95% CI: 27-32), which means that 31 students had to be screened in order to generate one successfully treated case of depression. The effects of the psychological treatments at post-test were compared to control conditions in the 8 studies comprising 12 contrast groups, with a total of 413 students. The mean effect size was 0.55 (95% CI: 0.35-0.76). There were not enough studies to examine whether specific psychotherapies were superior to other psychotherapies. Although the number of studies is small and their quality is limited, screening and early intervention at schools may be an effective strategy to reduce the burden of disease from depression in children and adolescents. More research on the (negative) effects of these interventions is needed.

The Mistreatment of Mood Disorders in Youth

Mood disorders in youth, specifically depression and bipolar disorder, have been increasingly prevalent. Treatment standards for youth essentially reflect those intervention strategies used with adults; however, there are serious concerns as to the effectiveness and safety of these interventions. Moreover, with growing pressures to use “evidence-based” treatments, clinicians are compelled to critically examine the literature to determine the most effective treatment course. This article examines current treatment approaches for mood disorders in youth and scrutinizes the justification for using psychotropic medications as a “front-line” intervention.

Prepubertal depression: diagnostic and therapeutic dilemmas

Childhood depression is underrecognized. Longitudinal studies have found that depression is a chronic and relapsing disorder in children aged 6 years and older. Now there is evidence that a depressive syndrome can occur in preschool children. Defining depressive syndromes in preschool and elementary-school children has been a challenge. Children should be seen in the context of their social environment (ie, family and peer group) and their larger physical and cultural surroundings. A developmental perspective is important in diagnosing psychopathology in children. Evaluation should include a complete medical assessment to rule out underlying medical causes. A structured clinical interview and rating scales are helpful in determining whether a child or adolescent is depressed. Evidence-based treatment guidelines are limited. The diagnosis of depression in young children remains an active area of debate and study. Clearly more research is needed.

Effectiveness of cognitive-behavioral therapy for adolescent depression: a benchmarking investigation

In this study, we examined the effectiveness of cognitive-behavioral therapy (CBT) for adolescent depression. Outcomes of 80 youth treated with CBT in an outpatient depression specialty clinic, the Services for Teens at Risk Center (STAR), were compared to a "gold standard" CBT research benchmark. On average, youths treated with CBT in STAR experienced significantly slower symptom improvement than youths in the CBT benchmark. However, outcomes for STAR teens were more similar to the research benchmark when accounting for differences in referral source (clinical versus advertisement) between the datasets. Results support further efforts to test the effectiveness of CBT in clinically representative community practice settings and samples.

Psychiatric comorbidity in Korean children and adolescents with attention-deficit hyperactivity disorder: psychopathology according to subtype

It is well-known that more than 50% of attention-deficit hyperactivity disorder (ADHD) cases also have comorbid psychiatric disorders. We evaluated the comorbid psychopathology of Korean children and adolescents with ADHD using a standardized diagnostic instrument. The Korean Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL-K) was administered and completed in 105 patients who had been referred to the outpatient and inpatient clinics at the Samsung Medical Center from March 2004 to May 2005. All of the cases were diagnosed as ADHD according to DSM-IV criteria. We analyzed their clinical characteristics and psychiatric comorbidities, and assessed the correlation of any comorbidity with gender, age and ADHD subtype. Among our 105 participants, 70 (66.7%) subjects were diagnosed with combined-type ADHD, 22 (21.0%) were the predominantly inattentive type, only 1 (1.0%) was determined to have the predominantly hyperactive-impulsive type of ADHD, and 12 (11.4%) were classified as not otherwise specified (NOS) ADHD. Eighty (76.2%) subjects had at least one comorbid disorder such as oppositional defiant disorder (n = 53, 50.5%), anxiety disorders (n = 35, 33.3%) and affective disorders (n = 15, 14.3%). Our patients ranged in age from five to 16 years. Among the factors including gender, age, and ADHD subtype, ADHD subtype was the only one significant to comorbidity in our study. The results of this study suggest that psychiatric comorbidity in Korean children with ADHD is similar to the results of previous studies in western countries. Out of all the ADHD subtypes, the combined-type group had a significantly higher ratio of comorbid disorders and psychopathologies.

Depression treatment during outpatient visits by U.S. children and adolescents

PURPOSE

Depression affects approximately 2-8% of all children and adolescents, and treatment of depression in children and adolescents has been the center of recent serious debates. We examined national trends in depression visits and treatment among outpatients aged 7 to 17 years.

METHODS

We analyzed visit-based data between 1995 and 2002 in two national ambulatory care surveys.

RESULTS

The number of visits by children and adolescents during which depression was reported more than doubled from 1995-1996 (1.44 million) to 2001-2002 (3.22 million). The proportion of these visits during which antidepressants were prescribed rose slightly from 47% in 1995-1996 to 52% in 2001-2002, whereas the proportion during which psychotherapy or mental health counseling was provided declined from 83% to 68%. Selective serotonin reuptake inhibitors (SSRI) represented 76% of all antidepressants prescribed in 1995-1996 and 81% in 2001-2002. In absolute terms, SSRIs were reported in 1.35 million visits in 2001-2002, reflecting a 2.6-fold increase from 1995-1996. Fluoxetine was prescribed in 207,914 visits in 1995-1996 and increased 100% to 415,580 visits in 2001-2002. The use of sertraline increased by 62% to 345,576 visits and paroxetine by 269% to 279,275 visits.

CONCLUSIONS

We observed a declining trend in the provision of psychotherapy/mental health counseling during outpatient visits by children and adolescents diagnosed with depression. Although the likelihood of receiving antidepressants remained essentially unchanged, the number of children and adolescents whose visits involved prescription of antidepressants, particularly SSRIs, has increased markedly through 2002. Although fluoxetine remained the most commonly prescribed, other SSRIs were increasingly prescribed through 2002. These trends raise concerns regarding the widespread off-label use of antidepressants lacking reliable evidence of safety and efficacy for use in children and adolescents.

How do primary care clinicians manage childhood mood and anxiety syndromes?

OBJECTIVE

To describe how primary care clinicians manage children in whom they diagnose mood or anxiety syndromes.

METHOD

This study is a secondary analysis of data from the multi-site Child Behavior Study (CBS)--a cross-sectional survey of primary care management of psychosocial problems. The management of children in whom clinicians identified mood or anxiety syndromes is described and compared with the management of children in whom they identified other psychosocial problems. Recruitment for the CBS occurred in 206 primary care practices in the United States, Puerto Rico, and Canada from October 1994 through June 1997. Participants were 20,861 consecutively sampled primary care attendees aged 4-15 years and 395 clinicians. Primary outcome measures for this report are rates of referral to specialized mental health care and rates of active primary care management (i.e., scheduling a follow-up appointment and/or providing ongoing counseling and/or psychotropic prescription).

RESULTS

Identification of a mood or anxiety syndrome was associated with increased rates of referral to mental health compared with rates for children with other psychosocial problems. There was no effect on the proportion of children counseled during the visit. In fact, unless accompanied by a co-morbid behavioral syndrome, children receiving the diagnosis of a mood or anxiety syndrome were less likely to be offered a scheduled follow-up appointment. Rates of prescription of anti-depressants or anti-anxiety agents were higher for mood/anxiety groups but this was still uncommon (6.7%).

CONCLUSIONS

Active management of childhood mood and anxiety syndromes in primary care was uncommon in the United States, Puerto Rico, and Canada in the mid-1990s.

The Food and Drug Administration's deliberations on antidepressant use in pediatric patients

On February 2, 2004, the Food and Drug Administration organized a joint meeting of the Neuro-Psychopharmacologic Advisory Committee and Pediatric Subcommittee of the Anti-Infective Drugs Advisory Committee to examine the occurrence of suicidality in clinical trials that investigate the use of the newer antidepressant drugs in pediatric patients. Committee members reconvened on September 13-14, 2004, and concluded that there was a causal link between the newer antidepressants and pediatric suicidality. This article provides a summary of the Food and Drug Administration deliberations for the pediatric clinician. We also provide research, regulation, education, and practice implications for care for children and adolescents who may be eligible for treatment with these medications.

Relations between cannabis use and dependence, motives for cannabis use and anxious, depressive and borderline symptomatology

This study investigated the relations between anxious, depressive and borderline symptomatology, motivations for cannabis use, and cannabis use and dependence among 212 adolescents and young adults, 114 of whom were cannabis users. Motives for cannabis use were assessed using the Marijuana Motives Measure (Simons, J., Correia, C. J., Carey, K. B., & Borsari, B. E. (1998). Validating a Five-Factor Motives Measure: Relations with use, problems and alcohol motives. Journal of Counseling Psychology, 45, 265-273.). In three sets of regression analyses, motives, cannabis use frequency, and cannabis dependence served as criterion variables. First, when motives were regressed on psychopathological measures, borderline symptomatology predicted expansion motives in both boys and girls. Second, when frequency of use was regressed on motives and psychopathological measures, enhancement motives were the only significant predictor among boys and expansion motives were the only significant predictor among girls. Finally, when cannabis dependence was regressed on motives and psychopathological measures, borderline symptomatology was the only significant predictor in boys and expansion motives were the only significant predictor in girls. This study suggests the importance of motives and borderline symptomatology in the understanding of cannabis use and dependence among adolescents and young adults.

Treatment of mania in children and adolescents

Bipolar disorder (BPD) is a severe and complex illness that seriously disrupts the lives of those afflicted. Increased rates of suicide attempts and completions, poorer academic performances, disturbed interpersonal relationships, increased rates of substance abuse, legal difficulties, and multiple hospitalizations all have been associated with BPD. At least 1% of children and adolescents have this disorder. This commentary is designed to review and summarize the recent literature on the treatment of manic and/or hypomanic phases of BPD in children and adolescents.

Concomitant pharmacotherapy among youths treated in routine psychiatric practice

OBJECTIVES

The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings.

METHODS

Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided.

RESULTS

Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting.

CONCLUSIONS

Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: a propensity-adjusted retrospective cohort study

CONTEXT

The US FDA has issued an advisory warning of a possible link between antidepressant treatment for paediatric patients with major depressive disorder (MDD) and an increased risk of suicidal behaviour. A large database of paid health insurance claims for adolescents with MDD provided the opportunity to examine this possible relationship.

OBJECTIVE

To examine the potential empirical link between antidepressant treatment and suicide attempts among adolescents aged 12-18 years using a community sample of managed care enrollees across the US.

DESIGN

A retrospective longitudinal cohort using paid insurance claims for all healthcare and prescription fills for adolescents who were newly diagnosed with MDD and had at least 6 months of follow-up data. A multivariate Cox proportional hazards regression analysis was used to test the hypothesis that antidepressant use increased the risk of suicide attempt, adjusting for propensity for allocation to each treatment group and for demographic and clinical characteristics.

SETTING

Managed care plans including both commercial and Medicaid plans in the east, midwest, south and western regions of the US from January 1997 to March 2003.

PARTICIPANTS

All adolescent insurance members aged 12-18 years at first diagnosis of MDD.

MAIN OUTCOME MEASURES

Suicide attempts as indicated by medical utilisation with International Classification of Diseases (9th edition) [ICD-9] or 10th edition (ICD-10) codes in any healthcare setting or by any covered provider.

RESULTS

24 119 adolescents met inclusion criteria (63% female). Crude suicide attempt rates ranged from 0.0-2.3% by index treatment group. Treatment with SSRIs (hazard ratio) [HR] = 1.59; CI 0.89, 2.82), other antidepressants (HR = 1.03; CI 0.43, 2.44), or multiple antidepressants (HR = 1.43; CI 0.70, 2.89) after index MDD diagnosis resulted in no statistically increased risk of suicide attempt. Treatment with antidepressant medication for at least 180 days (6 months) reduced the likelihood of suicide attempt compared with antidepressant treatment for <55 days (8 weeks) [HR = 0.34; CI 0.21, 0.55]. Other variables that were independently associated with greater risk of suicide attempts included female gender, severity of illness indicators, younger age at time of MDD diagnosis, and living in the midwest or west.

CONCLUSIONS

Antidepressant medication use had no statistically significant effect on the likelihood of suicide attempt in a large cohort of adolescents across the US after propensity adjustment for treatment allocation and controlling for other factors. The relationship between suicidal behaviour and antidepressant medication use is complex and requires further investigation.

Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study

OBJECTIVE

To evaluate the safety and feasibility of cognitive-behavioral therapy (CBT) for depression in physically ill adolescents.

METHOD

In an open trial, 11 adolescents (12-17 years) with inflammatory bowel disease and either major or minor depression underwent 12 sessions of a manual-based CBT enhanced by social skills, physical illness narrative, and family psychoeducation components. Standardized instruments assessed pre- to posttreatment changes in depression, physical health, global psychological functioning, and social functioning. Perceived helpfulness and satisfaction with CBT were assessed.

RESULTS

There were significant reductions in DSM-IV depression diagnoses and depressive symptoms and improvements in global psychological and social functioning. Adolescents' perceptions of their general health and physical functioning improved, although illness severity measures were unchanged. High subject satisfaction and helpfulness ratings for CBT were found along with no adverse events and high subject adherence.

CONCLUSIONS

A manual-based CBT approach adapted to treat depression in physically ill adolescents appears to be a safe, feasible, and promising intervention.

Mirtazapine in the treatment of adolescents with major depression: an open-label, multicenter pilot study

This multicenter, open-label study with a duration of 85 days was performed to evaluate the antidepressant efficacy and safety of mirtazapine (dose range, 30-45 mg) in 12-18-year-old adolescents diagnosed with major depression. Twenty-four (24) patients (15 female patients and 9 male patients) meeting the DSM-IV criteria for major depression and the Hamilton Rating Scale for Depression (HAM-D-17) score of 18 at baseline were enrolled in the study. The primary outcome measures were HAM-D-17, Beck Depression Inventory (BDI), and Clinical Global Impression (CGI) scales. Any changes in symptoms of anxiety were measured using the Hamilton Anxiety Rating Scale (HAM-A). The average age of the 23 subjects, who were eligible for analysis, was 16.3 years (standard deviation (SD) 6.11, median 17.3). The mean daily dose of mirtazapine was 32.9 mg. Mirtazapine showed a marked efficacy on all rating scales and was well tolerated. Mirtazapine had a beneficial effect on sleep. A rapid onset of sleep and pattern of action was seen. No dropouts due to adverse events were recorded. The most common treatment-emergent adverse events were tiredness, increased appetite, and dizziness. The results of this study suggest that mirtazapine may be an effective treatment for major depression in adolescents.

Effects of a primary care-based intervention on violent behavior and injury in children

OBJECTIVE

Although many major health care organizations have made recommendations regarding physicians' roles in preventing youth violence, the efficacy of violence prevention strategies in primary care settings remains to be empirically tested.

METHODS

We conducted a randomized, controlled trial to evaluate the effects of an office-based intervention on children's violent behaviors and violence-related injuries. Children 7 to 15 years of age who presented at 8 pediatric practices and scored positive on a brief psychosocial screening test (n = 224) were randomly assigned to an intervention group (clinicians saw the screening test results during the visit and a telephone-based parenting education program was made available to clinicians as a referral resource for parents) or a control group (clinicians did not see the screening test results).

RESULTS

Compared with control subjects, at 9 months after study enrollment, children in the intervention group exhibited decreases in aggressive behavior (adjusted mean difference: -1.71; 95% confidence interval [CI]: -2.89 to -0.53), delinquent behavior (adjusted mean difference: -0.71; 95% CI: -1.28 to -0.13), and attention problems (adjusted mean difference: -1.02; 95% CI, -1.77 to -0.26) on the Child Behavior Checklist. Children in the intervention group had lower rates of parent-reported bullying (adjusted odds ratio: 4.43; 95% CI: 1.87-10.52), physical fighting (adjusted odds ratio: 1.79; 95% CI: 1.11-2.87), and fight-related injuries requiring medical care (adjusted odds ratio: 4.70; 95% CI: 1.33-16.59) and of child-reported victimization by bullying (adjusted odds ratio: 3.23; 95% CI: 1.96-5.31).

CONCLUSIONS

A primary care-based intervention that includes psychosocial screening and the availability of a parenting education resource can decrease violent behavior and injury among youths.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review

OBJECTIVE

To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents.

METHOD

A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports.

RESULTS

Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found.

CONCLUSIONS

Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Selective serotonin reuptake inhibitor and venlafaxine use in children and adolescents with major depressive disorder: a systematic review of published randomized controlled trials

OBJECTIVE

This review critiques published randomized placebo-controlled trials pertaining to the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine in the treatment of major depressive disorder in children and adolescents.

METHOD

Medline was searched for articles meeting defined inclusion criteria. The following key terms were used: depressive disorders, antidepressive agents, fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine, venlafaxine, child, and adolescent.

RESULTS

Six articles met inclusion criteria. Only 2 studies claim efficacy by significant results in primary outcomes; both have since been contested in further analysis. Not one study adequately examines safety, particularly with respect to whether a link exists between antidepressant use and induction of suicidal ideation or attempts.

CONCLUSION

Published studies on SSRI or venlafaxine use in children and adolescents are inconclusive with respect to safety and efficacy, owing to inappropriate claims of efficacy, lack of improvement in global functioning scores, nonstandardized data collection regarding adverse effects, exclusion of suicidal subjects in the recruitment process, grouping of children and adolescents together, small sample sizes, conflict of interest posed by pharmaceutical company sponsorship, and publishing bias. Future investigators should consider these factors when developing study designs.

Innovative ways to address the mental health and medical needs of marginalized patients: collaborations between family physicians, family therapists, and family psychologists

This article describes an innovative program to meet the needs of homeless women, children, and families residing at a transitional living center in an urban setting. The program involves collaboration between medical and mental health professionals to address the multiple problems and unmet needs of this population. Recommendations for future work in expanding collaborative practice are discussed. ((c) 2004 APA, all rights reserved)

Cognitive vulnerability in remitted depressed children and adolescents

The cognitive model by Beck predicts that formerly depressed individuals remain vulnerable for future depressive episodes due to the existence of stable negative schemas. Activation of those schemas may explain high relapse rates in depression. The present study investigated cognitive vulnerability in remitted depressed children and adolescents. A sample of 44 in-patient youngsters was assigned to three groups after completing the CDI at two different times: a never depressed group, a currently depressed group and a remitted depressed group. All participants received a mood induction before they were given a self-referent encoding task. The results indicated that the currently and the remitted depressed groups rated more negative words as self-descriptive than the never depressed group. On the recall task, the never depressed group showed positive information processing compared to the currently depressed and the remitted depressed groups. The currently depressed group also showed a negative recall bias compared to the never depressed group. Implications and limitations of the findings are discussed.

Somatic treatment for depressive illnesses in children and adolescents

Numerous somatic interventions have been studied as potential treatments of depressive disorders in children and adolescents. These include antidepressant medications, light therapy, electro-convulsive therapy, and alternative therapies. The available evidence suggests that several somatic interventions hold promise as potentially safe and effective treatments for depressed youths; however, there is still much to be learned about these interventions. This article reviews what is known and what needs to be learned about the somatic treatment of pediatric depression.

Impact of antidepressant side effects on adolescent quality of life

OBJECTIVE

This study examines the relative impact of antidepressant side effects on adolescents with a history of major depression.

METHODS

We used Q-sort methodology to capture the opinions of adolescents with a history of depression (n = 22), adults with a history of depression (n = 20), healthy adolescents (n = 20), and clinicians (n = 18) on the impact of 40 common antidepressant side effects. We asked subjects to force rank the side effects, judging each side effect on its relative impact on their daily lives. We also examined the impact of these side effects on health status and medication compliance. Primary analyses compared adolescents with depression with the other groups on their mean rankings for each of the 40 side effects. Secondary analyses included paired comparisons for ratings on health status and compliance.

RESULTS

Although all groups ranked syncope and vomiting among the worst 5 side effects, significant differences were found between the groups on other side effects, such as anxiety, sleepiness, and hair loss. Based on the side effect with the most negative impact, adolescents with depression judged their own compliance (mean = 22%) to be higher than predicted by clinicians (mean = 11%). There were no significant differences between the groups on the mean rating of health status.

CONCLUSIONS

Adolescents with depression, adults with depression, healthy adolescents, and clinicians agreed on the negative impact of 2 side effects: vomiting and syncope. Q-sort methodology provides valuable insight into the similarities and differences in opinion regarding the potential impact of side effects in patient groups.

Depression in children and adolescents

Depression is a common problem in children and adolescents. The disorder may be overlooked because of the prominent irritability seen in children with depression and because of the perception that moodiness is a normal phase of childhood. Depression frequently is associated with other psychiatric problems and neurologic disorders. Therapy consists of psychotherapy and medication, with SSRIs the first choice for pharmacotherapy.

An open-label pilot study of St. John's wort in juvenile depression

OBJECTIVE

This pilot study examined the effectiveness, safety, tolerability, and pharmacodynamics of Hypericum perforatum (St. John's wort) in the treatment of youths diagnosed with major depressive disorder.

METHOD

Youths 6 to 16 years of age meeting DSM-IV criteria for major depressive disorder with depressive symptoms of at least moderate severity were eligible to enroll between January 1999 and January 2001 in this 8-week, prospective, open-label, outpatient study. Outcome measures included the Children's Depression Rating Scale-Revised (CDRS-R) and the Clinical Global Impressions (CGI) scale. A priori criteria for response consisted of a CDRS-R score of </=28 and a CGI severity score </=2. Patients were initially prescribed 150 mg St. John's wort three times daily. If at the end of week 4 the patient did not meet a priori response criteria, the dose was increased to 300 mg three times daily.

RESULTS

Thirty-three youths with a mean (SD) age of 10.5 (2.9) years were enrolled. After 4 weeks of St. John's wort therapy, 22 youths had their dose increased to 900 mg/day. Twenty-five of the patients met response criteria after 8 weeks of treatment. Overall, St. John's wort was well tolerated.

CONCLUSION

St. John's wort may be an effective treatment for youths diagnosed with major depressive disorder. Placebo controlled trials seem indicated.

Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention

Suicide is rare in childhood and early adolescence, and becomes more frequent with increasing age. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds, respectively. In most countries, males outnumber females in youth suicide statistics. Although the rates vary between countries, suicide is one of the commonest causes of death among young people. Due to the growing risk for suicide with increasing age, adolescents are the main target of suicide prevention. Reportedly, less than half of young people who have committed suicide had received psychiatric care, and thus broad prevention strategies are needed in healthcare and social services. Primary care clinicians are key professionals in recognizing youth at risk for suicide. This article reviews recent population-based psychological autopsy studies of youth suicides and selected follow-up studies of clinical populations and suicide attempters, analyzing risk factors for youth suicides. As youth suicides are rare, research on risk factors for youth suicidal ideation and attempted suicide is also briefly reviewed. The relationship between psychiatric disorders and adolescent suicide is now well established. Mood disorders, substance abuse and prior suicide attempts are strongly related with youth suicides. Factors related to family adversity, social alienation and precipitating problems also contribute to the risk of suicide. The main target of effective prevention of youth suicide is to reduce suicide risk factors. Recognition and effective treatment of psychiatric disorders, e.g. depression, are essential in preventing child and adolescent suicides. Research on the treatment of diagnosed depressive disorders and of those with suicidal behavior is reviewed. In the treatment of youth depression, psychosocial treatments have proved to be useful and efficacious. Although studies on the effectiveness of selective serotonin reuptake inhibitors are limited in number, evidence supports their use as first-line antidepressant medication in youth depression. Available evidence suggests that various treatment modalities are useful in the treatment of suicidal youths, e.g. cognitive behavioral therapy and specialized emergency room interventions. Much of the decrease in suicide ideation and suicide attempts seems to be attributable to nonspecific elements in treatment. For high-risk youth, providing continuity of care is a challenge, since they are often noncompliant and commonly drop out or terminate their treatment prematurely. Developing efficacious treatments for suicidal children and adolescents would offer better possibilities to prevent suicides.

Psychosocial and pharmacological interventions for child crime victims

Children may develop a variety of difficulties following victimization, including posttraumatic stress disorder (PTSD), other anxiety symptoms, depressive disorders, externalizing symptoms, or substance use disorders. Some children appear to be resilient in the face of victimization and do not report significant difficulties. A growing number of treatment studies for child abuse victims has supported the efficacy of trauma-focused cognitive-behavioral therapy (CBT); however, more research is needed to determine the critical components and optimal dosage of CBT, and to evaluate the efficacy of this approach for other groups of child crime victims. Psychopharmacological treatments are widely used for childhood PTSD, but little research has evaluated such treatments. Treatment guidelines and future directions are discussed.

Negative Affect and HIV Risk in Alcohol and Other Drug (AOD) Abusing Adolescent Offenders

Various depressive symptoms have been linked to elevated levels of HIV risk across diverse adult populations in multiple studies. However, this link has been examined in a much more limited manner among adolescents, despite an exceedingly heightened risk of both HIV and negative affect in this age group. To address the current lack of clinically pertinent knowledge in this area, we analyzed baseline data from 256 male and 107 female inner city, culturally diverse adolescent offenders. Relatively "high" and "low" negative affect subgroups were formed by conducting a median split on scores from the well-validated depressive affect scale of the Millon Adolescent Clinical Inventory (MACI). Compared to the low negative affect subgroup, the high negative affect participants reported significantly more sexual partners, unprotected sex, and increased susceptibility to HIV, as well as more marijuana, cocaine, and alcohol use (all p's < .05). Although demonstrating better condom skills, negative affect participants reported less favorable attitudes towards using condoms, less knowledge about HIV transmission, and lower sexual self-efficacy than non-depressive participants. Symptoms of negative affect are therefore of particular concern for adolescents, who are at risk not only for generally acknowledged difficulties such as suicide, but also for multiple HIV risk factors. The theoretical and applied implications of these findings will be discussed.

National prescribing practices of adolescent psychiatrists for psychotropic medications in outpatient care in Finland

We studied national prescribing practices for psychotropic drugs in adolescent psychiatric outpatient care in Finland in the cross-sectional survey study in 1999. A questionnaire was sent to the adolescent psychiatrists employed in the community outpatient clinics covering all Finland. The response rate was 81% (n=34). On average, the respondents reported that 33% of their outpatients were treated with drugs. Selective serotonin reuptake inhibitors (SSRIs) were the drug of choice in the treatment of depression and obsessive-compulsive disorder (OCD). Atypical antipsychotics played an important role in the treatment of psychotic adolescents. Adolescent psychopharmacology is an important and developing part of treatment of mentally disordered young people, on the understanding that drug therapies are adjunct to other treatment interventions.

Depression in children and adolescents. When "moodiness" merits special attention

Depression does occur in children and adolescents and can result in significant morbidity and mortality. Therefore, identification and treatment of depression are essential. Referral to a mental health clinician, preferably a child and adolescent psychiatrist, is important for suicide evaluation, psychotherapy, and management of complicated medication treatment regimens. The SSRIs are most often used in youngsters because of their favorable side effect profiles and their efficacy as documented in some double-blind, placebo-controlled studies.

A prospective study of the role of depression in the development and persistence of adolescent obesity

BACKGROUND

Adolescent obesity is a strong predictor of adult obesity, and adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index (BMI) in adulthood. Whether depression leads to obesity or obesity causes depression is unclear.

OBJECTIVE

To determine in longitudinal analyses whether depressed mood predicts the development and persistence of obesity in adolescents.

METHODS

A prospective cohort study of 9374 adolescents in grades 7 through 12 who completed in-home interviews for the National Longitudinal Study of Adolescent Health. Assessments were made at baseline (1995) and at follow-up 1 year later. Depressed mood was assessed with the Center for Epidemiologic Studies Depression Scale. BMI (kg/m2) was calculated from self-reported height and weight. BMI percentiles and z scores were computed using the 2000 Centers for Disease Control and Prevention growth charts. Obesity was defined as BMI > or =95th percentile, overweight as BMI > or =85th percentile and <95th percentile, and normal weight as BMI <85th percentile. A parental respondent gave information on household income, parental education, and parental obesity.

RESULTS

At baseline, 12.9% were overweight, 9.7% were obese, and 8.8% had depressed mood. Baseline depression was not significantly correlated with baseline obesity. Among the 9.7% who were obese at follow-up, 79.6% were obese at baseline, 18.6% were overweight at baseline, and 1.8% were normal weight at baseline. Having depressed mood at baseline independently predicted obesity at follow-up (odds ratio: 2.05; 95% confidence interval: 1.18, 3.56) after controlling for BMI z score at baseline, age, race, gender, parental obesity, number of parents in the home, and family socioeconomic status. This finding persisted after controlling further for the adolescents' report of smoking, self-esteem, delinquent behavior (conduct disorder), and physical activity. After controlling for all these same factors, depressed mood at baseline also predicted obesity at follow-up among those not obese at baseline (odds ratio: 2.05; 95% confidence interval: 1.04, 4.06) and follow-up BMI z score among those obese at baseline (beta = 0.11; standard error beta = 0.05). In contrast, baseline obesity did not predict follow-up depression.

CONCLUSIONS

Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence. Understanding the shared biological and social determinants linking depressed mood and obesity may inform the prevention and treatment of both disorders.

Assessment and treatment of depression in medically ill children

The consequences of depression in medically ill children include the disability and morbidity that is associated with depression in any patient. They also include an exacerbation of the underlying medical disease and nonadherence to treatment. Thus, medically ill children who are depressed constitute a special, high-risk group of patients who may suffer from severe consequences above and beyond those that are expected in a medically sound population. This manuscript reviews methodologic and practical difficulties that are associated with the diagnosis and treatment of depression in this group of patients. Because treatment of depression in medically ill children may well lead to improvement in medical and psychiatric outcome, there is pressing need for the careful study of potential treatment options in this specific group of patients.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with the biological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Evidence-based treatment for mental disorders in children and adolescents

In the past decade, increased emphasis has been placed on identifying treatments for childhood disorders that are supported by empirical evidence of their effectiveness. This process was spearheaded by an American Psychological Association division 12 task force that identified evidence-based treatments--mostly for disorders of adulthood. Because of the publication of the task force results, other studies have been published that contribute to the knowledge base of evidence-based treatment, and these studies are briefly reviewed. Across evidence-based treatments, common features of effective treatments, such as parent involvement, use of a treatment manual, and the emphasis on generalization of treatment effects to natural settings, are also identified and reviewed.Introduction

Relation between anxiety and depressive disorders in childhood and adolescence

Current research indicates that there is a strong relationship between pediatric anxiety disorders and depression. Assessment measures show high rates of correlation between depression and anxiety and much of the overlap may be related to a common domain of negative affectivity. Anxious youth and depressed youth share a cognitive style marked by a negative bias in information processing. Anxiety disorders and depression are frequently comorbid in children and adolescents. About 25-50% of depressed youth have comorbid anxiety disorders and about 10-15% of anxious youth have depression. Twin and family studies have demonstrated that pediatric anxiety disorders and depression likely share some common genetic factors or influences. Selective serotonin reuptake inhibitors and cognitive-behavioral therapy have been shown in randomized controlled trials to be efficacious for both pediatric depression and anxiety disorders. Integrating the treatment literature with studies of phenomenology, biology and genetics indicates that pediatric anxiety disorders and depression may share a genetically determined neurobiological component that could involve neural circuits that include or are modulated by serotonergic neurons. This component could contribute to the negative affective temperament that appears to be common in both pediatric depression and anxiety disorders.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Taking a stand: an adolescent girl's resistance to medication

Therapists and clients encounter pressure to seek medication for adolescent depression and dangerous behaviors. A review of current research indicates that medical practitioners prescribe antidepressants for adolescents despite questionable efficacy, side effects, and frequent refusal. Adolescent girls' expressions of distress expose them to systems that promote medication prescription. A critical look at medical, gender, and adolescent discourses sheds light on drug prescription as standard practice and highlights its impact on adolescent girls' agency, voice, and community connection. Resistance to medication is reconsidered as an act of personal and political choice. Amy, a 16-year-old girl, and her therapist describe strategies for managing depression without medication.

Depression in adolescence

Major depression is a common mental health disorder in adolescents that predicts a significant risk for recurrence in adulthood. Suicide is the third most frequent cause of deaths in this age group, and depression is a significant risk factor for suicidal ideation and attempts. Risks for depression and suicidal ideation are reviewed, and subtypes of depression are discussed. Difficulties associated with identification of depression and suicidal ideation in adolescents and biologic therapies for adolescent depression are reviewed.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Childhood depression: pharmacological therapy/treatment (pharmacotherapy of childhood depression)

Critiqued the published double-blind, placebo-controlled studies of antidepressant pharmacotherapy in child and adolescent major depressive disorder to assess their overall efficacy. The pharmacological mechanism of antidepressant action also was discussed. At best, antidepressant treatment for depressed youths is only modestly effective. In particular, the tricyclic antidepressants are not superior to placebo; however, early evidence with the selective serotonin reuptake inhibitors is more encouraging. The theoretical basis for this response pattern is discussed from a methodological perspective, from a neurodevelopmental status, and from a biological viewpoint. Study modifications are suggested which could improve some of the methodological limitations apparent in previous clinical drug trials.

Pediatrician and family physician prescription of selective serotonin reuptake inhibitors

OBJECTIVES

Selective serotonin reuptake inhibitor (SSRI) prescriptions for children and adolescents have increased greatly in recent years despite a paucity of demonstrated safety and efficacy data and a lack of clear guidelines for use. Our study sought to describe family physician and pediatrician SSRI prescribing patterns for children and adolescents, identify influences on SSRI prescription variations, and describe the use of SSRI within the overall management of depression and other mental disorders in primary care.

DESIGN

A survey was mailed to all 596 active North Carolina general pediatricians and a random sample of 557 family physicians in primary care practice. Family physicians who did not see children in their practice were excluded. The survey instrument consisted of a 4-page questionnaire. Survey items included physician demographics, practice characteristics, general management, volume of pediatric patients with depressive symptoms, prescription of SSRIs for depression and other diagnoses, and potential influences on SSRI prescribing practices. The main outcomes were self-reported physician prescription of SSRIs for children and adolescents. Results were analyzed using chi(2) comparisons and logistic regression.

RESULTS

The overall response rate was 66% (55% family physicians and 76% pediatricians). Of the physicians, 72% had prescribed an SSRI for a child or adolescent. Depression was the most common reason for prescribing an SSRI; over two thirds of respondents had prescribed an SSRI for depression in a child 18 years of age or younger. Over half of the physicians reported they had prescribed an SSRI for a diagnosis other than depression in a child 18 years of age or younger. Attention-deficit/hyperactivity disorder was the most frequent use cited other than depression, followed by obsessive-compulsive disorder, aggression, eating disorders, and enuresis. Primary care physicians prescribed SSRIs for adolescents more commonly than for younger children. Only 6% of the respondents had ever prescribed an SSRI for a child younger than 6 years of age. In terms of SSRI prescriptions written for depression in the last 6 months, 32% of the physicians had recently prescribed SSRIs for adolescent patients and 6% for patients younger than 12 years of age. Family physicians were more likely than pediatricians to have recently prescribed SSRIs for adolescent patients (41% vs 26%), but there was no difference in recent SSRI prescriptions for children <12 years of age by physician specialty (4% vs 6%). Prescription of SSRIs was not associated with decreased use of counseling for treatment of depression, but prescription of SSRIs was associated with decreased use of referrals (63% vs 74%). There was no difference in the use of counseling between family physicians and pediatricians (61% vs 59%). However, pediatricians were more likely to use referrals in their usual approach to depression (77% vs 48%) compared with family physicians. More family physicians had prescribed SSRIs for pediatric patients compared with pediatricians (91% vs 58%), and more family physicians had prescribed SSRIs in combination with other psychotropic medications (54% vs 31%). For the majority of respondents, SSRI prescriptions constituted most of the medications used to treat childhood depression (75% of family physicians vs 61% of pediatricians). Family physicians were more likely to report a belief in the safety (63% vs 48%) and effectiveness (40% vs 32%) of SSRIs. Only 8% of physicians reported adequate training in the treatment of childhood depression and just 16% were comfortable with the treatment of depression. There were no specialty differences in training for the treatment of childhood depression; however, more family physicians than pediatricians agreed that they were comfortable with the management of childhood depression (22% vs 11%). (ABSTRACT TRUNCATED)

Toward effective early intervention and prevention strategies for major affective disorders: a review of antecedents and risk factors

OBJECTIVE

To review critically the literature pertaining to risk factors and antecedent symptoms and syndromes in order to determine an empirically based strategy for early treatment and prevention of major mood episodes.

METHOD

The relevant literature is summarized, with particular emphasis on early-onset (child and adolescent) mood disorders.

RESULTS

A complex interaction between biological, psychological, and sociological factors contributes to the development of a major mood disorder. Having a positive family history of mood disorder (bipolar and unipolar) and being female (unipolar) are the strongest, most reliable risk factors. There is continuity between adolescent and adult mood disorders, and subsyndromal mood disturbance in adolescents has clinical and public health significance. However, more longitudinal study is required to reliably map the course and predictive importance of mood disorders in very young children.

CONCLUSIONS

Substantial evidence supports the effectiveness of early intervention and prevention efforts in children at risk for mood disorders (identified as having affected family members) and in adolescents manifesting significant mood symptoms and syndromes (especially if associated with a positive family history). However, the current level of understanding regarding the etiological significance and mechanism of risk factors associated with mood disorders does not support broad community-based primary prevention strategies in unselected populations.

Effective treatment for mental disorders in children and adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

Psychotropic medication use among children in foster care: relationship to severe psychiatric disorders

OBJECTIVES

This study sought to describe the level of psychotropic medication use and its relationship to severe psychiatric disorders among school-aged children in foster care.

METHODS

Home interviews with 302 foster parents and children aged 6 to 12 years and 266 follow-up clinical evaluations were conducted.

RESULTS

Thirteen percent of the children had taken psychotropic medication in the previous year, and 52% of those whose clinical status merited a medication evaluation had not received medication in the previous year.

CONCLUSIONS

As the efficacy of psychotropic medication treatment for severe child psychiatric disorders becomes more established, research on the appropriateness of such care can begin.

Bipolar disorder in children and adolescents

Bipolar disorder is an affective or mood disorder that affects children and adolescents as well as adults. Originally thought to be rare in childhood, this disorder is now diagnosed even in the prepubertal age group. With pediatricians providing health care for the majority of children and adolescents, these physicians will see the children early in their presentation with affective disorder. This review focuses on the early recognition of children with bipolar disorder or children who are at increased risk of developing mania. Early recognition can lead to early treatment and reduce both short- and long-term morbidity and mortality. This review covers the definition, epidemiology, presentation and differential diagnosis, comorbid diagnoses, precipitants, risk factors, treatment, and outcome.