Antidepressant treatments in children and adolescents. I. Affective disorders

Impersistence of Depression in Youth: Implications for Drug Study Design

Food and Drug Administration data show that most anti-depressant studies in youth do not show drug effect. The few positive studies used rigorous diagnostic screening procedures, suggesting major depressive disorder (MDD) may not be a persistent condition in a subgroup of youth. To investigate persistence of MDD, we serially assessed a cohort of inpatients admitted to the hospital with a clinical diagnosis of MDD. Assessments included a structured diagnostic interview, the Diagnostic Interview for Children and Adolescents-Revised (DICA-R), and measures of depressive symptomatology. Of 66 subjects (40 girls; mean age, 14.4 +/- 2.2 years), 34 (51.5%) met DICA-R criteria for MDD at the initial postadmission assessment. Of these, only 8 (23.5%) met DICA-R criteria for MDD at any subsequent assessment. Similar reductions were found on other ratings of depression. In conclusion, MDD did not persist in this sample. The findings suggest a multigated assessment procedure should be employed before randomization in antidepressant clinical trials.

Pharmacotherapies for adolescent substance use disorders

There is a paucity of research on pharmacotherapies in adolescents with substance use disorders. This paucity is partly because of the fact that most people with substance dependence do not get diagnosed until early adulthood, that is, after 18 years of age. This article reviews pharmacotherapies used for aversion, substitution, anti-craving, and detoxification of alcohol, nicotine, cocaine, and opioids dependence. Adult research is referenced when applicable and generalized to adolescents with caution. Continued evaluation and development of pharmacotherapy for youth in controlled studies are needed to examine medication effectiveness, safety, potential for abuse, compliance, and potential interactions with other medications or substances of abuse.

Ect and Young Minds: Why Choose It?

Comprehensive evaluation of the risks and benefits of applying ECT to young minds would probably not support the practise. This paper explores why some practitioners continue to choose ECT over viable alternative interventions, and argues for improved safeguards against unnecessary and potentially harmful treatments. Ethical decision making must look beyond rapidity of treatment effects, and consider the pros and cons of all available treatments.

Clinical ethics for the treatment of children and adolescents: a guide for general psychiatrists

Clinical work--psychotherapy, assessment, consultation, or research--with emotionally ill children and adolescents is challenging, complex, and exceedingly rewarding. Psychiatrists must remain mindful of children's vulnerabilities but also remain respectful of their rights, regardless of any legal barriers or developmental limitations that exist. To varying degrees, youths are afforded the rights of integrity, autonomy, informed consent or assent, protection of health care information, and participation in research. All physicians who work with children and adolescents are obliged to possess the requisite skills necessary for the provision of beneficial assessments, psychotherapy and psychopharmacology, the protection and advocacy that vulnerable children may require, and the ability to collaborate with families, schools, and other systems in which children regularly function. This work requires self-examination and awareness of one's values and attitudes about children and families and self-monitoring of one's motivations and intents during therapeutic interactions. Additionally, psychiatrists are reminded to seek consultation from valued colleagues whenever an ethical quandary presents itself. Finally, while negotiating the multiple requirements of children, families, communities, legal statutes, and professional ethics and standards, psychiatrists must maintain an ardent commitment to the safety and well-being of their young patients.

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.

Perspectives on the efficacy of antidepressants for child and adolescent depression

Raz looks at the ongoing controversies surrounding the use of SSRI antidepressants in children.

Psychopharmacology in the Treatment of Conduct Disorder Children and Adolescents: Rationale, Prospects, and Ethics

The rationale for psychopharmacological treatments of conduct disorder (CD) in children and adolescent is discussed with reference to the presumed neurophysiological basis of the disorder. Specific psychopharmacological treatments for children with CD are identified and briefly evaluated in terms of their empirical foundations. The lack of a secure knowledge base on the biochemical basis of CD and the efficacy of psychopharmacological treatments with children and adolescents suggests the need for caution in the wide use of pharmacotherapy with these populations. Psychopharmacological treatments with children and adolescents with CD are particularly indicated for reactive aggression, and CD with comordid conditions. Conceptual and methodological improvements in use of psychotropic medications with children and adolescents are discussed as well as the associated ethical considerations.

Sudden death related to selected tricyclic antidepressants in children: epidemiology, mechanisms and clinical implications

The association between tricyclic antidepressant (TCA) use in children and increased risk of sudden death is unclear, but still possible. There are suitable alternatives to TCAs for all of the indications in which they have shown efficacy. A prudent practice model for the utilisation of TCAs has been developed. This includes initial utilisation of alternative agents, with TCAs as secondary or tertiary choices; informed consent from patient and family, including mention of the possible relationship of TCA with sudden death; vigilance of the emerging literature; and finally, systematic monitoring of patients, including electrocardiograms, drug serum concentrations and vital signs. This protocol needs to be validated with regard to utility and the degree of assistance it provides in the management of children treated with TCAs.

A retrospective study of citalopram in adolescents with depression

Recent evidence suggests that the selective serotonin reuptake inhibitors are safe and efficacious in treating juveniles with depression. However, citalopram has not been reported in adolescents with depression. This study assessed the effectiveness and tolerability of citalopram in all adolescents with depressive disorders treated naturalistically in a community mental health center during a 1-year interval. Medical charts were retrospectively reviewed for 21 adolescents treated with citalopram for major depression (n = 14), bipolar depression (n = 4), or dysthymia (n = 3). An independent rater compared last visit to baseline depression using the Clinical Global Impression (CGI) Severity and Improvement scales. Adolescents received citalopram for an average of 128.5 +/- 84 days at a final average dose of 26.5 +/- 13.1 mg/day. Sixteen of these 21 adolescents (76%) exhibited much to very much improvement as measured by the CGI, and severity of depression diminished significantly (z = 3.007, p < 0.0026). Mild side effects, including headaches, dizziness, nausea, sedation, agitation, and sweating were reported by 7 (33%) of the patients. These data suggest that citalopram may be effective, safe, and well tolerated in the treatment of adolescents with depressive disorders and that controlled trials are warranted in this population.

Manual-Driven group cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a pilot study

OBJECTIVE

Concerns about isolation, compromised development, partial pharmacotherapy response, therapist scarcity, and inadequate cognitive-behavioral therapy (CBT) adherence led the authors to adapt a CBT protocol to a group format for adolescents with obsessive-compulsive disorder (OCD). A naturalistic, open trial of group CBT for adolescent OCD is described. The authors predicted symptom improvement and format acceptability.

METHOD

Over a 1 -year period, 18 adolescents aged 13 to 17 years with OCD received 14-week group CBT based on March and Mulle's OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual in four consecutive sessions of five to nine patients. Eighty-three percent had undergone at least one medication trial, and 78% had previous CBT experience.

RESULTS

OCD symptoms measured by the Children's Yale-Brown Obsessive Compulsive Scale improved significantly, both statistically and clinically. Adolescents consistently shared information and designed exposure interventions for themselves and others during sessions. Repeated self-report measures confirmed adolescents' satisfaction with therapy.

CONCLUSIONS

This pilot study demonstrates that a manual-based treatment protocol may be exported for clinical use, adaptable for the end-user's needs, and palatable to adolescent patients. Clinical improvement and patient satisfaction justify further investigation in a controlled study.

Depression in youth: psychosocial interventions

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Therapeutic effects and tolerability of fluvoxamine treatment in adolescents with dysthymia

OBJECTIVE

The aim of the study was to evaluate therapeutic effects and tolerability of fluvoxamine (150-200 mg daily) in 21 dysthymic adolescents.

SUBJECTS

Twenty-one adolescents, attending psychiatric clinics, who met DSM-III-R criteria for dysthymia, without significant co-morbidity were the subjects.

METHODS

Axis I and II diagnoses were made by using SCID-P and SCID II. Score A of >13 on HAMD-S at baseline was mandatory. The HAMD-S was completed after 4, 8, and 26 weeks. Adverse effects were recorded after 1, 2, 4, and 8, weeks. Tolerability was assessed by using CGI-T after 1, 2, and 4 weeks. Adverse effects caused three subjects to withdraw from the study.

RESULTS

Good clinical response (decrease of HAMD-S score >50%) was observed after 4 weeks in 48% of patients; after 8 weeks in 56% of patients, and after 26 weeks in 44% patients. Relapse occurred in 34% of subjects. Fluvoxamine was well tolerated in 76.2% of the adolescents; poor toleration resulted in its discontinuation in 14.2% adolescents.

Prediction of response to fluoxetine and placebo in children and adolescents with major depression: a hypothesis generating study

BACKGROUND

The results of multivariate analyses to identify potential predictors of response to fluoxetine or placebo separately in 96 child and adolescent outpatients with major depressive disorder from a recent controlled trial are presented.

METHODS

A variety of clinical, demographic and laboratory factors were examined as possible predictors of response to fluoxetine or placebo using logistic regression models.

RESULTS

No single variable or combination of variables strongly predicted response to fluoxetine. For the placebo group, a younger age, a shorter duration of depressive episode, and a lower socioeconomic status predicted response with an overall predictive power of 81%.

CONCLUSIONS

This study is limited by the small sample size and should be considered hypothesis generating rather than confirming.

Multicenter open-label sertraline study in adolescent outpatients with major depression

OBJECTIVE

The aim of this multicenter outpatient study was to assess the therapeutic benefits, response patterns, and safety of sertraline in adolescent major depressive disorder (MDD).

METHOD

Fifty-three adolescent outpatients with MDD were treated in an open-label, 10-week, acute-phase trial with sertraline and, if responders, for an additional 12-week continuation phase. Diagnostic and response assessments included the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), 17-item K-SADS-derived depression severity score, Hamilton Depression Rating Scale, Beck Depression Inventory, and Clinical Global Impression Scale.

RESULTS

By 2 weeks, when analyzed as continuous variables, all severity scores showed significant differences from baseline. This pattern persisted through 10 weeks, with a significantly greater response occurring when treatment was extended from 6 to 10 weeks. Both clinician- and patient-rated improvement was maintained during continuation treatment. Response rates varied considerably when depression rating scales were analyzed categorically. Sertraline was generally well tolerated and did not induce manic symptoms.

CONCLUSIONS

In open treatment of adolescent MDD with sertraline, significant improvement occurred early on and was maintained for 22 weeks. Absolute response rates varied depending on the rating scales used, definition of response, and length of treatment. Maximal response rates were obtained by clinician-defined ratings after 10 weeks of treatment.

The context of depression in clinic-referred youth: neglected areas in treatment

OBJECTIVE

To review the empirical, methodological, and conceptual limitations of psychotherapy and pharmacotherapy for childhood and adolescent depression and to present descriptive data on key characteristics of a depressed sample to illustrate gaps in treatment.

METHOD

Interview-based assessment of psychiatric features and psychosocial functioning, family psychopathology and marital adjustment, and child and parent stressful life events was performed in a sample of 43 depressed youngsters seeking outpatient treatment.

RESULTS

The empirical and conceptual review indicated that treatments based on downward extensions of adult procedures are limited in number and success. Also, the treatments generally neglect the following characteristics revealed in the descriptive data: depressed youngsters have high rates of recurrent depression and comorbid conditions, impaired academic and social functioning, exposure to high rates of parental psychopathology, parental assortative mating, severe marital dysfunction, and high rates of severe stressors.

CONCLUSIONS

Treatments need to be informed by and address the actual characteristics of depressed youngsters and their environments, which are highly dysfunctional.

Newer antidepressants. Beyond selective serotonin reuptake inhibitor antidepressants

This article outlines the use of alternative agents to TCAs and SSRIs. Features of the more commonly used alternative antidepressant agents are outlined. In addition, antidepressant agents that are currently either under development or used in other countries are indicated for completeness because it seems likely that many of these will be introduced in the United States within the next few years. Many of these agents will be used by pediatricians and child psychiatrists for treatment of depression in children, and although much further research is needed, the future for alternative antidepressants and augmenting strategies is extremely promising.

The use of tricyclic antidepressants in children and adolescents

For children and adolescents, TCAs have proven efficacy in the treatment of enuresis, OCD, and ADHD, with less compelling evidence in anxiety and tic disorders and as-yet unproven efficacy in major depression. The TCAs continue to be a valuable second-line treatment in the previously mentioned conditions. Given the possible adverse effects caused by these medications and the individual variability in plasma levels, effective, responsible use of these medications includes careful monitoring by the prescribing clinician.

Updating What We Know About Depression in Adolescents

1. Despite an 80% increase in prescriptions written for antidepressants for the treatment of pediatric depression, little empirical research has been done on the effects of antidepressant therapy on children and adolescents. 2. What little research has been done does not support the efficacy of antidepressants use in children. Moreover, some antidepressants may actually be harmful to pediatric populations. 3. Nurses have an obligation to keep abreast of the latest research findings in the literature because the knowledge base changes daily.

Changing patterns of psychotropic medications prescribed by child psychiatrists in the 1990s

The active (1994) and closed (1988 to 1992) outpatient records of youths seen in four separate community mental health centers (CMHC) in Baltimore County, Maryland were reviewed in mid-1994 to document recent changes in the medication-prescribing practices of local child psychiatrists. Inpatient summaries of previously hospitalized CMHC youths were also reviewed to supplement the outpatient medication assessment with hospital data. This regional survey of medication treatments in child psychiatry revealed that, during the half decade before 1994, there was an increase in overall psychotropic medication treatment, multiple concurrent medication treatments (polypharmacy), and antidepressant treatment with serotonin reuptake inhibitors (SRIs). Inpatient youths were consistently prescribed more psychotropic medications and diagnosed more frequently with major depressive disorder than outpatients. Medications typically used to first treat mood disorders became the predominant medication prescribed for both outpatients and inpatients by child psychiatrists in 1994, leading to a proportional decline in prescribed stimulant treatment. The shift from tricyclic antidepressants to SRI antidepressants in the 1990s by child psychiatrists matches the same recent practice shift by adult psychiatrists. Likewise, the increased prescription of drugs to treat mood disorders and the increased rate of polypharmacy notable of late among child psychiatrists now also mirrors adult psychiatry practice. Wide geographic variations in neuroleptic and antidepressant medication patterns were noted, even among facilities in the same metropolitan region. After psychiatric hospitalization, most youths who continued treatment at a CMHC outpatient clinic discontinued their inpatient medications within 3 months; the sole exception were children who had been placed on psychostimulants.

Practitioner review: the pharmacotherapy of adolescent depression

This paper is a review of the pharmacotherapy of adolescent depression. It begins with a brief discussion regarding the nature of adolescent depression and then critically evaluates the available evidence regarding the efficacy and tolerability of psychotropic intervention as it has, to date, been reported. As the available evidence suggests that tricyclic antidepressants have failed to show efficacy, yet demonstrate significant problems with tolerability and safety, the remainder of the article describes how clinicians should prescribe antidepressants using the serotonin reuptake inhibitors. Areas covered include assessment, treatment initiation, dosing, outcome evaluation, adverse events, and combinations. The review concludes with a discussion of long-term therapy with antidepressant medications.

Pills or therapy--which is better?

The debate about the strengths and limitations of psychotherapy in the treatment of depression has been bolstered in a critique by Mufioz et al (1994) of the US Agency for Health Care Policy and Research (AHCPR) 'Depression in Primary Care' guidelines. The author's evaluation of the guidelines suggest that psychotherapy alone is more effective than medication and that combined psychotherapy with medication is no more effective than psychotherapy alone. Such data has important implications for the management of depressions in Australia and provides support for the role of the nurse/therapist within the treatment team.

Case study: nefazodone for juvenile mood disorders

OBJECTIVE

Despite the increasing recognition of juvenile mood disorders, few medications have been shown to be effective. Nefazodone is a novel antidepressant that remains untested in children. Seven cases are described, including four with bipolar depression, in which nefazodone was used for depression.

METHOD

The authors systematically studied the response to nefazodone used naturalistically in seven treatment-refractory and very comorbid children and adolescents (mean age +/- SD, 12.4 + 3.1) with a juvenile mood disorder that was diagnosed clinically and confirmed by structured psychiatric interview. Response to treatment was evaluated retrospectively by an independent rater using the Clinical Global Impression (CGI) of severity and improvement of depression.

RESULTS

Children and adolescents received nefazodone for 13 (+/-8) weeks at a mean daily dose of 357 +/- 151 mg (3.4 mg/kg). Fifty-six percent of children and adolescents previously unresponsive to multiple medication trials manifested much to very much improvement as measured by the CGI. Two of four children with bipolar depression responded well to treatment, whereas the other two had mild manic activation. Overall, nefazodone was well tolerated, with adverse effects reported in only three subjects.

CONCLUSION

Nefazodone appears to be a well-tolerated compound that may provide a treatment option for juveniles with mood disorders. Further controlled trials are warranted.

Case study: two additional sudden deaths with tricyclic antidepressants

Since 1990, there have been five reported cases of sudden death in children treated with desipramine. This case study describes the sudden deaths of two additional children treated with tricyclic antidepressants, one with desipramine, 3.3 mg/kg per day, the other with imipramine, 6 mg/kg per day and thioridazine, 1 mg/kg per day. The reports add to concerns about the use of tricyclics in children.

The Emanuel Miller Memorial Lecture 1994. Depressive disorders in childhood: an impressionistic landscape

To convey an impressionistic landscape of depressive disorders in childhood, studies of clinically referred and diagnosed patients as well as community samples, and data from experimental investigations are used to consider five questions: Are depressive syndromes morbid states in childhood? Should we be concerned about depression in childhood? How do very early-onset depressions arise? What happens to depressed children as they grow up? And how can we help youngsters who suffer from depression? The information is discussed with respect to its implications for the management of clinically depressed children, as well as the prevention of very early-onset depressive disorders.

Nonpharmacological response in hospitalized children with conduct disorder

OBJECTIVE

There is a paucity of research regarding the effects of hospitalization and/or the response to placebo in children with conduct disorder who are hospitalized for chronic and severe aggression. However, many children with this problem are hospitalized and immediately begin pharmacotherapy. In this report, the effects of hospitalization and placebo administration were examined.

METHOD

Subjects were forty-four children (37 males, 7 females) with conduct disorder, aged 9.83 to 17.14 years, who were hospitalized for chronic and severe aggression. This was a 4-week double-blind and placebo-controlled study with a 2-week single-blind placebo lead-in period. During the 2-week placebo baseline period, aggression was measured on a 24-hour basis, using the Overt Aggression Scale. Only subjects meeting a specific aggression criterion were randomized to the treatment period of the trial.

RESULTS

Of the 44 subjects enrolled, 23 (52.3%) met the aggression criteria for entering the treatment period (baseline nonresponders), while 21 (47.7%) did not (baseline responders). Thus, almost half of the subjects, while taking no active medication, benefited from the inpatient milieu/structure and/or placebo.

CONCLUSION

This finding has important treatment and research implications. Medication to treat aggression should not be initiated immediately upon hospitalization because improvements associated with hospitalization may be attributed inaccurately to pharmacotherapy, resulting in unnecessarily medicating children. A placebo baseline period is essential to decrease the risk of a type II error in pharmacological research concerning aggression.

Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and adolescents

OBJECTIVE

Tricyclic antidepressants (TCAs) play an important role in the treatment of pediatric psychiatric disorders. Despite widespread clinical use, concerns about their possible cardiovascular risk have arisen following several published reports of sudden death associated with their use in children. Accordingly, available evidence concerning TCA-associated cardiovascular effects in children and adolescents was surveyed.

METHOD

A systematic literature search from 1967 to 1996 identified relevant pediatric studies that evaluated cardiovascular effects of TCAs.

RESULTS

Twenty-four studies involving 730 children and adolescents given imipramine, amitriptyline, desipramine, or nortriptyline were found. TCA treatment was associated with minor increases in systolic and diastolic blood pressure, in heart rate, and in the electrocardiographic (ECG) conduction parameters, PR, QRS, and QTc. Holter ECG monitoring and exercise testing also revealed minor treatment effects. Some ECG changes related to specific TCAs emerged. Few age-related ECG differences in TCA-treated children, adolescents, or adults were detected. Associations of ECG abnormalities and relatively higher serum TCA levels were found.

CONCLUSION

TCA treatment in children and adolescents, like that in adults, is associated with cardiovascular changes of uncertain, but probably minor, clinical significance. More information is needed on the contribution of other physiological conditions on the cardiovascular system during exposure to TCAs. Guidelines for using TCAs in children and adolescents are presented.

A clinical approach to the pharmacotherapy of aggression in children and adolescents

Overt aggression in its various forms is the most prevalent symptom presenting to pediatric mental health providers, regardless of setting. It is a behavior with a heterogeneous etiology and requires a comprehensive approach to evaluation and treatment. Evaluation of the aggressive child must assess medical, neurologic, psychiatric, psychosocial, familial, and/or educational contributions to behavioral dyscontrol. Multimodal treatment is generally required. At present, there is no single medication to recommend for the treatment of aggressive behavior. Multiple medications have clinically been used in a nonspecific fashion to target excessive childhood aggression. Although successful for some, this approach increases risk for ineffective interventions accompanied by side effects. Until a scientific understanding of the developmental neurobiology of aggression leads to more specific treatment, this review suggests the use of a diagnostic-based approach to the pharmacology of aggression (FIG. 1). Descriptive diagnostic techniques should be used to define the presence of any primary or comorbid psychiatric disorder that presents with aggression as an associated symptom. Treating aggression in the context of these psychiatric syndromes appears to be the most direct approach. Aggression occurring in the context of a medication-responsive psychiatric diagnosis appears most sensitive to pharmacologic intervention. Presently, evidence for efficacy is strongest for aggression in the context of ADHD, psychotic disorder, adolescent-onset bipolar disorder, and ictal aggression It remains less clear that medication can help aggression when it occurs independently of a pharmacologically treatable comorbid psychiatric disorder. Aggression may respond to a target symptom approach where discrete behavioral symptoms that contribute to aggression, such as irritability, explosiveness, fear, or impulsivity, may be modified by medication intervention (FIG. 1). When treatment is approached in this fashion, it is standard practice to use the least toxic and safest intervention first. Behavioral treatment based on contingency management principles could be initially recommended. Medication trials should first use medications that have demonstrated empiric efficacy in reducing aggression (TABLE 1) and that have a favorable safety profile. Neuroleptics to treat aggression in nonpsychotic psychiatrically referred youth should be kept to a minimum, secondary to their significant adverse risk profile. Alternative medications, such as selective serotonin reuptake-inhibiting antidepressants, buspirone, lithium, anticonvulsants, opiate blocking agents, propranolol, nadolol, and clonidine, deserve more clinical research in pediatric aggression. These medications may offer effective and less toxic alternatives in the pharmacologic treatment of inappropriate excessive childhood aggression.

Discriminating depression and anxiety in youth: a role for diagnostic criteria

OBJECTIVE

To test the hypothesis that anxiety and depression in youth, as in adults, become increasingly discriminable when youth meet criteria for an emotional disorder.

METHOD

The study uses cross-sectional data at two points in time from a large (n = 776) community sample of youths, aged eight to twenty. Associations between major depression and five anxiety disorders (overanxious, obsessive compulsive and separation anxiety disorders, and social and simple phobias) are examined by symptom scale and diagnosis.

RESULTS

Anxiety and depression are moderately correlated, and substantially comorbid by diagnostic category. Symptoms are more discriminable among youths with diagnoses of at least one emotional disorder than among those without. A single factor accounts for symptoms among the non-diagnosed but multiple factors are required for the diagnosed group.

CONCLUSIONS

Anxiety and depression are discriminable among youth who meet criteria for a specific emotional disorder but more highly associated among youths without such a diagnosis. This suggests that in youth, as has been shown in adults, depression and anxiety become increasingly discriminable as emotional psychopathology becomes more severe.

Neuropsychological status of children with Tourette's syndrome with and without attention deficit hyperactivity disorder

To determine the frequency of learning disabilities (LD) and describe the neuropsychological profile of children with Tourette's syndrome (TS) with and without attention deficit hyperactivity disorder (ADHD), we analyzed psychosocial, psychoeducational, and neuropsychological data from 65 children between the ages of 6 and 14 years selected from a larger study of LD. Three groups were formed: TS only, TS+ADHD, and TS +/- ADHD. The third group was composed of children whose ADHD status was not as strongly confirmed by the three different instruments used for ADHD diagnosis. From other (non-TS) research projects in the Center, a comparison group of 27 unaffected siblings who had no diagnosis of ADHD was formed. All children were unmedicated at the time of assessment and had the full set of data available for analysis. LDs were present in 23% of the total TS sample, but LD was not present in the TS-only group. All TS groups had scores at or below 1 SD from the mean on measures of choice reaction time, but the TS-only group was significantly poorer on a measure of executive function (letter word fluency). We discuss the implication of the finding in the TS-only group in terms of a slowing of linguistic productivity.

Sleep onset abnormalities in depressed adolescents

Sleep measures were obtained in 16 depressed and 21 control adolescents following 1 week of adherence to a uniformly imposed and strictly enforced sleep/wake schedule. Three nights of baseline electroencephalographic (EEG) sleep on the same 10:00 PM to 7:00 AM schedule revealed prolonged sleep latency and reduced rapid eye movement (REM) latency in the depressed adolescents. Following baseline measures, sleep was restricted for 2 nights (10:00 PM-4:00 AM) and measures of recovery sleep were obtained showing further sleep latency differences. There was no evidence for delta sleep changes or sleep continuity differences in depressed adolescents. These results suggest that control over sleep/wake schedules is an important methodological issue in adolescent sleep studies. Furthermore, the findings are consistent with a larger body of evidence indicating that dysregulation near sleep onset represents a primary psychobiological change in early-onset depression.

Antidepressants for children. Is scientific support necessary?

This article is concerned with issues pertaining to the degree to which clinical therapeutic decisions can reasonably depart from the best available scientific data. There is a tension between the traditions of practitioner autonomy and the boundaries set by research findings. Ambiguity exists as to how much freedom practitioners have to accept or reject the existing scientific paradigm. The nature of the dilemma is explored by analyzing the current problems confronting child psychiatrists and pediatricians who choose to treat depressed children with antidepressants. Despite unanimous literature of double-blind studies indicating that antidepressants are no more effective than placebos in treating depression in children and adolescents, such medications continue to be in wide use. The strategies used to resolve this sort of contradiction are considered, and certain ethical puzzles are appraised.

Current approaches to the psychopharmacologic treatment of depression in children and adolescents

TOPIC

A review of major depressive disorder and antidepressant drug treatment in children and adolescents.

PURPOSE

This paper provides a synthesis of current information regarding diagnosis, psychobiology, psychopharmacology, and practice guidelines for psychiatric nurses involved in the treatment of depression in children and adolescents.

SOURCES

Recent journal and book publications regarding the psychopharmacological treatment of depression in children and adolescents.

CONCLUSION

Although there is far less research to guide the psychopharmacological treatment of depression in children and adolescents than there is for adults, these treatments can be safely administered and effective for some individuals in this age group.

Electrocardiographic changes during desipramine and clomipramine treatment in children and adolescents

OBJECTIVE

With the increased use of tricyclic antidepressants in children, and several reports of several sudden deaths associated with desipramine (DMI) treatment, systematic study of their cardiac effects is indicated. In the present study, DMI's and clomipramine's (CMI) short-term effects on the electrocardiogram (ECG) were compared, as well as the long-term effects of CMI.

METHOD

The ECGs of 47 children and adolescents in treatment trials were examined at baseline, after 5 weeks of CMI and of DMI treatment, and during CMI maintenance (mean duration 24.6 months).

RESULTS

At 5 weeks of CMI and of DMI treatment, the heart rate, PR, QRS, and QT-corrected (QTc) intervals on ECG were significantly increased from baseline (p < .05); DMI increased PR and QRS intervals more than CMI (p < .05), and CMI increased QTc more (p < .05). Tachycardia was the most common change (36%). More patients experienced an incomplete intraventricular conduction delay during DMI treatment (23%, 9/39) than during CMI (2%, 1/47) (p < .05). Four patients (9%) acutely developed a prolonged QTc during either DMI or CMI. Long-term maintenance ECGs during CMI treatment (n = 25) were not significantly different from that at week 5, although some individuals developed or resolved specific ECG changes.

CONCLUSION

CMI and DMI both produced ECG changes typically reported for tricyclic antidepressants, and they differed on specific ECG changes. Changes in ECG measures for individuals from short to long term suggest that continued monitoring is required.

Treatment of bipolar disorder in children and adolescents

OBJECTIVE

To evaluate the current status of research in the treatment of bipolar disorder in children and adolescents.

METHOD

A Medline search was conducted for articles on pharmacological or psychosocial treatment of bipolar disorder in children and adolescents.

RESULTS

There are no controlled studies with adequate sample size of the efficacy of lithium (or any other treatments) in bipolar children and adolescents. Two large open studies suggest that, overall, lithium is beneficial, but there also are reports of lithium resistance in bipolar children and adolescents. Small open studies suggest that mood-congruent delusions and hallucinations may be treated successfully with lithium alone. Data on adjuncts or alternatives to lithium in bipolar children and adolescents are sparse. Several controlled studies have been published on psychosocial treatment of child and adolescent depression, but none on mania.

CONCLUSIONS

Pharmacological and psychosocial treatments of bipolar disorder in children and adolescents are understudied. There is a need for well-designed, controlled studies of lithium and alternative medications as well as adjunctive psychosocial treatments.

Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis

OBJECTIVE

To examine whether tricyclic antidepressants are superior to placebo in the treatment of child and adolescent depression.

DESIGN

Meta-analysis of 12 randomised controlled trials comparing the efficacy of tricyclic antidepressants with placebo in depressed subjects aged 6-18 years.

MAIN OUTCOME MEASURES

Most studies employed several depression rating scales. For each study the "best available" measure was chosen by using objective criteria, and individual and pooled effect sizes were calculated as the number of standard deviations by which the change scores for the treatment groups exceeded those for the control groups. Where authors had reported numbers "responding" to treatment we calculated individual and pooled ratios for the odds of improvement in treated compared with control subjects.

RESULTS

From the six studies presenting data which enabled an estimation of effect size the pooled effect size was 0.35 standard deviations (95% confidence interval of -0.16 to 0.86) indicating no significant benefit of treatment. From the five studies presenting data on the number of "responders" in each group, the ratio of the odds of a response in the treated compared with the control subjects was calculated and the pooled odds ratio was 1.08 (95% confidence interval of 0.53 to 2.17); again indicating no significant benefit of treatment. The pooled sample had more than an 80% chance of detecting a treatment effect of 0.5 standard deviations or greater. There was an inverse relation between study quality and estimated treatment effect.

CONCLUSIONS

Tricyclic antidepressants appear to be no more effective than placebo in the treatment of depression in children and adolescents.

Relationships between mental disorders in childhood and adulthood

Research findings on continuities and discontinuities in psychopathology between childhood and adult life are reviewed with respect to major depressive disorders, anxiety states, obsessional conditions, anorexia nervosa, conduct disorders, hyperkinetic disorders, autism, specific developmental disorders of language and schizophrenia. The findings are used to consider both the conceptual issues and possible mediating mechanisms.