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

Increasing depression and suicidality among American adolescent girls: Current findings, associated factors, and implications

The Youth Risk Behavior Survey (YRBS) Data Summary & Trends Report for 2011-2021 released in February 2023 showed higher rates among female high school students relative to their male peers in endorsements of experiencing poor mental health. This review provides a developmental orientation to promote a biopsychosocial conceptualization of these recent national findings. Young women have higher rates of depressed mood, suicidal ideation, and suicidal plans relative to men, and this gender discrepancy is widening. Higher rates of endorsed school and electronic bullying, social media use, substance use, sexual victimization, and school safety concerns among young women are considered in relation to their sex-specific impact. Recommendations for clinicians are offered to improve the awareness of these important factors and to guide tailored interventions.

Treatment and Outcomes Among North Carolina Medicaid-Insured Youth With Depression

Objective

Youth depression is increasing and is associated with adverse concurrent and long-term outcomes. Understanding receipt of depression treatment and outcomes is critical for population-level efforts to address youth depression. This study aimed to understand treatment patterns and their association with depression-related outcomes.

Method

North Carolina Medicaid claims were used to conduct a retrospective cohort study of treatment and depression-related outcomes in pediatric Medicaid beneficiaries. The sample included 34,623 youth ages 5 to 21 years with an incident depression diagnosis. Psychotherapy and antidepressant medication were assessed for 6 months following diagnosis. Depression-related outcomes including suicidal or self-harming behaviors, emergency department use, and psychiatric hospitalization were analyzed using Cox proportional hazards models to calculate hazard ratios.

Results

Among youth with depression, 86% received treatment (39% psychotherapy, 16% medication, 31% combined), but few youth received guideline-recommended treatment duration. At 6 and 18 months, youth who received combined treatment had higher risk of adverse outcomes compared with the other groups. The untreated group had lower risk of outcomes other than all-cause emergency department visits. Single-session psychotherapy and inconsistent medication fills were also associated with poor outcomes; however, more psychotherapy sessions were associated with lower risk of all-cause emergency department visits.

Conclusion

These data show that the majority of youth who received depression treatment had suboptimal adherence to recommended guidelines. Youth who received combined treatment (both medication and therapy) had more adverse depression outcomes. As claims records do not include clinical data, the effect of treatment type, dose, depression severity, or a combination of these factors cannot be readily disentangled; therefore, these findings do not support a conclusion that combined treatment leads to poor outcomes. Rather, it is possible that youth with a more severe clinical profile are more likely to be prescribed combined treatment or to have poor adherence and thus worse outcomes. Understanding how to improve adherence in real-world settings is needed. Results suggest that many youth continue to struggle despite receipt of mental health care, indicating a call for enhancing existing treatment strategies. Research should aim to better understand population-level care for depression and to promote receipt of and adherence to recommended treatment duration across modalities.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Application of artificial intelligence tools in diagnosis and treatmentof mental disorders

Introduction: Artificial intelligence research is increasing its application in mental health services. Machine learning, deep learning, semantic analysis in the form of transcriptions of patients' statements enable early diagnosis of psychotic disorders, ADHD, anorexia nervosa. Of great importance are the so-called digital therapists. This paper aims to show the use of AI tools in diagnosing, treating, the benefits and limitations associated with mental disorders. Material and methodS: This literature review was conducted by searching scientific articles from 2015 to 2022. The basis were PubMED, OpenKnowledge, Web of Science, using the following keywords: artificial intelligence, digital therapy, psychiatry, machine learning. Results: A review indicates the widespread use of AI tools in screening for mental disorders. These tools advance the clinical diagnosis medical specialists make up for several years. They impact solving medical staff shortages, lack of access to medical facilities and leveling patient resistance to treatment. The benefits are ultra-fast analysis of large sets of information, effective screening of people in need of specialized psychiatric care, reduction of doctors' duties and maximization of their work efficiency. During the current COVID 19 pandemic, robots in the form of digital psychotherapists are playing a special role. Conclusions: The need for further research, testing and clarification of regulations related to the use of AI tools is indicated. Ethical and social problems need to be resolved. The tools should not form the basis of autonomous therapy without the supervision of highly trained professionals. Human beings should be at the center of analysis just as their health and well-being. Keywords: artificial intelligence, digital therapy, psychiatry, machine learning

Clinical practice guideline recommendations on tapering and discontinuing antidepressants for depression: a systematic review

BACKGROUND

Tapering and discontinuing antidepressants are important aspects of the management of patients with depression and should therefore be considered in clinical practice guidelines.

OBJECTIVES

We aimed to assess the extent and content, and appraise the quality, of guidance on tapering and discontinuing antidepressants in major clinical practice guidelines on depression.

METHODS

Systematic review of clinical practice guidelines on depression issued by national health authorities and major national or international professional organisations in the United Kingdom, the United States, Canada, Australia, Singapore, Ireland and New Zealand (PROSPERO CRD42020220682). We searched PubMed, 14 guideline registries and the websites of relevant organisations (last search 25 May 2021). The clinical practice guidelines were assessed for recommendations and information relevant to tapering and discontinuing antidepressants. The quality of the clinical practice guidelines as they pertained to tapering and discontinuation was assessed using the AGREE II tool.

RESULTS

Of the 21 included clinical practice guidelines, 15 (71%) recommended that antidepressants are tapered gradually or slowly, but none provided guidance on dose reductions, how to distinguish withdrawal symptoms from relapse or how to manage withdrawal symptoms. Psychological challenges were not addressed in any clinical practice guideline, and the treatment algorithms and flow charts did not include discontinuation. The quality of the clinical practice guidelines was overall low.

CONCLUSION

Current major clinical practice guidelines provide little support for clinicians wishing to help patients discontinue or taper antidepressants in terms of mitigating and managing withdrawal symptoms. Patients who have deteriorated upon following current guidance on tapering and discontinuing antidepressants thus cannot be concluded to have experienced a relapse. Better guidance requires better randomised trials investigating interventions for discontinuing or tapering antidepressants.

The prevalence of depression in Iranian children: A systematic review and meta-analysis

INTRODUCTION

The present study was conducted to evaluate the prevalence of depression in Iranian children.

METHOD

This meta-analysis was registered in PROSPERO with code (CRD42020216632) and performed based on the MOOSE protocol and PRISMA guidelines. Title and abstract of articles were searched without time limit until April 2020 in international databases PubMed/Medline, Scopus, Embase, Science Direct, Cochrane Library, CINAHL, EBSCO, Web of Science, Google Scholar, and Iranian databases.

RESULTS

In 34 studies with a sample size of 23,779 Iranian children, the prevalence of depression was estimated 42.3 % (95 %CI: 34.9-50.0). Prevalence of depression in girls in 20 studies with a sample size of 11,170 was estimated 42.1 % (95 %CI: 32.7-52.1) and the prevalence of depression in males in 20 studies with a sample size of 4678 was estimated 29.6 % (95 %CI: 21.2-39.7). The odds ratio of female to male depression was 1.33 (95 %CI: 1.07-1.65, P < 0.011). Prevalence of mild, moderate, major and deep depression was 20.3 % (95 %CI: 16.4-24.9), 15.0 % (95 %CI: 11.3-19.7), 14.5 % (95 %CI: 10.8-19.1), and 4.3 % (95 %CI: 1.8-9.8), respectively. In subgroup analysis for prevalence of depression in Iranian children, the variables of geographical area (P = 0.258), quality of studies (P = 0.186), type of questionnaire (P = 0.907), sample size (P = 0.500) and year of studies (P = 0.538) were not significant, but subgroup analysis of province (P < 0.001) and school grade (P < 0.001) were significant.

CONCLUSION

The results of the present meta-analysis showed that depression is common in Iranian children and is much higher than global estimates. These findings emphasize the importance of identifying and providing treatment to children who are most in need.

Exercise as Treatment for Youth With Major Depression: The Healthy Body Healthy Mind Feasibility Study

The goals of this study were to determine the feasibility of engaging youth with major depressive disorder (MDD) in a multimodal exercise intervention (Healthy Body Healthy Mind) plus usual care and to evaluate the magnitude of its effects on psychological, physical fitness, and biomarker outcomes to inform a future randomized controlled trial. Youth (15 to 25 y of age) with MDD diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) were eligible to participate. Feasibility measures included recruitment, retention, and program adherence rates. The exercise program consisted of a single session of motivational interviewing to enhance exercise adherence, then 1-hour, small-group supervised exercise sessions 3 times per week for 12 weeks. Assessments were administered at baseline and at 12 weeks. Depression symptoms were assessed using the Beck Depression Inventory (BDI-II). Physical fitness and blood biomarkers were also measured. Three males and 10 females with MDD, who were 18 to 24 years of age, participated. Retention at 12 weeks was 86%, and attendance at exercise sessions averaged 62%±28%. After 12 weeks, 69% of participants experienced a remission of MDD based on the SCID. Mean BDI-II scores decreased from 31.9±9.1 to 13.1±10.1 [Cohen d effect size (ES)=1.96]. Improvements were observed in upper (ES=0.64) and lower (ES=0.32) body muscular endurance. Exercise session attendance was moderately correlated with changes in BDI-II scores (Pearson r=0.49). It appears feasible to attract and engage some youth with MDD in an exercise intervention. The positive impact on depression symptoms justifies further studies employing exercise interventions as an adjunct to routine care for young people with MDD.

Pre-pubertal, low-intensity exercise does not require concomitant venlafaxine to induce robust, late-life antidepressant effects in Flinders sensitive line rats

A significant number of adolescents are considered insufficiently active. This is of concern considering the negative association between physical activity and major depressive disorder (MDD). There is a lack of approved pharmacological treatment options in this population partly due to limited information on the risks associated with lasting effects during early life. Therefore, interest in non-pharmacological strategies is gaining popularity with low- to moderate-intensity exercise being especially attractive for its antidepressant-like effects and augmentation properties in combination with antidepressants. Early-life development might present a unique "window of opportunity" to induce long-term beneficial effects in individuals treated with central acting drugs, such as antidepressants. Therefore, we investigated the bio-behavioural effects of pre-pubertal, low-intensity exercise (EXE) and/or venlafaxine (VEN) on depressive-like behaviour in juvenile (postnatal day 35 (PND35)) and young adult (PND60) stress-sensitive Flinders sensitive line (FSL) rats. Interventions were introduced during pre-pubertal development, that is PND21-34, followed by a 26-day washout/sedentary period, when bio-behavioural analyses were performed in the early adulthood group. VEN, alone or in combination with EXE, proved ineffective in inducing any bio-behavioural changes in either age group. EXE did not induce early-life antidepressant-like effects, despite increasing frontal serotonin (5-HT) and noradrenaline (NA) levels. Later in life (PND60), pre-pubertal exercise reduced immobility and increased coping behaviours, together with increased cortical 5-HT levels, despite a significant reduction in locomotor activity. These findings emphasize a strong serotonergic basis to the observed delayed antidepressant effects of EXE later in life.

Immediate and long-term antidepressive-like effects of pre-pubertal escitalopram and omega-3 supplementation combination in young adult stress-sensitive rats

Major depressive disorder (MDD) affects a significant number of children and adolescents, yet treatment options for this population remain very limited. Escitalopram (ESC) is one of only two antidepressants approved as treatment for juvenile depression. Still, delayed onset of action, and immediate plus the risk of lasting side effects contribute to low patient adherence, and places the medical prescriber in a difficult situation weighing the potential long-term effects of juvenile treatment against the known consequences of untreated MDD. Research into alternative or augmentation strategies and their long-term effects are needed to improve clinical outcome and better our understanding of the long-term consequences of early-life treatment. We investigated the early-life (postnatal day 35 (PND35)) and lasting (PND60) bio-behavioural effects of pre-pubertal (PND21 to PND34) escitalopram (ESC) administration and/or ω-3 supplementation (OM3) in stress sensitive Flinders Sensitive Line rats. Only ESC treatment showed a strong trend to decrease depressive-like behaviour via significantly increased climbing behaviour on PND35. However, OM3 treatment reduced locomotor activity and increased hippocampal neuroplasticity on PND35, suggesting improved coping behaviour and masking of possible antidepressant-like effects. Reduced locomotor activity lasted into early-adulthood on PND60, despite a treatment-free period from PND35 to PND60. Regardless, early-adulthood antidepressive-like behaviour was only observed in the combination treatment (ESC + OM3) group, despite a significant increase in serotonin turnover, suggesting strong neurodevelopmental process to be involved. Taken together, the combination of ESC and OM3 might induce lasting beneficial neurodevelopmental effects in a stress-sensitive population, suggesting a possible role in current treatment strategies.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.

RESULTS

Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Neural Correlates of Antidepressant Treatment Response in Adolescents with Major Depressive Disorder

OBJECTIVE

The neural changes underlying response to antidepressant treatment in adolescents are unknown. Identification of neural change correlates of treatment response could (1) aid in understanding mechanisms of depression and its treatment and (2) serve as target biomarkers for future research.

METHOD

Using functional magnetic resonance imaging, we examined changes in brain activation and functional connectivity in 13 unmedicated adolescents with major depressive disorder (MDD) before and after receiving treatment with a selective serotonin reuptake inhibitor medication for 8 weeks. Specifically, we examined brain activation during a negative emotion task and resting-state functional connectivity (RSFC), focusing on the amygdala to capture networks relevant to negative emotion. We conducted whole-brain analyses to identify how symptom improvement was related to change in brain activation during a negative emotion task or amygdala RSFC.

RESULTS

After treatment, clinical improvement was associated with decreased task activation in rostral and subgenual anterior cingulate cortex and increased activation in bilateral insula, bilateral middle frontal cortices, right parahippocampus, and left cerebellum. Analysis of change in amygdala RSFC showed that treatment response was associated with increased amygdala RSFC with right frontal cortex, but decreased amygdala RSFC with right precuneus and right posterior cingulate cortex.

CONCLUSION

The findings represent a foothold for advancing understanding of pathophysiology of MDD in adolescents by revealing the critical neural circuitry changes that underlie a positive response to a standard treatment. Although preliminary, the present study provides a research platform for future work needed to confirm these biomarkers at a larger scale before using them in future target engagement studies of novel treatments.

Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety

The pediatric practitioner is often the first point-of-contact for children and adolescents suffering from mental illness. Part of the treatment planning for psychiatric diagnoses includes consideration of medication. Attention-deficit/hyperactivity disorder, one of the most common diagnoses, is very responsive to stimulant medications; for children who are unable to tolerate stimulants or who do not achieve satisfactory symptom management, central α-agonists and atomoxetine are effective and generally well-tolerated alternative or augmentative agents. Depression and anxiety disorders are also frequently encountered in the pediatric office setting. The use of selective serotonin reuptake inhibitors is considered first-line psychopharmacology for depression and anxiety symptoms. Despite concerns for suicidal ideation related to this medication class, the benefits typically outweigh the risks. This review provides basic clinical pharmacology of stimulant and nonstimulant attention-deficit/hyperactivity disorder medications and selective serotonin reuptake inhibitors intended to serve as a primer for the general pediatrician.

A tale of two diatheses: Temperament, BIS, and BAS as risk factors for mood disorder

OBJECTIVE

Learning more about how biological traits, like temperament and sensitivity in the behavioral inhibition (BIS) and behavioral activation (BAS) systems, relate to mood pathology is consistent with the Research Domain Criteria initiative׳s goal of investigating mechanisms of risk.

METHOD

Korean young adults (n=128) and American young adults (n=630, of whom 23 has recent treatment for bipolar disorder, and 21for depression) completed self-report questionnaires, including the TEMPS-A, the BIS/BAS scales, Beck Depression Inventory (BDI), and Hypomanic Checklist (HCL-32). Linear regression quantified relations between mood symptoms, sample characteristics, temperament, and BIS/BAS.

RESULTS

Temperament styles explained 49% of the variance in BDI scores. BIS explained an additional 1% of the variance in BDI scores. BAS Fun and Reward (p<.01), in addition to cyclothymic and hyperthymic temperaments (p<.001) explained 21% of the variance in HCL-32 scores. Sample characteristics were not significant predictors in the full model.

LIMITATIONS

Differences in sample size, the cross-sectional study design, and lack of collateral report or behavioral measures of constructs are limitations.

CONCLUSIONS

Affective temperament and BIS/BAS are complementary but distinct constructs. Affective temperament, particularly cyclothymic, may represent a stronger diathesis for mood pathology, and seems potent irrespective of culture or diagnosis. Assessing temperament may help overcome some challenges in diagnosing mood disorders.

Key issues in addressing the comorbidity of depression and pediatric epilepsy

Depression is a common comorbidity associated with epilepsy. However, the etiology of depression is difficult to establish given the heterogeneity in both epilepsy and depression. Nevertheless, the co-occurrence is so common that a bidirectional relationship between depression and epilepsy has been theorized. Persons with temporal lobe seizure foci and partial-onset epilepsy may be more vulnerable to the development of depression. In pediatrics, depression differs but may be readily identified by understanding nuances of mood states and variability of neurovegetative symptom presentation. Although no clear treatment guidance exists in the context of epilepsy, antidepressants have been relatively well studied in pediatrics and are effective and well tolerated. Anticonvulsant drugs may also improve depressive symptoms though clinical research is lacking in pediatrics. Treatment of depression may independently improve outcome for epilepsy and for quality of life. Future studies will clarify etiologies of depression in the context of epilepsy and improve the evidence base for treatment outcomes.

Depressed Adolescents Treated with Exercise (DATE): A pilot randomized controlled trial to test feasibility and establish preliminary effect sizes

The Depressed Adolescents Treated with Exercise (DATE) study evaluated a standardized aerobic exercise protocol to treat nonmedicated adolescents that met DSM-IV-TR criteria for major depressive disorder. From an initial screen of 90 individuals, 30 adolescents aged 12-18 years were randomized to either vigorous exercise (EXER) (>12 kg/kcal/week [KKW]) or a control stretching (STRETCH) activity (< 4 KKW) for 12 weeks. The primary outcome measure was the blinded clinician rating of the Children's Depression Rating Scale - Revised (CDRS-R) to assess depression severity and Actical (KKW) accelerometry 24hr/7days a week to assess energy expenditure and adherence. Follow-up evaluations occurred at weeks 26 and 52. The EXER group averaged 77% adherence and the STRETCH group 81% for meeting weekly target goals for the 12 week intervention based on weekly sessions completed and meeting KKW requirements. There was a significant increase in overall weekly KKW expenditures (p < .001) for both groups with the EXER group doubling the STRETCH group in weekly energy expenditure. Depressive symptoms were significantly reduced from baseline for both groups with the EXER group improving more rapidly than STRETCH after six weeks (p < .016) and nine weeks (p < .001). Both groups continued to improve such that there were no group differences after 12 weeks (p = .07). By week 12, the exercise group had a 100% response rate (86% remission), whereas the stretch group response rate was 67% (50% remission) (p = .02). Both groups had improvements in multiple areas of psychosocial functioning related to school and relationships with parents and peers. Anthropometry reflected decreased waist, hip and thigh measurements (p = .02), more so for females than males (p = .05), but there were no weight changes for either gender. The EXER group sustained 100% remission at week 26 and 52. The STRETCH group had 80% response and 70% remission rates at week 26 and by week 52 only one had not fully responded. The study provides support for the use of exercise as a non-medication intervention for adolescents with major depressive disorders when good adherence and energy expenditure (KKW) are achieved.

Psychiatric comorbidity in children and adolescents with restless legs syndrome: a retrospective study

OBJECTIVE

Children and adolescents with restless legs syndrome (RLS) are commonly diagnosed with comorbid attention deficit hyperactivity disorder and behavioral disturbances. Uncertainty exists over the significance of other co-occurring psychiatric disorders and their pharmacologic management in children with RLS. The purpose of this study was to determine the prevalence and nature of psychiatric disorders in children with RLS and to describe the use of psychotropic medications in our study cohort.

METHODS

The electronic medical records of children younger than 18 years of age who had been diagnosed with RLS between January 1, 2003, and December 31, 2009, were reviewed. Only those patients whose findings were consistent with the 2003 NIH workshop diagnostic criteria for probable or definite restless legs syndrome were included in this study. The medical records were cross-referenced for encounters with a child psychiatrist or psychologist. Likewise, only psychiatric diagnoses whose medical records explicitly reflected DSM-IV diagnostic criteria for psychiatric disorder(s) were included. Demographic data, serum ferritin, psychotropic medications, and in some cases, the results of pharmacogenomic testing were included in the data analysis in an ad hoc fashion.

RESULTS

We found 374/922 patients who met diagnostic criteria for childhood onset RLS. The mean age of the subjects was 10.6 years (range 0 to 18) and the male to female ratio was approximately 1:1. Overall, 239/374 (64%) patients with RLS had one or more comorbid psychiatric disorders. Attention deficit hyperactivity disorder was found in 94/374 (25%) patients, mood disturbances were found in 109/374 (29.1%) patients, anxiety disorders in 43/374 (11.5%) patients, and behavioral disturbances in 40/374 (10.9%) patients. Attention deficit hyperactivity disorder and disruptive behavior disorders were more common in males (OR = 1.94 for both), whereas mood disturbances and anxiety disorders were more common in females (OR = 1.6 and 1.26, respectively). Mean serum ferritin levels derived from all patients without any psychiatric disorder were compared to all patients with one or more psychiatric disorder. No differences were found. The number of new psychotropic medication trials increased significantly with increase in patient age. Stimulants and antidepressant medications were the most commonly prescribed agents. As a part of clinical care, 15 of these patients underwent pharmacogenomic testing. Metabolic abnormalities were predicted by genotyping in 12/15 (80%) patients.

CONCLUSION

Comorbid psychiatric conditions occurred in two-thirds of children with RLS, underscoring the need for multidisciplinary management of this condition. An important relationship might exist between psychotropic medication, and possibly pharmacogenomic factors, in children and adolescents with symptoms of restless legs syndrome. These findings are consistent and build on those reported in the adult literature.

Depressive symptomatology in children and adolescents with chronic renal insufficiency undergoing chronic dialysis

This paper presents a descriptive study, using the Birleson Scale to determine the frequency of depressive symptomatology in children and adolescents with chronic renal insufficiency (CRI) undergoing hemodialysis (HD) and chronic peritoneal dialysis (CPD). There were 67 patients (40 female and 27 male) with a mean age of 14.76 ± 2.71 years, duration of illness ≥3 months, 43 (64.18%) patients with CPD and 24 (35.82%) undergoing HD. The frequency of high occurrence, low occurrence, and absence of depressive symptomatology was 10.45% (n = 7), 43.28% (n = 29), and 46.27% (n = 31), respectively; all of the seven (100%) patients with high occurrence of depressive symptomatology were female (P = 0.04), and none of these (0%) had a friend to confide in (P = 0.03). Depressive symptomatology in patients with CPD was associated with a lower weekly K(t)/V compared to those without depressive symptomatology (2.15 ± 0.68 versus 2.52 ± 0.65; P = 0.01). There was no association with patient age, caregiver, time and dialysis type, anemia, bone disease, nutritional or financial status, origin, schooling, or employment.

Anxiety and mood disorders in children and adolescents: A practice update

Anxiety and mood disorders are among the most common disorders in children and adolescents. They presage later emotional difficulties and disabilities. An understanding of the disorders' presentation, common contributing factors and methods of intervention will enable paediatricians and family doctors to provide optimal support to these children and their families. The present paper briefly reviews the epidemiology of anxiety and mood disorders in children and adolescents. Phenomenology is referred to according to the major diagnostic categories for anxiety and depression. Contributing factors, including genetic and environmental components and their possible interaction, are discussed. The management of the disorders, including common strategies for encouraging coping responses, stress reduction and medication, is also described.

Long-term treatment of pediatric depression with psychotherapies

Major depressive disorder in children and adolescents is associated with significant morbidity and mortality, and benefits from intervention. However, studies have focused on acute treatment. Thus, data are limited on long-term treatment (ie, both continuation and maintenance treatment). This article discusses the naturalistic course of depression following acute treatment with psychotherapy and the efficacy of long-term psychotherapy for the prevention of relapse and recurrence in depressed children and adolescents.

Toward a technology of treatment individualization for young children with autism spectrum disorders

Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are not yet well understood, recent research in the field of autism has heavily emphasized the importance of early intervention (i.e. treatment before the age of 4 years). Currently, several methods have been demonstrated to be efficacious with some children however no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will be best for all children, or will work for any one child throughout his or her educational career. Thus, this paper examines early research validating different technologies for individualizing treatment. A discussion of current research on pre-treatment characteristics associated with differential outcomes in treatment, including child, family, and practitioner variables; and how specific intervention techniques address each of those pre-treatment characteristics is provided. The ultimate goal of this line of research is to enable practitioners to prospectively tailor treatments to specific children and increase the overall rate of positives outcomes for children with autism. Research that furthers understanding of how to match clients with efficacious treatments will decrease the outcome variability that characterizes early intervention research at present, and provide for the most efficient allocation of resources during the critical early intervention time-period. This type of research is in its infancy, but is imperative if we are to determine a priori which treatment method will be most effective for a specific child.

Depressive and adjustment disorders - some questions about the differential diagnosis: case studies

BACKGROUND

Diagnosis and treatment of mood disorders in youth are still problematic because in this age the clinical presentation is atypical, and the diagnostic tools and the therapies are the same as that used for the adults. Mood disorders are categorically divided into unipolar disorders (major depressive disorder and dysthymic disorder) and bipolar disorder in Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision), but mood symptoms are also comprised in the diagnostic criteria of the adjustment disorder (AD), which occur in many different psychiatric disorders, and may also be found in some physical conditions. The differential diagnosis is not much addressed in the midst of clinical investigation and so remains the major problem in the clinical practice.

AIMS

The associations between some variables and the depressive disorder and AD were analyzed to make considerations about differential diagnosis.

PATIENTS AND METHODS

We reported a retrospective study of 60 patients affected by depressive disorder and AD. The analysis has evaluated the association between some variables and the single diagnostic categories. We have considered 10 variables, of which 6 are specific to the disorders, and 4 have been considered related problems.

RESULTS

The statistical analysis showed significant results for the associations of 3 variables (prevalent symptoms, treatment, and family history) with the single diagnostic categories.

CONCLUSION

The discriminate analysis resulted in statistically significant differences between patients with depressive disorders and those with AD on 3 variables, of which 2 are specific to the disorders, and 1 is included in the related problems. The other variables were weakly associated with the single diagnostic categories without any statistically significant differences. The 3 variables that were associated with the single diagnostic categories support the distinct construct validity of the 2 diagnostic categories, but, to date, it is difficult to establish if these variables can be considered diagnostic predictors. On the other hand, the other variables did not support the distinct construct validity of the 2 diagnostic categories, which suggest an overlapping and dimensional concept. The spectrum approach could unify categorical classification that is essential with a dimensional view. Combination of dimensional and categorical principles for classifying mood disorders may help to reduce the problems of underdiagnosis and undertreatment.

Investigation of posttraumatic stress disorder in children after animal-induced injury in China

OBJECTIVE

Dogs are important members of many families in many countries. However, posttraumatic stress disorder (PTSD) in children after animal attacks has always been underestimated, and a more-detailed study of PTSD in children after animal attacks is needed.

METHODS

The charts and follow-up data for 358 children after animal-induced injuries were reviewed. Family Apgar Scale assessment and PTSD screening were performed at emergency department admission. On week 1 after the emergency department admission, the patient underwent evaluation for acute stress disorder (ASD) diagnosis, by using the Child Acute Stress Questionnaire. PTSD screening and interim history-taking were performed 3 months after the emergency department admission, by telephone or in face-to-face interviews, by using the Clinician-Administered PTSD Scale for Children and Adolescents. P values of <.05 were considered significant.

RESULTS

A total of 19 patients developed PTSD, including 10 patients with severe injuries, 8 patients with moderate injuries, and 1 patient with a mild injury (chi(2)=48.104; P=.000). No significant differences in PTSD occurrence according to gender and age were observed. Family Apgar Scale scores were not significantly related to PTSD (P=.781). ASD and PTSD symptom severity scores were significantly associated (r=0.51; P < .005).

CONCLUSIONS

Child victims of severe animal attacks should be considered at risk for the development of PTSD, family support was not correlated with posttraumatic stress symptoms in school-aged children after animal attacks, and ASD seems to be an early predictive indicator of PTSD.

Explaining racial and ethnic differences in antidepressant use among adolescents

We investigate the extent to which antidepressant use among adolescents varies across racial and ethnic subgroups. Using a representative sample of U.S. adolescents, we find that non-Hispanic White adolescents are over twice as likely as Hispanic adolescents, and over five times as likely as non-Hispanic Black adolescents to use antidepressants. Results from a decomposition analysis indicate that racial/ethnic differences in characteristics, including household income, parental education, health insurance, and having a usual source of care explain between one half and two thirds of the gap in antidepressant use between Hispanics and non-Hispanic Whites. In contrast, none of the gap between Whites and Blacks in antidepressant use is explained by differences in observed characteristics. Further analysis suggests that there are large racial/ethnic differences in the extent to which behavioral and mental health problems prompt antidepressant use and that this may, in part, account for the large differences across race/ethnicity observed in our study.

Omega-3 fatty acids in depression: a review of three studies

We review three studies of omega-3 fatty acids in the treatment of depression that were carried out by our research group at the Beer Sheva Mental Health Center. The first study examined eicosapentaenoic acid (EPA) versus placebo as an adjunct to antidepressant treatment in 20 unipolar patients with recurrent major depression. The second study used omega-3 fatty acids in childhood major depression; 28 children aged 6-12 were randomized to omega-3 fatty acids or placebo as pharmacologic monotherapy. The third study was an open-label add-on trial of EPA in bipolar depression. Twelve bipolar outpatients with depressive symptoms were treated with 1.5-2.0 g/day of EPA for up to 6 months. In the adult unipolar depression study, highly significant benefits were found by week 3 of EPA treatment compared with placebo. In the child study, an analysis of variance (ANOVA) showed highly significant effects of omega-3 on each of the three rating scales. In the bipolar depression study, 8 of the 10 patients who completed at least 1 month of follow-up achieved a 50% or greater reduction in Hamilton depression (Ham-D) scores within 1 month. No significant side effects were reported in any of the studies. Omega-3 fatty acids were shown to be more effective than placebo for depression in both adults and children in small controlled studies and in an open study of bipolar depression. (This review discusses three studies, all from our group, completed before the clinical trial registry was initiated.)

Adolescent depression: views of health care providers in a pediatric emergency department

OBJECTIVE

Pediatric emergency department (PED) providers are strategically positioned to identify adolescents with depression. Our objectives were to describe health care providers' perspectives on adolescent depression and the role of depression screening in the PED.

METHODS

We conducted semistructured interviews with 41 health care providers from an urban, academic PED (including PED attending physicians and trainees, social workers, and psychiatrists). Interviews were audiotaped, transcribed, and entered into the N6 qualitative data analysis software version 6 (QSR International Pty Ltd, Cambridge, Mass) for coding and analysis. A multidisciplinary team used content analysis to identify 2 primary domains: (1) provider attitudes about adolescent depression and (2) factors associated with adolescent depression screening processes in a PED setting.

RESULTS

The PED-based providers demonstrated a clear understanding of the clinical burden of adolescent depression but described complex individual and system-level barriers to addressing the issue. All providers recognized the high prevalence of adolescent depression and its impact on health and described adolescent depression as a moderate-to-large problem that was greatly underrecognized but applied primarily a biomedical model for treatment options. The respondents endorsed computerized screening as a useful approach. Concerns were raised universally regarding the ability of the health care system to respond to screened adolescents found to be depressed.

CONCLUSIONS

The study describes the perspectives of multiple, key stakeholders necessary for a system response to the identification, assessment, and management of adolescent depression in the PED. The PED providers were generally supportive of computerized depression screening in the PED setting but also voiced the need for system-level responses that facilitate access to quality mental health care services for adolescents.

Improving the mental health, healthy lifestyle choices, and physical health of Hispanic adolescents: a randomized controlled pilot study

BACKGROUND

Obesity and mental health disorders are 2 major public health problems in American adolescents, with prevalence even higher in Hispanic teens. Despite the rapidly increasing incidence and adverse health outcomes associated with overweight and mental health problems, very few intervention studies have been conducted with adolescents to improve both their healthy lifestyles and mental health outcomes. Even fewer studies have been conducted with Hispanic youth. The purpose of this study was to evaluate the preliminary efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) program, a manualized educational and cognitive behavioral skills-building program, on Hispanic adolescents' healthy lifestyle choices as well as mental and physical health outcomes.

METHODS

A cluster randomized controlled pilot study was conducted with 19 Hispanic adolescents enrolled in 2 health classes in a southwestern high school. One class received COPE and the other received an attention control program.

RESULTS

Adolescents in the COPE program increased their healthy lifestyle choices and reported a decrease in depressive and anxiety symptoms from baseline to postintervention follow-up. A subset of 7 overweight adolescents in the COPE program had a decrease in triglycerides and an increase in high-density lipoproteins. In addition, these overweight adolescents reported increases in healthy lifestyle beliefs and nutrition knowledge along with a decrease in depressive symptoms.

CONCLUSION

The COPE TEEN program is a promising school-based strategy for improving both physical and mental health outcomes in adolescents.

Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): acute and long-term outcomes

OBJECTIVE

We examine remission rate probabilities, recovery rates, and residual symptoms across 36 weeks in the Treatment for Adolescents with Depression Study (TADS).

METHOD

The TADS, a multisite clinical trial, randomized 439 adolescents with major depressive disorder to 12 weeks of treatment with fluoxetine, cognitive-behavioral therapy, their combination, or pill placebo. The pill placebo group, treated openly after week 12, was not included in the subsequent analyses. Treatment differences in remission rates and probabilities of remission over time are compared. Recovery rates in remitters at weeks 12 (acute phase remitters) and 18 (continuation phase remitters) are summarized. We also examined whether residual symptoms at the end of 12 weeks of acute treatment predicted later remission.

RESULTS

At week 36, the estimated remission rates for intention-to-treat cases were as follows: combination, 60%; fluoxetine, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. Paired comparisons reveal that, at week 24, all active treatments converge on remission outcomes. The recovery rate at week 36 was 65% for acute phase remitters and 71% for continuation phase remitters, with no significant between-treatment differences in recovery rates. Residual symptoms at the end of acute treatment predicted failure to achieve remission at weeks 18 and 36.

CONCLUSIONS

Most depressed adolescents in all three treatment modalities achieved remission at the end of 9 months of treatment.

Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school-based health centers

INTRODUCTION

The purpose of this study is to describe the development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS), a time-efficient screening tool to assess for multiple adolescent risk behaviors.

METHOD

A retrospective chart audit was conducted to obtain descriptive data of middle school (N = 106) and alternative high school (N = 39) adolescents who completed the 17- to 18-item RAAPS questionnaire. Surveys assessed providers' evaluations of the RAAPS.

RESULTS

Descriptive statistics and qualitative analysis indicated that providers using the RAAPS were able to identify risk behaviors/factors, provide counseling for these behaviors, and refer 26% of 9- to 15-year-olds and 43% of 16- to 20-year-olds for further assessment or ongoing risk counseling. In one brief clinic visit, the providers were able to address and document most risk behaviors/factors reported by the adolescents.

DISCUSSION

Although psychometric analysis is needed, the RAAPS is a time efficient and comprehensive risk assessment tool. Early risk identification can assist providers in tailoring specific preventative education counseling and intervention programs that are geared to meet the specific needs of the adolescent population.

Testing the hierarchical structure of the Children's Depression Inventory: a multigroup analysis

Using exploratory and confirmatory factor analyses, the aims were (a) to obtain, describe, and compare different solutions of three, five, and six first-order factors raised in the previous literature about the Children's Depression Inventory (CDI); (b) analyze the number and nature of the second-order factors; (c) test which model best reproduces the CDI structure; and (d) test possible developmental differences between child and adolescent samples. The CDI was applied to 4,707 Spanish children and adolescents with an age range between 7 and 16 years. Results show that best models considered five or six factors, including Social Problems (Anhedonia), Negative Affect, Externalizing, School Problems, and Negative Self-Esteem (Self-Deprecation). Also, a factor of Biological Dysregulation obtained some support. Higher-order factors do not reproduce the classical distinction between internalizing and externalizing symptoms. Finally, no large developmental differences in the CDI structure were found between children and adolescents samples.

Evidence-based psychosocial treatments for child and adolescent depression

The evidence-base of psychosocial treatment outcome studies for depressed youth conducted since 1998 is examined. All studies for depressed children meet Nathan and Gorman's (2002) criteria for Type 2 studies whereas the adolescent protocols meet criteria for both Type 1 and Type 2 studies. Based on the Task Force on the Promotion and Dissemination of Psychological Procedures guidelines, the cognitive-behavioral therapy (CBT) based specific programs of Penn Prevention Program, Self-Control Therapy, and Coping with Depression-Adolescent are probably efficacious. Interpersonal Therapy-Adolescent, which falls under the theoretical category of interpersonal therapy (IPT), also is a probably efficacious treatment. CBT provided through the modalities of child group only and child group plus parent components are well-established intervention approaches for depressed children. For adolescents, two modalities are well-established (CBT adolescent only group, IPT individual), and three are probably efficacious (CBT adolescent group plus parent component, CBT individual, CBT individual plus parent/family component). From the broad theoretical level, CBT has well-established efficacy and behavior therapy meets criteria for a probably efficacious intervention for childhood depression. For adolescent depression, both CBT and IPT have well-established efficacy. Future research directions and best practices are offered.

Maintenance study for adolescent depression

OBJECTIVE

Although recent studies and meta-analyses confirm the efficacy of antidepressants in the acute phase of treatment for adolescent depression, there are few data available to allow assessment of the value of continued use of antidepressants in depressed adolescents after acute response. This study examines the benefit of maintenance treatment with sertraline in adolescents aged 13-19 years with major depression using a multi-site randomized placebo controlled discontinuation design.

METHODS

Subjects with a diagnosis of depression who responded to open-label treatment with sertraline in a 12-week acute phase and did not relapse with open-label continuation treatment for 24 weeks were randomized to placebo or continued treatment with sertraline for 52 weeks.

RESULTS

Twenty-two subjects were randomized to maintenance treatment with sertraline (n = 13) versus placebo (n = 9). A higher proportion of subjects treated with sertraline (38%) remained well as compared to those on placebo (0%). Survival analyses found no significant differences between the groups (p = 0.17).

CONCLUSIONS

This is the first study to examine the outcome to maintenance treatment for adolescents with major depression. Although the sample size was small, the findings suggest a possible benefit of maintenance treatment with sertraline over placebo. A larger clinical trial with adequate power is required to confirm or disconfirm these findings.

New-generation antidepressants, suicide and depressed adolescents: how should clinicians respond to changing evidence?

The purpose of the present paper was to identify, from the voluminous literature on efficacy and safety in new-generation antidepressants (NGAs) with depressed children and adolescents, practical clinical strategies for acute phase treatment. To this end a pragmatic survey of studies and reviews was undertaken. Meta-analyses of randomized controlled trials of NGAs in depressed children and adolescents have noted a comparative lack of efficacy, and a weak but statistically significant increased risk of self-harm and suicidal thoughts. But NGA prescription rates and youth suicide rates are generally inversely related, and ensuing 'black box' warnings about NGAs, by deterring NGA prescribing, have possibly contributed to rising youth suicide rates. In moderate-severe depression, benefits for fluoxetine and possibly other NGAs demonstrably outweigh risks. NGAs are not present in adolescents who die by suicide. Concern about NGA risks must be balanced against risks of non-treatment. While mild depression entails regular review, psychoeducation, self-care strategies and psychological interventions, NGAs should be administered concurrently with psychological treatments if depression is moderate- to severe, or if mild depression persists. Patients should be warned about off-label status of NGAs in depression, serious side-effects such as 'activation', suicidality, emotional blunting and manic switches, the need for adherence and avoiding abrupt discontinuation. They should be monitored early and regularly. Better evidence is required regarding psychological treatments, clinical course, and clinical practice trends. In moderate-severe depression the risk of suicide if NGAs are not used may outweigh any risk of self-harm associated with them.

Achievement and maintenance of sustained response during the Treatment for Adolescents With Depression Study continuation and maintenance therapy

CONTEXT

The Treatment for Adolescents With Depression Study evaluated fluoxetine (FLX), cognitive behavioral therapy (CBT), and FLX/CBT combination (COMB) vs pill placebo in 439 adolescents with major depressive disorder. Treatment consisted of 3 stages: (1) acute (12 weeks), (2) continuation (6 weeks), and (3) maintenance (18 weeks).

OBJECTIVE

To examine rates of achieving and maintaining sustained response during continuation and maintenance treatments.

DESIGN

Randomized controlled trial. Response was determined by blinded independent evaluators.

SETTING

Thirteen US sites.

PATIENTS

Two hundred forty-two FLX, CBT, and COMB patients in their assigned treatment at the end of stage 1.

INTERVENTIONS

Stage 2 treatment varied based on stage 1 response. Stage 3 consisted of 3 CBT and/or pharmacotherapy sessions and, if applicable, continued medication.

MAIN OUTCOME MEASURES

Sustained response was defined as 2 consecutive Clinical Global Impression-Improvement ratings of 1 or 2 ("full response"). Patients achieving sustained response were classified on subsequent nonresponse status.

RESULTS

Among 95 patients (39.3%) who had not achieved sustained response by week 12 (29.1% COMB, 32.5% FLX, and 57.9% CBT), sustained response rates during stages 2 and 3 were 80.0% COMB, 61.5% FLX, and 77.3% CBT (difference not significant). Among the remaining 147 patients (60.7%) who achieved sustained response by week 12, CBT patients were more likely than FLX patients to maintain sustained response through week 36 (96.9% vs 74.1%; P = .007; 88.5% of COMB patients maintained sustained response through week 36). Total rates of sustained response by week 36 were 88.4% COMB, 82.5% FLX, and 75.0% CBT.

CONCLUSIONS

Most adolescents with depression who had not achieved sustained response during acute treatment did achieve that level of improvement during continuation and maintenance therapies. The possibility that CBT may help the subset of adolescents with depression who achieve early sustained response maintain their response warrants further investigation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00006286.

Depression in young people: description, assessment and evidence-based treatment

OBJECTIVE

The literature on depression in children and adolescents was reviewed to provide an update for clinicians.

REVIEW PROCESS

Literature of particular relevance to evidence-based practice was selected for critical review. Meta-analyses and controlled trials were prioritized for review along with key assessment instruments.

OUTCOMES

An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was provided.

CONCLUSIONS

Depression in children and adolescence is a relatively common, multifactorially determined and recurring problem which often persists into adulthood. Psychometrically robust screening questionnaires and structured interviews facilitate reliable assessment. There is growing evidence for the effectiveness of cognitive behaviour therapy, psychodynamic therapy, interpersonal therapy and family therapy in the treatment of paediatric depression. There is also evidence that SSRIs may be particularly effective for severe depression, although they may carry the risk of increased suicidality.

Expert survey for the management of adolescent depression in primary care

OBJECTIVE

Primary care clinics have become the "de facto" mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent.

METHODS

Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item.

RESULTS

Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, "active monitoring" was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation.

CONCLUSIONS

Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management

OBJECTIVES

To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This second part of the guidelines addresses treatment and ongoing management of adolescent depression in the primary care setting.

METHODS

Using a combination of evidence- and consensus-based methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee.

RESULTS

These guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in primary care, including (1) active monitoring of mildly depressed youth, (2) details for the specific application of evidence-based medication and psychotherapeutic approaches in cases of moderate-to-severe depression, (3) careful monitoring of adverse effects, (4) consultation and coordination of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and its evidence base are summarized.

CONCLUSIONS

These guidelines cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist primary care clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of youth with depression in primary care is needed, including the usability, feasibility, and sustainability of guidelines and determination of the extent to which the guidelines actually improve outcomes of youth with depression.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management

OBJECTIVES

To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee.

RESULTS

Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

Suicide and suicide attempts in adolescents

Suicide is the third-leading cause of death for adolescents 15 to 19 years old. Pediatricians can take steps to help reduce the incidence of adolescent suicide by screening for depression and suicidal ideation and behavior. This report updates the previous statement of the American Academy of Pediatrics and is intended to assist the pediatrician in the identification and management of the adolescent at risk of suicide. The extent to which pediatricians provide appropriate care for suicidal adolescents depends on their knowledge, skill, comfort with the topic, and ready access to appropriate community resources. All teenagers with suicidal thoughts or behaviors should know that their pleas for assistance are heard and that pediatricians are willing to serve as advocates to help resolve the crisis.

Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review

OBJECTIVE

To characterize the adverse effects of treatment with selective serotonin reuptake inhibitors (SSRIs) started in children under age 7 yr.

METHODS

We conducted a retrospective review of medical records for all children who had begun treatment with an SSRI under age 7 at an academic psychiatry department in Boston.

RESULTS

Thirty-nine children (26 males, 13 females) met the inclusion criteria. Mean age at start of treatment was 5.9 +/- 0.8 yr, and median treatment duration was 5.0 months. The target diagnoses for SSRI treatment were anxiety disorders in 54%, depressive disorders in 23%, and both anxiety and depressive disorders in 20% of patients. There were no reports of suicidal ideation or attempt. No children were medically or psychiatrically hospitalized for adverse effects (AEs). Eleven patients (28%) reported an AE of at least moderate severity; 7 (18%) discontinued the SSRI due to the AE. Six patients discontinued due to behavioral activation and 1 due to gastrointestinal upset. The median time to onset of an AE was 23 days, and median resolution was 19 days from onset.

CONCLUSIONS

The high rate of adverse effects, especially activation, in this sample argues for continued caution in using SSRIs in young children. Controlled trials are warranted.

Psychopharmacologic treatment of pediatric major depressive disorder

RATIONALE

The role of pharmacotherapy in the treatment of major depressive disorder (MDD) in youth has received much attention in recent years due to concerns of efficacy and safety of the antidepressants for the treatment of MDD in youth.

OBJECTIVES

This review describes the existing published and unpublished literature regarding the efficacy and short-term safety of the antidepressants and decision-making process required for the use of these medications for youth with MDD. In addition, current continuation and maintenance treatments are discussed.

RESULTS

In general, nine depressed youth must be treated with an antidepressant to obtain one clinical response above that achieved with placebo. To date, fluoxetine has showed the most consistent positive treatment effects. Depressed youth had also acutely responded to other antidepressants, but the response to placebo has also been high. Overall, the antidepressants are well tolerated, but 1-3 children and adolescents of 100 taking antidepressants showed onset or worsening of suicidal ideation and, more rarely, suicide attempts.

CONCLUSIONS

There is a positive risk-benefit ratio for the use of antidepressants in the acute treatment of depressed youth. First-line antidepressant treatment with-or without-specific types of psychotherapy is indicated for youth with MDD of at least moderate severity. All youth taking antidepressants must be closely monitored for suicidality and medication side effects. Many youth will likely require psychotherapy or additional medication treatments to address comorbid disorders. Treatments to prevent relapses and recurrences require further study.

Comparison of psychosocial correlates in primary school age children with attention deficit/ hyperactivity disorder- combined type, with and without dysthymic disorder

In this study, standardized assessments of maternal psychopathology, family functioning and marital adjustment were compared between 115 medication naïve, clinically referred primary school age children with Attention Deficit Hyperactivity Disorder combined type (ADHD-CT) alone and 29 children with comorbid dysthymic disorder (DD) and ADHD-CT. The mothers of children with ADHD-CT and DD reported higher rates of anxiety and depression than those of children with ADHD-CT alone. These results reinforce the need for early recognition of comorbid DD when working with children with ADHD-CT. Increased rates of maternal anxiety and depression in children with ADHD-CT and DD may contribute to the children's symptoms, require specific psychological and/or medication treatments and careful ongoing monitoring of these specific treatments.