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See Figure 3 for a suggested approach to the management of depression in children and adolescents.43,50. And some research indicates that suicide rates in children decrease when they take antidepressants. CBT usually consists of behavioral activation techniques and methods to increase coping skills, improve communication skills and peer relationships, solve problems, combat negative thinking patterns, and regulate emotions.8,3436 In contrast, interpersonal therapy generally focuses on adapting to changes in relationships, transitioning personal roles, and forming interpersonal relationships.8,36 The effects of CBT on depressive symptoms are moderate,37,38 but it has not been proven more effective than placebo for treating acute depression in adolescents.39 A combination of CBT and medication has been shown to be more effective than medication alone in attaining remission of depression.37,40 Interpersonal therapy has not been compared with medication, combination treatment, or placebo, but it has been proven more effective than wait-list control groups with no therapy, and as effective or more effective than CBT.41,42, Although psychotherapy is a major component in the treatment of childhood and adolescent depression, adjuvant use of medication is sometimes appropriate. Gabriel M, et al. Still, understand there may be times when they don . All antidepressants have a boxed warning for an increased risk of suicide; therefore, close monitoring is recommended (e.g., weekly telephone calls, scheduled visits for the first month of therapy) to assess for suicidality and other adverse effects, such as gastrointestinal effects, nervousness, headache, and restlessness.47,49 If there is limited improvement or no remission of symptoms after all first-line medications have been attempted, a psychiatric consultation is strongly recommended.50, Treatment of depression in children and adolescents should continue for six months after remission.49,51 A double-blind, placebo-controlled trial of adolescents receiving fluoxetine found that those who received placebo after treatment had a shorter time to relapse than those who continued therapy.52 Patients in the fluoxetine group were significantly less likely to have a relapse of depressive symptoms (34 versus 60 percent). Treatment of Depression in Children and Adolescents | AAFP Psychotherapy should be used in combination with medication for the treatment of moderate to severe depression in children and adolescents. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Editor's Note:American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings. Dealing with Teen Depression - HelpGuide.org Asking about suicide or using depression screening tools can be a means for assessing suicidal ideation in children and adolescents in the primary care setting. If a patient has suicidal thoughts, further assessment should include questions about the frequency of thoughts; the presence and specificity of a plan; the lethality or availability of means to follow through with the plan; whether there are protective factors, such as social support; and whether there are any other factors, such as substance use or a previous suicide attempt. Cognitive-behavioral therapy for adolescent depression and suicidality Screening tools include the Beck Depression Inventory for Primary Care for adolescents 12 to 18 years of age, and the Children's Depression Inventory for children and adolescents seven to 17 years of age.16,17 The Beck Depression Inventory for Primary Care is a self-report tool that includes seven questions that are scored from zero to three points each (Figure 1).17,18 A score of at least 4 warrants further evaluation for depression.19 The Children's Depression Inventory is available in self-report, parent-report, and teacher-report versions; scores are converted to a T-score, with scores of 65 or more indicating clinical significance.20 Additional screening tools are described in Table 2.2124 Screening tools should be selected based on patient's age, reading level, and time available to complete the measures. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Prescription sleeping pills: What's right for you? However, the warning should be taken as a caution to carefully weigh the pros and cons of using antidepressants in children and teenagers against the real risk of suicide as a result of untreated depression. The search included reviews, meta-analyses, randomized controlled trials, and clinical trials. Antidepressants come with a medication guide that advises parents and caregivers about risks and precautions. There is no symptom improvement with serotonin-norepinephrine reuptake inhibitors compared with placebo in adolescents with major depressive disorder. It should also provide a way for the patient to communicate during an acute crisis (e.g., providing phone numbers for people to contact if suicidal thoughts occur, creating a list of coping skills, educating the parents on how to recognize if the patient is a risk to self or others).38 If the danger of suicide becomes imminent, psychiatric evaluation in a hospital emergency department or psychiatry crisis clinic is needed. 2 - 34 In children 12 years and younger, depression is . None of the children in any of the studies actually took their own life. Vande Voort JL (expert opinion). Asking your child about suicide will not make them die of suicide. Effective/efficient mental health programs for school-age children: a In thinking about the case of Candace described earlier, do you think that Candace benefitted or suffered as a result of consistently being passed on to the next grade? Published April 23, 2022 Updated April 27, 2022 Leer en espaol Health risks in adolescence are undergoing a major shift. U.S. Food and Drug Administration. 2017; doi:10.1503/cmaj.160991. The FDA has approved certain antidepressants for use in children and teenagers for different types of diagnoses. 4 Phenomenologically, depression appears consistent across adolescence. Paroxetine may be associated with increased suicidal ideation. Revisions to product labeling. Overcoming depression: How psychologists help with depressive disorders May 28, 2021. Medical conditions that may present similarly to depression include hypothyroidism, anemia, autoimmune disease, and vitamin deficiency. Accessed July 7, 2021. What is behavior therapy? Psychotherapy for Children and Adolescents: Different Types - AACAP Another normal reaction is to gear up into action mode, looking for answers and wanting to act now. Accessed May 15, 2021. By continuing to use our site, or clicking "Continue," you are agreeing to our, The JAMA Pediatrics Patient Page is a public service of, To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. The doctor may do a physical exam and ask in-depth questions about your teenager's health to determine what may be causing depression. Effectiveness of physical activity interventions for improving Serious adverse events and withdrawal because of adverse events are more common with SSRIs compared with placebo. Paroxetine may cause increased suicidal ideation or behavior in adolescents and children. Drizalma Sprinkle (prescribing information). Antidepressants and suicidality: A re-analysis of the re-analysis. Sandoz Inc.; 2019. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7d52c40c-bbcb-4698-9879-d40136301d31&audience=consumer. The criteria for including a trial in the present review were: (a) that the mean age of participants was between 12 and 18 years old; (b) a primary diagnosis of depression; (c) randomized controlled trial; (d) valid and reliable depression assessment measures; (e) comparison of at least one psychological treatment with another . To diagnose major depressive disorder, criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Accessed May 15, 2021. How to treat depression will be different based on multiple factors including how severe it is; whether there are other accompanying mental illnesses such as attention-deficit/hyperactivity disorder, anxiety, substance use, or bipolar disorder; and on treatment preferences. Considerations for initiating antidepressant therapy include depression severity and history (Table 5).43,44 Extrapolation of adult data on antidepressant medications to children and adolescents may not be accurate, because neural pathways may not be fully developed, and serotonin and norepinephrine systems have different maturation rates.45, Tricyclic antidepressants were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children.46 Consensus guidelines recommend fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft) as first-line treatments for moderate to severe depression in children and adolescents.47 A Cochrane review found that fluoxetine was the only agent with consistent evidence (from three randomized trials) that it is effective in decreasing depressive symptoms.48 Escitalopram (Lexapro) is also licensed for the treatment of depression in adolescents 12 years and older. Dwyer JB, et al. Patients taking SSRIs were more likely to withdraw from treatment because of serious adverse events. Depressive symptoms may manifest as irritability in children and adolescents, and patients often have low self-esteem and poor social skills. Depression is a debilitating and chronic disorder, affecting between 12% and 25% of adolescents. Fluoxetine is approved for patients eight years and older, and escitalopram is approved for patients 12 years and older. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Author disclosure: No relevant financial affiliations. OCD features a pattern of unwanted thoughts and fears (obsessions), leading to repetitive behaviors (compulsions) that interfere with daily activities. Family therapy focuses on the family and interpersonal relationships, as opposed to other forms of therapy, which are child focused.5,6 The spirituality intervention was an eight-week online program based on principles of spirituality such as gratitude and forgiveness.7 When pharmacotherapy was added to nonpharmacologic therapy, there was a benefit for symptoms and functional status compared with nonpharmacologic therapies alone.1, Depressive symptoms and function were improved with SSRIs but not serotoninnorepinephrine reuptake inhibitors. Mayo Clinic on Incontinence - Mayo Clinic Press, The Essential Diabetes Book - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, A Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, How to tell if a loved one is abusing opioids, Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills, Mental illness in children: Know the signs. Adolescence is always an unsettling time, with the many physical, emotional, psychological and social changes that accompany this stage of life. Consultation with or referral to a mental health subspecialist is warranted if symptoms worsen or do not improve despite treatment and for those who become a risk to themselves or others. It affects how a teen thinks and behaves and can negatively impact school, family, and social functioning. A final important prevention for suicide is having open and supportive communication in your family. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure, (1) Depressed mood most of the day, nearly every day, as indicated by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful), (2) Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day (as indicated by subjective account or observation made by others), (3) Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in one month), or decrease or increase in appetite nearly every day, (4) Insomnia or hypersomnia nearly every day, (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feeling of restlessness or being slowed down), (6) Fatigue or loss of energy nearly every day, (7) Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick), (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (by subjective account or as observed by others), (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide, B. Antidepressants carry a U.S. Food and Drug Administration (FDA) black box warning about a risk of increased suicidal thinking and behavior in some individuals under the age of 25. In one study, nurses in a pediatric emergency department used the Ask Suicide-Screening Questions (ASQ) tool to assess suicide risk in 970 adolescents who presented with psychiatric problems.44 Of those who screened positive, 53% did not present with suicide-related problems. Make sure your child doesn't stop antidepressant treatment without the guidance of the prescribing doctor. Teen Depression: The Who, What, Why | BetterHelp Major depressive disorder, or clinical depression, is a mental health condition that can get in the way of your life. Treatment can be highly effective and . Risk factors include a family history of depression, parental conflict, poor peer relationships, deficits in coping skills, and negative thinking. Behavior therapy teaches children and their families how to strengthen positive child behaviors and eliminate or reduce unwanted or problem behaviors. include protected health information. American Academy of Child and Adolescent Psychiatry. However, not all mental health researchers believe these warnings are necessary. Centers for Medicare and Medicaid Services. The frequency of follow-up visits may be increased, and patients may benefit from education on how to seek assistance after hours (e.g., emergency departments, crisis hotlines).8,3032 Parents and family members should be educated about behaviors that would warrant immediate follow-up, such as increased suicidal ideation, impulsivity, irritability, restlessness, pressured speech, or psychomotor agitation.31,33, Treatment of childhood and adolescent depression consists of psychotherapy, pharmacotherapy, or a combination of these. All rights reserved. However, if the depression does not improve or the child deteriorates even with treatment, consultation with or referral to a child or adolescent psychiatrist is necessary. Pfizer Inc.; 2018. https://www.pfizer.com/products/product-detail/zoloft. Copyright 2023 American Academy of Family Physicians. privacy practices. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Adolescents should be screened annually for depression. Treatment There is no single treatment plan that is entirely effective for every teenager that struggles with depression, as each young person is unique with distinct needs. The most effective way to treat adolescent depression is Tricyclic antidepressants are not effective in children and adolescents. Prozac (prescribing information). To use the PHQ-9 as a diagnostic aid for major depressive disorder: To use the PHQ-9 to screen for all types of depression or other mental illness: To use the PHQ-9 to aid in the diagnosis of dysthymia: To use the PHQ-9 to screen for suicide risk: To use the PHQ-9 to obtain a total score and assess depressive severity. Skip to content Care at Mayo Clinic Care at Mayo Clinic About Mayo Clinic Request Appointment https://www.nimh.nih.gov/health/publications/teen-depression/. The most effective way to treat adolescent depression is typically through a combination of approaches, including a combination of drug therapy and cognitive behavior therapy (CBT).However, it's important to note that the choice of treatment may vary depending on the severity of the depression and individual circumstances. These treatments have changed the lives of countless patients worldwide for the better and will continue to do . Depression in Teens | Mental Health America Whereas CBT focuses on cognition and behaviors, interpersonal psychotherapy concentrates on improving interpersonal relationships and typically includes around 12 to 16 sessions. Diagnostic criteria are the same for children and adults, with the exception that children and adolescents may express irritability rather than sad or depressed mood, and weight loss may be viewed in terms of failure to reach appropriate weight milestones. For more severe depression, evidence indicates greater response to treatment when psychotherapy (e.g., cognitive behavior therapy) and an antidepressant are used concurrently, compared with either treatment alone. This content is owned by the AAFP. Add up the numbers endorsed for questions 1 to 9 and obtain a total score. Tricyclic antidepressants, other selective serotonin reuptake inhibitors, and serotonin-norepinephrine reupta ke inhibitors have not been shown to be effective in treating depression in children and adolescents.46,5254 If neither fluoxetine nor escitalopram is effective and antidepressant therapy is desired, referral to a child or adolescent psychiatrist is recommended. One study found that rates of depression among a nationally representative sample of US adolescents (aged 12 to 17) increased . 2020 Mar 24;323(12):1125. doi: 10.1001/jama.2020.2406. MOLLY S. CLARK, PhD, KATE L. JANSEN, PhD, AND J. ANTHONY CLOY, MD. Fluvoxamine maleate (prescribing information). Treatment should begin at the lowest dosage available and titrated according to the patient's response and adverse effects. The PHQ-A is shown in Figure 1 and Table 2, along with four questions not used in scoring that address suicidality, dysthymia, and severity of depression.40,41. Sunovion Pharmaceuticals Inc.; 2019. https://www.latuda.com/. Management of depression - Wikipedia This series is coordinated by Joanna Drowos, DO, MPH, MBA, contributing editor. Krieger CA (expert opinion). Monitoring for suicidality is necessary in children and adolescents receiving pharmacotherapy, with frequency of monitoring based on each patient's individual risk. The most effective way to treat adolescent depression is ___ | Quizlet Identify the development of personality, relationships, and self-concept in infancy and childhood.