Summary of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders

Principal Authors: Boris Birmaher, M.D., David A. Brent, M.D., and R. Scott Benson, M.D. This Summary was developed by the Work Group on Quality Issues: William Bernet, M.D., Chair, and John E. Dunne, M.D., former Chair, Maureen Adair, M.D., Valerie Arnold, M.D., R. Scott Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and David Rue, M.D. AACAP Staff: Elizabeth Sloan, L.P.C.

This summary and the full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders is available to Academy members on the World Wide Web (www.aacap.org) and appears in the 1998 supplement to the JAACAP. The full text of these parameters was reviewed at the 1997 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council on May 28, 1998. Reprint requests to AACAP Publications Department, 3615 Wisconsin Ave., N.W., Washington, DC 20016. [XXXX] © 1998 by the American Academy of Child and Adolescent Psychiatry.

ABSTRACT

This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Depressive disorders in children and adolescents are marked by core symptoms similar to those seen in adults, although symptom expression varies greatly with developmental stage. These disorders are common, chronic, and recurrent, and are associated with comorbid psychiatric conditions and poor outcome that can be alleviated by early identification and treatment. Opinions differ regarding treatment planning and duration of treatment required. Development of a treatment relationship with the patient and family is crucial for a successful outcome. Psychotherapy is an appropriate treatment for all children and adolescents with depressive disorders. Antidepressants may prove useful in some cases and are especially recommended for those patients with psychosis, bipolar depression, and severe depression. Continuation treatment is necessary in all patients after the acute phase; long-term maintenance is required in some. Early detection and intervention is effective in ameliorating the poor psychosocial outcome. Key words: children and adolescents, depression, dysthymia, antidepressants, psychotherapy, practice parameters, and practice guidelines.

These guidelines offer the clinician direction in diagnosing and treating major depressive disorder (MDD) and dysthymic disorder (DD) in children and adolescents. Recommendations are based on extensive review of the scientific literature and clinical consensus among experts in the subject. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1998). MDD and DD are common disorders occurring in approximately 2% of children and 4% to 8% of adolescents. Early, aggressive treatment is required because these recurrent disorders are frequently accompanied by poor psychosocial outcome, comorbid conditions, and high risk of suicide and substance abuse. The prevalence of depression increases during adolescence, possibly due to biological (e.g., sexual maturation), environmental (e.g., increased social and academic expectations, more chance of exposure to negative events), and psychological (e.g., increased autonomy and abstract thinking) factors. Adolescent girls appear to have more risk factors for depression than boys. Studies in adults and youth have suggested that each successive generation since 1940 is at greater risk for developing a depressive disorder, and that these disorders are being recognized at successively younger ages.

CLINICAL PRESENTATION

Every child can be sad occasionally. However, to be diagnosed with MDD or DD, a child must meet the diagnostic criteria of the DSM-IV. Symptoms should not be attributable only to substance abuse, use of medications, other psychiatric illnesses, bereavement, or medical illness. The clinical picture of MDD and DD in children and adolescents varies considerably across different developmental stages and diverse ethnic groups. For example, children usually show more anxiety symptoms, somatic complaints, auditory hallucinations, temper tantrums, and behavioral problems. In middle and late childhood, children may begin to report the cognitive components of their dysphoric mood and low self-esteem, guilt, and hopelessness. The normative push for autonomy may complicate the presentation of symptoms in depressed adolescents, who manifest more sleep and appetite disturbances, delusions, suicidal ideation and attempts, and impairment of functioning than younger children, but fewer neurovegetative symptoms and perhaps more irritability than adults with MDD. It is important to assess for symptom clusters that define the subtypes of depression (e.g., seasonality, atypical symptoms, psychosis, or hypomania) in order to develop appropriate treatment strategies. Manic and depressive symptoms may be mixed (the so called "mixed state"), a common presentation of bipolar disorder. The differential diagnosis of psychotic depression includes bipolar disorder, substance abuse, schizophrenia, dissociative states, and trauma-related "hallucinations." Most youth with MDD have other psychiatric disorders, with many having 2 or more comorbid diagnoses. The most frequent comorbid diagnoses are dysthymia (the so-called "double depression"), anxiety disorders, disruptive behavior disorders, and substance use disorders. Separation anxiety disorder is a common comorbidity in younger children. Personality disorders, especially borderline personality disorder, are frequently reported, although some of the personality symptoms may be secondary to the mood disorder. The family relationships of depressed youth frequently are characterized by conflict, maltreatment, rejection, and problems with communication, with little expression of positive affect and support. Parents of depressed children may themselves be depressed or suffer from other psychiatric or medical illnesses that reduce effectiveness of parenting. On the other hand, parenting role problems may be secondary to interaction with a depressed, irritable, or oppositional child. There is evidence that early adverse experiences (e.g., parental death or separation) raise the risk for depression or anxiety in adulthood. The effect of parental loss through separation or death may be aggravated by parental discord associated with the separation and/or by the social and economic sequelae of family disruption.

CLINICAL COURSE

The average duration of a major depressive episode is 7 to 9 months. Even with successful acute therapy, half of patients relapse. Relapse may be the natural course of MDD or may be due to poor compliance or premature interruption of treatment. Most episodes remit 1 to 2 years after onset, but 6% to 10% become protracted. Half of patients have a recurrence 1 to 2 years after treatment, while 70% have a recurrence 5 years after treatment. Age of onset, increased number of previous episodes, severity of index episode, presence of comorbid psychiatric disorders, poor compliance, exposure to negative life events (e.g., family conflict), presence of psychiatric disorders in parents, and poor psychosocial functioning may predict a protracted course and recurrence. Bipolar disorder develops in 20% in 40% of depressed children and adolescents with MDD. Patients vulnerable to the development of bipolar disorder may be noted by the presence of an early onset, psychomotor retardation, psychotic features, family history of bipolar disorder or psychotic depression, and/or pharmacologically-induced hypomania. Depressive disorders affect a child s development of social, emotional, cognitive, and interpersonal skills and the attachment between parent and child. Depressive disorders confer a high risk for suicidal behavior, substance abuse (including nicotine dependence), physical illness, early pregnancy, and poor vocational, academic, and psychosocial functioning. Psychosocial difficulties often persist long after the remission of a major depressive episode. Paralleling the increase in MDD, the adolescent suicide rate has quadrupled since 1950 (2.5 to 11.2 per 100,000), and currently represents 12% of total mortality for this age group. Predisposing factors for suicidality include past suicidal attempts, family history of mood disorders, family history of suicidal behavior, exposure to family violence, exposure to abuse, impulsivity, availability of lethal agents (e.g., firearms), and comorbid psychiatric disorders.

ASSESSMENT

The single most useful tool in the diagnosis of depressive disorders in children and adolescents is the comprehensive psychiatric diagnostic evaluation, including interviews with the child, parents, and collateral informants, such as teachers and social services personnel. The psychiatric assessment of depressed children and adolescents can be difficult and must be performed by a clinician trained to consider how developmental and cultural factors impact the patient's clinical presentation. Patients may have difficulty expressing feelings, or be irritable and uncooperative. However, when appropriately assessed, depressed youth report the common symptoms of MDD or DD. The longitudinal course of the illness can be documented with a mood lifetime chart and a mood diary. Standardized interviews developed for research settings are too long for use in clinical settings, require special training, and are not suitable for young children. Psychiatric symptom checklists derived from these standardized interviews and DSM-IV symptom categories have been developed and may be useful in clinical settings. Popular self-administered and clinician-administered rating scales are not recommended for diagnosing clinical depression, but can be used to screen for symptoms, assess the severity of depressive symptoms, and monitor clinical improvement. It is important for the clinician to assess the patient's global functioning as well as clinical symptoms both initially and on an ongoing basis to monitor response to treatment.

TREATMENT

The treatment of depressive youth should be provided in the least restrictive treatment setting that is safe and effective for a given patient. Selection of treatment setting in the continuum of care (e.g., outpatient, partial hospitalization or day treatment, inpatient, and residential) depends on the availability of a safe environment, the severity of the illness, the motivation of the patient and/or his family toward treatment, and the severity of additional psychiatric ( e.g., substance abuse) or medical conditions.

ACUTE PHASE

The choice of initial interventions depends in part on the treatment setting. Other factors to consider are the number of prior episodes, chronicity, subtype of depression (e.g., psychotic, bipolar, or atypical), age of the patient, and contextual issues (family conflict, academic problems). For example, adolescents may be reluctant to participate in family therapy; a socially phobic patient may refuse group therapy; or an anxious parent or patient may refuse medications as the first line of treatment. In addition, the availability and expertise of the clinician may modify the choice of treatment. Given the developmental and psychosocial context in which depression unfolds, pharmacotherapy alone usually is not sufficient. The high degree of comorbidity and the severity of psychosocial and academic consequences of depression suggest a multi-modal treatment approach. Once remission is achieved, patients should continue therapy for at least 6 to 12 months. The treatment that helped the patient achieve remission is maintained through this continuation phase and may be indicated for maintenance to prevent recurrence.

Psychotherapeutic Interventions

The treatment relationship begins with the first contact with the patient and family. Education involves them as informed partners in the treatment team, and helps them understand depression as an illness, identify and manage affect, address psychosocial deficits, and learn the importance of compliance with treatment. Participation by parents may help them identify their own depressive symptoms. There is an emerging recognition that the combination or integration of technical variables intrinsic to cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), psychodynamic psychotherapy, and other psychotherapies may be brought together in the best interests of the patient. Psychodynamic psychotherapy can help youth understand themselves, identify feelings, improve self-esteem, change maladaptive patterns of behavior, interact more effectively with others, and cope with ongoing and past conflicts. CBT is based on the premise that depressed patients have cognitive distortions in how they view themselves, the world, and the future; that these cognitive distortions contribute to their depression. CBT teaches patients to identify and counteract these distortions. Clinical studies found a high rate of relapse upon follow-up, suggesting the need for continuation treatment. IPT focuses on problem areas of grief, interpersonal roles, disputes, role transitions, and personal difficulties. IPT has been shown to be useful in the acute treatment of adolescents with MDD. The rate of relapse may be relatively low after acute IPT treatment Age at onset of depression, severity of depression, presence of comorbid psychiatric disorders, lack of support, parental psychopathology, family conflict, exposure to stressful life events, socioeconomic status, quality of treatment, and motivation of both patient and therapist predict treatment response to psychotherapy. Comorbid anxiety or dysthymia, which predicts poor response and may persist after an episode of MDD, should be a target of treatment.

Pharmacological Interventions

Antidepressant medications seem indicated for children and adolescents with non-rapid-cycling bipolar or psychotic depression; with severe symptoms that prevent effective psychotherapy; whose symptoms fail to respond to an adequate trial of psychotherapy; and with chronic or recurrent depression. For patients requiring pharmacotherapy, SSRIs are the initial antidepressants of choice, although the presence of comorbidities may require alternate initial agents. A child with MDD and comorbid ADHD, for example, may benefit more from a TCA, bupropion, or venlafaxine than an SSRI. Prior to initiating treatment, specific target symptoms should be defined with the patient and parents. They should be informed about side effects, dose schedule, the lag in onset of therapeutic effect, and the danger of overdose. Parents should maintain responsibility for storing and administering the medications to enhance compliance and minimize suicidal risk from overdose. Quantity of dispensed TCAs should be monitored carefully. There is no indication for laboratory tests before or during the administration of SSRIs. For TCAs, baseline electrocardiogram (EKG), resting blood pressure and pulse (supine or sitting, standing), and weight should be monitored regularly. Selective Serotonin Reuptake Inhibitors. Reports that SSRIs are efficacious for the treatment of adults and youth with MDD with a relatively safe side effect profile, very low lethality from overdose, and easy administration (once a day), favor the SSRIs as first line medications. The SSRIs differ in elimination half-life, drug interactions, and antidepressant activity of metabolites . Since improvement with the SSRIs may take 4 to 6 weeks, patients should be treated with adequate and tolerable doses for at least 4 weeks. At 4 weeks, if patients have not shown even minimal improvement, treatment should be modified (e.g., increase dose, change medications). If the patient shows improvement at 4 weeks, the dose should be continued for at least 6 weeks. The SSRIs have a relatively flat dose-response curve, suggesting that maximal clinical response may be achieved at minimum effective doses The side effects of all SSRIs are similar, dose-dependent, and may subside with time. SSRIs may induce "behavioral activation," in which patients become impulsive, silly, agitated, and daring. Other side effects include gastrointestinal symptoms, restlessness, diaphoresis, headaches, akathisia, bruising, and changes in appetite, sleep, and sexual functioning. Abrupt discontinuation of SSRIs with shorter half-lives, such as paroxetine, may induce withdrawal symptoms that mimic a relapse or recurrence of a depressive episode. The withdrawal symptoms can appear after as few as 6 to 8 weeks on the SSRI. SSRIs inhibit to varying degrees the metabolism of several medications which depend on the cytocochrome P450 isoenzymes. Tricyclic Antidepressants. TCAs are not recommended as first line treatment for youth with depressive disorders because of the lack of efficacy and potential side effects. Nevertheless, individual patients may respond better to the TCAs than other medications.

CONTINUATION PHASE

Given the high rate of relapse and recurrence of depression, continuation therapy is recommended for all patients for at least 6 months. Psychotherapy can be used to help patients and families consolidate the skills learned during the acute phase, cope with the psychosocial sequelae of the depression, effectively address environmental stressors, and understand inner conflicts that may trigger a depressive relapse. The patient and his or her family should be taught to recognize early signs of relapse. If the patient is taking antidepressants, continuation psychotherapy helps to foster medication compliance. Antidepressants must be continued at the same dose used to attain remission of acute symptoms. At the end of the continuation phase, for patients who do not require maintenance treatment, medications should be discontinued gradually over 6 weeks or longer.

MAINTENANCE PHASE

After the patient has been asymptomatic for 6 to 12 months, the clinician must decide whether to administer maintenance therapy. The main goal of the maintenance phase, which may extend from 1 year to indefinitely, is to prevent recurrence. Patients who have only a single uncomplicated episode of depression, mild episodes, or a lengthy interval between episodes (e.g., 5 years) probably do not require maintenance treatment. Clinicians should consider maintenance therapy for patients with multiple or severe episodes of depression and those at high risk for recurrence. Factors associated with recurrence include a family history of bipolar disorder or recurrent depression, comorbid psychiatric disorders, stressful or non-supportive environments, and residual or subsyndromal symptomatology. The treatments that were used to induce remission in the acute phase should be used for maintenance therapy. Clinical experience suggests that full-dose antidepressants (mainly TCAs and possibly SSRIs) and psychotherapy alone or in combination are effective in prevention of recurrences. Youth with two or more episodes of depression should receive maintenance treatment for at least 1 to 3 years. Patients with recurrent episodes accompanied by psychosis, severe impairment, severe suicidality, and treatment-resistance, as well as patients with more than 3 episodes, should be considered for longer, even lifelong treatment.

TREATMENT OF COMORBID CONDITIONS

Treatment of the comorbid conditions that influence the initiation, maintenance, and recurrence of depression is critical to successful outcome. In many cases, the psychosocial and pharmacological treatments used for the treatment of depression also may be useful for the treatment of comorbid conditions. For example, TCAs and SSRIs may help both anxiety disorders and MDD; SSRIs may help both bulimia and MDD.

TREATMENT OF CLINICAL VARIANTS

Suicidal Ideation and/or Attempts

Suicidal depressed youth require additional focus on assessment, monitoring, and amelioration of suicidality. Suicide risk assessment considers functional impairment, degree of hopelessness, presence of psychosis, stability of family environment, and quality of available support. If the risk of suicide is high, treatment in a more restrictive setting is indicated. Outpatient treatment may be appropriate when an adequate safety plan is developed. All lethal agents, especially firearms and toxic medications, should be removed from the home. Because of the increased risk of death after an overdose, TCAs should be avoided as a first-line treatment for suicidal patients. Individual and family therapy is required for the comorbid substance use, personality disorders, school problems, and physical and sexual abuse that frequently plague suicidal adolescents. Psychotic Depression

In patients with psychotic depression, recovery appears to be more rapid when antidepressants (TCAs or SSRIs) are combined with an antipsychotic agent. Neuroleptics confer the risk of tardive dyskinesia, and therefore, should be tapered after remission of the depression. The newer antipsychotic medications, including risperidone, olanzapine, and clozapine, may be useful alternatives to neuroleptics. Anecdotal reports suggest that ECT may be efficacious for depressed psychotic adolescents.

Seasonal Affective Disorder

Studies in youth have shown that bright light therapy is efficacious for the treatment of SAD. The most widely used protocol is a light box with 10,000 lux at a distance of 1 foot from the face of the patient for 30 minutes per day. Treatment can be extended to 1 hour in cases of partial response. It appears that patients may respond better to treatment during the morning hours.

Bipolar Disorder

Symptoms and signs such as psychosis, psychomotor retardation, or family history of bipolar disorder may warn the clinician that the child may be at risk to develop a manic episode. If indicators are present, the clinician should consider initiating a prophylactic mood-stabilizing agent, such as lithium carbonate, valproate, or carbamazepine. For patients who do not respond to mood stabilizers alone, an antidepressant should be added to the treatment.

Treatment-resistant Depression

The most likely reasons for treatment failure include inadequate drug dosage, inadequate length of drug trial, inadequate length of psychotherapy, inadequate fit with, and/or skill level of, psychotherapist, lack of compliance with treatment, comorbidity with other psychiatric disorders, comorbid medical illness, bipolar depression, and exposure to chronic or severe life events (e.g., sexual abuse) that may require different modalities of therapy. Sometimes, after a medication-free period of 4 to 6 weeks, patients respond to previously unsuccessful antidepressant trials. In addition, psychotherapeutic interventions also appear to be beneficial. Several psychopharmacological strategies have been recommended for adults: optimization (extending the initial medication trial and/or adjusting the dose), switching to the same or a different class of medications, augmentation or combination (e.g., lithium, T3), and the use of ECT. Each strategy requires implementation in a systematic fashion, education of the patient and family, and support to avoid the development of hopelessness.

TREATMENT OF DYSTHYMIC DISORDER

Clinical practice and theory support the use of psychotherapies of varying degrees of intensity, including psychoanalysis, psychodynamic psychotherapy, CBT, and IPT, to treat DD. In the absence of published studies of psychotherapeutic or pharmacologic treatment of children and adolescents with DD or comorbid MDD and DD, clinicians are advised to use interventions recommended for the treatment of youth with MDD.

PREVENTION

Youth with subclinical depressive symptoms are at high risk to develop clinical depression. When these symptoms persist after an episode of depression continuous treatment until full remission is recommended. For patients who have not had an episode of depression, psychosocial interventions to reduce environmental and family stressors and CBT strategies appear to be efficacious to prevent deterioration. Children with DD usually have a first episode of MDD 2 to 3 years after the onset of the DD, suggesting that DD is a gateway to recurrent mood disorders and indicating the need for early intervention with mild to moderate depression. Early intervention with depressed youth also may avert the development of comorbid psychiatric disorders. For example, MDD often precedes the onset of substance use disorders and treatment of depression may prevent their development.

REFERENCE

American Academy of Child and Adolescent Psychiatry (1998), Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. J Am Acad Child Adolesc Psychiatry, 37(10suppl)

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