Minding Matters: Battling Depression in Children

Facts of Life:
Issue Briefings for Health Reporters
Vol. 9, No. 9
September 2004

Depression is the leading cause of disability in the United States. It now occurs earlier in life [11] and affects up to 3 percent of children ages 6 to 12 and 7 percent of teenagers. Current research suggests that young people’s symptoms are similar to those in adults: persistent sadness, irritability, crying, poor sleep, doing poorly at school and distance from one-time friends. [12]

Parents may find a depressed child daunting, but treatment can be very effective. Psychotherapy can help, and one antidepressant drug (fluoxetine, or Prozac) has proved successful in clinical trials and is approved for use with children. “Depression has serious consequences and results,” says child psychiatrist David Fassler, M.D. “The most dangerous thing we can do is not treat these kids.”

Reports of suicidal behavior in children who are taking SSRI antidepressants have moved the Food and Drug Administration to commission a study. Suicidal or self-destructive behavior early in drug treatment may be due to the drugs or the severity of the disease, or it may represent an interim effect as depressed people gain renewed energy and take action on suicidal thoughts as medication begins to work. The FDA recommends close monitoring of patients who start or change antidepressant medications. [13]

Choices for Treatment

Parents should not leap to a diagnosis if a child appears depressed, but they should be aware of changes in a child’s behavior. If a formerly happy child now spends time alone, lacks energy, shows changes in eating or sleeping patterns or expresses thoughts of suicide, parents should seek help, the American Academy of Child and Adolescent Psychiatry suggests.

In addition to family history, social, situational or environmental factors may trigger depression. These may include witnessing domestic violence, being bullied or abused, having an undiagnosed learning disability or experiencing the death of a parent or friend.

“Growing up is tough enough,” says Martin T. Stein, M.D., a behavioral pediatrician at the University of California at San Diego. “When you add peer pressure and a sexually overt media diet, it may well trigger depression in some kids.”

If depression is suspected, the first step is getting a good evaluation and accurate diagnosis, says David Fassler, M.D., a child and adolescent psychiatrist in Burlington, Vt. “Depression is not the easiest condition to recognize in a child or adolescent. It can share symptoms with many things — ADHD, bipolar disorder or learning disorders.”

The next step is to set up an individualized treatment plan for counseling, family and school, which may include medications, Fassler says. Even if depression is purely biological in origin and can be treated with medication, young patients need to build the coping skills to handle both present and future episodes of depression.

“Medications can be helpful, lifesaving tools but are rarely adequate alone,” he says. “They are just one component of a comprehensive treatment plan.”

Only one SSRI antidepressant, fluoxetine (Prozac), is approved to treat depression in children. In March, the FDA recommended “close observation of adult and pediatric patients treated with SSRIs for worsening depression or the emergence of suicidality.” [13]

Close monitoring is the key, Fassler says. Most prescriptions for antidepressants are written not by psychiatrists but by primary care physicians or pediatricians, who usually do not see these patients weekly or more frequently. “You can’t write a prescription and not monitor these patients,” he says.

A major recent study agrees, finding that 71 percent of young patients responded to combined treatment on fluoxetine plus cognitive behavioral psychotherapy, compared to 60 percent on fluoxetine alone, 43 percent on therapy alone and 35 percent on placebo. [14]

Martin T. Stein, M.D.
University of California, San Diego School of Medicine
(619) 543-3758
mtstein@ucsd.edu

Kenneth Towbin, M.D.
National Institute of
Mental Health
(301) 443-3600
NIMHpress@nih.gov
(c/o NIMH communications office)

David Fassler, M.D.
University of Vermont
College of Medicine
(802) 865-3450
dfassler@zoo.uvm.edu

1. Compton SN, March JS, Brent D, Albano AM 5th, Weersing R, Curry J. Cognitive-Behavioral Psychotherapy for Anxiety and Depressive Disorders in Children and Adolescents: An Evidence-Based Medicine Review. J Am Acad Child Adolesc Psychiatry. 2004 Aug;43(8):930-959

2. Twenge JM, Nolen-Hoeksema S. Age, gender, race, socioeconomic status, and birth cohort differences on the children's depression inventory: a meta-analysis. J Abnorm Psychol. 2002 Nov;111(4):578-88. PMID: 12428771

3. Born L, Shea A, Steiner M. The roots of depression in adolescent girls: is menarche the key? Curr Psychiatry Rep. 2002 Dec;4(6):449-60. PMID: 12441025)

4. Coyle JT, Pine DS, Charney DS, Lewis L, Nemeroff CB, Carlson GA, Joshi PT, Reiss D, Todd RD, Hellander M; Depression and Bipolar Support Alliance Consensus Development Panel. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2003 Dec;42(12):1494-503.

5. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA. 2004 Jul 21;292(3):338-343.

6. Wessely S, Kerwin R. Suicide risk and the SSRIs. JAMA. 2004 Jul 21;292(3):379-381

7. Clarke GN, Hornbrook M, Lynch F, Polen M, Gale J, Beardslee W, O'Connor E, Seeley J. A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Arch Gen Psychiatry. 2001 Dec;58(12):1127-1134.

8. Stice E, Ragan J, Randall P. Prospective relations between social support and depression: differential direction of effects for parent and peer support? J Abnorm Psychol. 2004 Feb;113(1):155-159

10. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet. 2004 Apr 24;363(9418):1341-1345.

14. March JS, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. JAMA. 2004 18 Aug;292(7):807-820. (commentary, 861-863)