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Treating a Major Depressive Episode in Childhood and Adolescence

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.


Controversy Regarding Antidepressants for Children and Adolescents with Depression

There is controversy about using antidepressants for children or adolescents with Depression.  Some studies have shown that antidepressants may slightly increase the rates of suicidal tendencies in youth under age 18, especially during the first weeks when the medications are started [ref, ref; contradictory evidence: ref]. These suicidal tendencies include thoughts or acts of self-harm, but not actual suicide attempts. Venlafaxine seems to cause higher rates of these problems than most other antidepressants [ref].

Another issue is that these medications seem to be only modestly better than a placebo pill for treating Depression in children or adolescents [ref].  A placebo is a pill that looks just like a regular medication but has no active ingredients. Normally, in all areas of medicine, a medication needs to be found to work better than a placebo pill for it to be considered as an effective treatment. However, in the case of youth with Depression, their rates of improvement with a placebo pill are actually strikingly high; anywhere from 30-60% of these youths will experience a significant improvement in their depressive symptoms when they take a placebo pill [ref].

SSRI antidepressants bring an improvement in about 40-70% of cases of moderate or severe Depression in children and adolescents [ref]. This is a respectable figure, and is similar to the success rate of these medications when used by adults. However, because these rates are only slightly better than from a placebo pill, it works out that, statistically, you actually need to treat 10 youths for just one of them to have an improvement in their depressive symptoms that is better than from a placebo [ref].

While some people may argue that this means that antidepressants do not work very well for youths, it should be remembered that in actual practice doctors will not give placebo pills to their patients out of ethical and medico-legal reasons (a placebo pill only works when a person believes that it is a real medication, and doctors cannot lie to their patients about the medications they are prescribing). Not to prescribe anything would mean that many of these children or adolescents will not find relief from their symptoms. In fact, because of all of the above controversies, during the mid 2000's doctors began prescribing fewer antidepressants to children and adolescents; within a couple of years, the rates of suicide among these youths rose in North America [ref].

SSRI antidepressants continue to be recommended for treating children and adolescents with moderate or severe Depression [ref, ref]. The Tricyclic Antidepressants, an older form of antidepressants, are not recommended because they have not been shown to be better than placebo [ref]. Fluoxetine and Citalopram are two SSRIs that stand out as having a more robust effect for these youths as well as a being reasonably well tolerated [ref, ref].

Treatment Strategies for Children and Adolescents with Depression

A thorough assessment by a mental health professional in order to arrive at an accurate diagnosis is always important before starting treatment. In about a third of cases, youths who suffer from Depression will eventually be found to have Bipolar Disorder [ref]. This fact must be kept in mind by health care professionals treating these youths, especially in cases where the youth is not improving with the treatments.

Supportive counseling for mild cases of Depression in youth

For cases of mild, brief and uncomplicated Depression, many children and adolescents will do well with supportive counseling; that is, with speaking to a counselor in their school or community who can provide a listening ear, be supportive, and offer some encouragement and direction. These youths may not require a formal course of psychotherapy or any medications [ref].

Psychotherapy is first line for moderate or severe cases of Depression in youth

In more complex, moderate or severe cases, a reasonable first option would be to start a course of psychotherapy. CBT and IPT, either in individual or group format, would be the first choices, but Family Therapy or Psychodynamic Therapy can also be considered [ref]. Monthly "booster" sessions are recommended for a year after the regular therapy sessions have ended [ref].

Medications have a role for treating Depression in youth

In cases where psychotherapy alone is not providing enough improvement, or when it is not the preferred choice of the patient or not readily available in the community, then an antidepressant should be tried [ref]. Fluoxetine or Citalopram would be the first choices, followed by the other SSRIs; Venlafaxine should be avoided [ref].

It should be noted that combining psychotherapy such as CBT with a medication like Fluoxetine helps to reduce the rate of suicidal tendencies compared with using the medications alone [ref], and also shortens the time to recovery compared with using either treatment alone [ref].

There is some preliminary research suggesting that supplementing a diet with Omega-3 fatty acids may improve depressive symptoms in children and adolescents [ref].

In cases of Depression with psychotic features, it is recommended to add an Atypical Antipsychotic to the antidepressant [ref].

Once the child or adolescent's depressive symptoms have resolved, it is recommended that they be continued on medications that were helpful for 6-12 months, although those with more severe or complicated cases may require longer periods of maintenance treatment [ref].

Using psychotherapy to prevent Depression in youth

There is some evidence that using psychotherapy, such as group CBT, can help prevent Depressions for occurring in youths who would be at risk for this [ref]. At-risk youths are those who have a parent with Major Depressive Disorder, and who also had a past episode of Depression themselves or are experiencing various depressive symptoms [ref].


Unless otherwise indicated, the above information is based on the treatment guidelines developed by the American Academy of Child and Adolescent Psychiatry [ref].


Major Depressive Episode with Psychotic Features

During Pregnancy