Patient information: Depression treatment options for adolescents

DEPRESSION OVERVIEW

Depression is a treatable condition. Psychotherapy (counseling), drug therapy, and other measures can alleviate symptoms and help adolescents to succeed in school, develop and maintain healthy relationships, and feel more self-confident.

This topic review discusses the treatment options available for adolescents with depression. The causes, symptoms, and diagnosis of depression are discussed separately. (See "Patient information: Depression in adolescents".) Parents who are unsure if their adolescent is depressed should read that topic review first.

Topic reviews about depression in adults are also available. (See "Patient information: Depression in adults" and "Patient information: Depression treatment options for adults".)

STEP ONE: EDUCATION

In adolescents, treatment for depression is most successful when the parents are involved. Learning about depression is an important component of depression treatment. Family education is also important before decisions are made about the adolescent's treatment plan.

Understanding how depression affects the teen's mood and behavior can help the adolescent and his or her family in several ways:

• Family members can learn about the symptoms of depression and how these symptoms impact the teen's relationships with friends and family, willingness to attend school, and ability to complete school work.
• Family members can learn how to recognize if the adolescent's depressive symptoms are recurring or coming back.
• Other family members might be able to identify their own depressive symptoms and need for treatment.
• Family members can learn how to help the teen with depression. It is important to clarify the role of parents, other family members, and teachers in the teen's treatment and recovery.
• Family members can learn how to make the environment safer for depressed adolescents. For example, the need to limit access to certain items (eg, prescription medications, weapons) should be discussed.
• Family members can learn about the treatment options that are available to treat depression, including the pros and cons of various treatment options, so that they can make well informed decisions.

DEPRESSION TREATMENT OPTIONS

Major depression is the medical term for depression that meets particular criteria. A person can have mild, moderate, or severe major depression. Adolescents with mild or moderate depression are usually treated with counseling alone. If the depressive symptoms do not begin to improve within six to 12 weeks, or if symptoms worsen, an antidepressant medication may be recommended.

Adolescents with severe depression generally require counseling in addition to one or more medications. Treatment with medication and counseling increases the likelihood of improved symptoms and relationships with family and friends; it can also improve self-confidence and the ability to cope effectively.

Compared to adults, there have been relatively few high quality studies of treatment for adolescent depression. Current practice guidelines for treating adolescent depression are based upon a combination of data from studies of depressed adolescents, adult depression research, and practical experience.

COUNSELING TO TREAT DEPRESSION

Counseling, also called psychotherapy or talk therapy, teaches patients and their families to understand themselves and the nature of depression, including how to manage relationships and life stressors associated with depression.

Therapy sessions are usually conducted in the therapist's office once per week for 30 to 60 minutes. The adolescent, parents, and therapist should work together to determine the optimal schedule.

During a therapy session, the teen talks to the therapist about their feelings, thoughts, behaviors, and relationships. The patient and therapist can discuss alternate ways of thinking or taking action, which often helps the teen to cope more effectively with depressive symptoms, improve social skills, and increase self-confidence.

While it is important to involve parents in some aspects of their adolescent's treatment (particularly regarding education and ensuring safety), parent(s) usually do not sit in the room with the teen and therapist throughout therapy discussions. The reason for this is that adolescents have a right to privacy and may be reluctant to openly discuss important topics when parents are present.

The initial therapy sessions often focus on trying to identify the factors that are contributing to depression. This often includes changing unproductive behavior patterns that are common during episodes of depression. Although psychotherapy can lessen depression within several weeks, the greatest benefit of therapy may not be seen for eight to 10 weeks or longer.

Psychotherapy can be provided by any healthcare professional with appropriate training, including a licensed psychologist, psychiatrist, clinical social worker, or clinical nurse specialist. When choosing a therapist, it is important to consider the therapist's training and experience with adolescents as well as the therapist's willingness to incorporate family members in the therapy.

Below are some examples of useful questions to ask of the therapist:

• What type of training or experience do you have treating depression in adolescents?
• Are family members included in some aspects of the treatment? How?
• What is your experience in using cognitive behavioral or interpersonal therapy for depression? These types of therapy have been shown to be effective in adolescents.

Teens with severe depression and those at risk for suicide are often hospitalized in a psychiatric facility for a short period of time. During the hospitalization, the teen usually has a group of clinicians (psychiatrist, psychologist, social workers, etc.) who comprise the treatment team. Depression treatment often includes medication management, individual, group and/or family therapy. Other activities may include physical exercise, art/music therapy and school work.

ANTIDEPRESSANT MEDICATION

If an adolescent needs an antidepressant medication, he or she may be treated by their pediatrician or referred to a psychiatrist.

A psychiatrist is a medical doctor with specialized training in the treatment of mental health issues. The psychiatrist should have training and experience in child and adolescent psychiatry or, if the person has adult-only training, he or she should have experience treating teenagers. In some cases, a psychiatrist provides counseling and prescribes medications if needed; in other cases, a therapist provides counseling and a psychiatrist prescribes medication.

Treatment with an antidepressant medication helps to reestablish the normal balance of chemicals in the brain. Classes of antidepressants used to treat depression in adolescents include: selective serotonin reuptake inhibitors (SSRIs) or other atypical antidepressants and tricyclic antidepressants (TCAs).

If a healthcare provider recommends an antidepressant medication for an adolescent's depression, the following issues should be discussed before treatment begins:

• The expected benefits and possible risks and side effects
• The instructions for the dose and timing
• Potential interactions with other prescription or non-prescription medications
• Alternatives to medication (eg, continued therapy)

An information sheet for parents about antidepressants in adolescents is provided in table 1 (table 1). The American Academy of Child and Adolescent Psychiatry, in partnership with the American Psychiatric Association, also has a medication guide for parents, available online at www.parentsmedguide.org/pmg_depression.html.

Selective serotonin reuptake inhibitors (SSRIs) — The selective serotonin reuptake inhibitors (SSRIs) increase levels of the neurochemical serotonin in the brain. Low levels of serotonin may be one cause of depression. SSRIs are generally the first-line medication for depression in adolescents because there are few or no side effects and the medication is only taken once per day.

SSRIs that have been studied for use in adolescents include fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), and citalopram (Celexa®). Fluoxetine is the only antidepressant that is approved by the United States Food and Drug Administration (FDA) to treat depression in youth (7 years and older). However, there may be sound clinical reasons to prescribe an antidepressant other than fluoxetine. Questions or concerns about any antidepressant should be discussed with the individual clinician.

Side effects — Side effects of SSRI antidepressants often improve with time (one to two weeks), but may include headache, abdominal pain, diarrhea and nausea, sleep changes, jitteriness, agitation, or sexual side effects (decreased libido, delayed ability or inability to experience orgasm/ejaculate).

• Serotonin syndrome — A more serious potential side effect of SSRIs is serotonin syndrome. Symptoms of serotonin syndrome can include agitation, confusion, and overheating (hyperthermia). This can occur with high doses of an SSRI or if an SSRI is taken in combination with another antidepressant medication called a monoamine oxidase inhibitor (MAOI).

There is a very small risk of serotonin syndrome when an SSRI is combined with a class of migraine medications called triptans (eg, sumatriptan (Imitrex®), zolmitriptan (Zomig®), naratriptan (Amerge®), rizatriptan (Maxalt®), almotriptan (Axert®), eletriptan (Relpax®) and frovatriptan (Frova®)). Many headache experts feel that it is safe to use an SSRI and a triptan in combination as long as the person is monitored for symptoms.

• Risk of suicide — Depression significantly increases an adolescent's risk of having suicidal thoughts and committing suicide. Many parents are concerned about a possible association between suicide and antidepressant medications.

There is no evidence that antidepressants increase the risk of a teenager actually committing suicide. However antidepressants have been associated with a slightly increased risk of suicidal thinking in adolescents and young adults, particularly during the initial weeks of treatment.

In considering whether or not to use medication to treat depression, the parent(s) and psychiatrist must balance the small increased risk of suicidal thoughts against the very real risk of suicide if the teen's depression is not adequately treated. Any mention of suicidal thoughts or feelings in a depressed adolescent should be taken seriously.

Parents who are concerned that their child is considering suicide should seek care as soon as possible. A depressed adolescent who is at risk of attempting suicide will be provided with emergency treatment for depression; this may include hospitalization, antidepressant medication, and intensive therapy.

Treatment of depression decreases the risk of suicide, but does not eliminate the risk. For this reason, most experts recommend that the parents and healthcare providers (eg, therapist, psychiatrist, pediatrician) closely monitor the adolescent for evidence of suicidal thoughts or behaviors for at least the first 12 weeks of depression treatment and if the antidepressant medication dose is changed.

If suicidal thoughts or behaviors develop during treatment with an antidepressant, the dose may be lowered, an alternative antidepressant may be tried, or the medication may be discontinued.

Atypical antidepressants — Atypical antidepressants may be considered if the first line treatment is not effective or cannot be tolerated. Available options include venlafaxine (Effexor®), duloxetine (Cymbalta®), mirtazapine (Remeron®), and bupropion (Wellbutrin®). However, these medications are not well studied in children and adolescents.

Tricyclic antidepressants — Tricyclic antidepressants (TCAs) alter levels of several different neurochemicals in the brain. Drugs in this class include imipramine (Tofranil®), amitriptyline (Elavil®), desipramine (Norpramin®), nortriptyline (Pamelor®), and clomipramine (Anafranil®).

Because of the numerous side effects associated with these drugs and the availability of an effective alternative (SSRIs), TCAs are less commonly used as a first-line treatment. The side effects of TCAs may include dry mouth, blurred vision, constipation, nausea, difficulty urinating, drowsiness, weight gain, and rapid heart beat.

Nevertheless, many patients use TCAs safely, and their benefit is equivalent to that of other antidepressants.

ANTIDEPRESSANT MEDICATION ISSUES

Time required for a response — Some people respond to antidepressant medication after about two weeks, but for most, the full effect is not seen until four to six weeks or longer. During the first few weeks, the dose is usually increased gradually. The adolescent usually sees the medical provider (the psychiatrist) once per week for the first four weeks, then every two weeks for the next four weeks, and then every one to three months; if problems develop at any point, more frequent visits may be recommended. This usually means that the teen will have at least two appointments per week for medication monitoring and counseling during the first few months of treatment.

By six to eight weeks after starting an antidepressant medication, it is usually possible to determine if the medication is effective. If symptoms have improved somewhat during this time, the dose of the medication may be increased. If there has been no improvement in symptoms, an alternate antidepressant medication may be recommended.

Duration — In most cases, the antidepressant medication is continued for at least nine to 12 months after the symptoms of depression improve. This recommendation varies greatly depending upon the individual's situation. The decision to stop antidepressant medication should be shared between the adolescent, parent(s), and the clinician.

When antidepressants are stopped, they should be tapered slowly over two to four weeks to minimize the potential side effects associated with abruptly stopping medication. Side effects associated with stopping antidepressant medication quickly can include jitteriness, dizziness, nausea, fatigue, muscle aches, chills, anxiety, and irritability. Although these symptoms are not dangerous and usually improve over one to two weeks, they can be quite distressing and uncomfortable.

A relapse in depression is relatively common after stopping antidepressant medications; in some cases, longer-term treatment is recommended (see 'Maintenance drug therapy' below)

Maintenance drug therapy — Maintenance drug therapy (long-term antidepressant therapy) may be appropriate for adolescents who are at high risk for a relapse of depression. One study found that 37 percent of adults who were treated for depression experienced a relapse within 12 months of stopping antidepressant therapy [1]. Maintenance therapy may last from one year to indefinitely, depending upon the individual's situation and personal history of depression.

Therapy with other medications — In some people, depression is accompanied by other psychiatric conditions, such as panic attacks, obsessive-compulsive disorder, or mania. Treatment with more than one medication, including an antidepressant and an antipsychotic, antianxiety, mood-stabilizing, or anticonvulsant medication may be recommended in this situation.

OTHER TREATMENT OPTIONS FOR DEPRESSION

Several other treatment options may alleviate depression in some people.

Omega-3 fatty acids — A large international study found a beneficial effect of omega-3 fatty acids, which are found in fish, in the treatment of depression in adults [2]. A small trial also found a benefit in children, although further studies are needed to confirm these results [3].

St. John's wort — St. John's wort (Hypericum perforatum) appears to alter levels of several neurochemicals in the brain. Studies in adults suggest that St. John's wort is more effective than a placebo and as effective as tricyclic antidepressants for the treatment of mild to moderate depression [4]. However, antidepressant medications are not usually recommended for adolescents with mild to moderate depression, and St. John's wort has not been studied adequately in adolescents.

A good source for updated information about St. John's wort can be found at the National Center for Complementary and Alternative Medicine, a branch of the National Institutes of Health (www.nccam.nih.gov/health/stjohnswort/).

Electroconvulsive therapy (ECT) — During electroconvulsive therapy (ECT), an electrical current is passed through the brain, triggering a seizure. For unknown reasons, the seizure helps to restore the normal balance of neurochemicals in the brain. ECT is especially effective for people with depression who also have delusions (powerful, irrational beliefs) and for people who have severe depression that has not improved with maximal drug therapy. The parent(s), adolescent, and psychiatrist must all agree to a trial of ECT before it is considered; state and local guidelines may also apply. (See "Medical consultation for electroconvulsive therapy".)

Patients who undergo ECT are given general anesthesia to induce sleep and prevent discomfort. The patient is monitored carefully before, during, and after the treatment. Side effects of this therapy include brief confusion and memory loss. Although ECT has been negatively portrayed in the media, it often provides rapid and dramatic relief of depression and has few side effects. Most people who undergo ECT find it a helpful treatment for their depression.

More detailed information about ECT is available on the American Psychiatric Association's web site, www.psych.org/Departments/APIREandResearch/ResearchTraining/clin_res/index.aspx.

ANTIDEPRESSANTS AND PREGNANCY

Information about the safety of antidepressant medications in pregnancy is available in a separate topic review. (See "Patient information: Depression treatment options for adults", section on 'antidepressants and pregnancy'.)

WHERE TO GET MORE INFORMATION

Your adolescent's healthcare provider is the best source of information for questions and concerns related to your adolescent's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your adolescent's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to depression
Patient information: Depression in adolescents
Patient information: Depression in adults
Patient information: Depression treatment options for adults

Professional Level Information:
Complications and screening in children and adolescents with type 1 diabetes mellitus
Depression in adolescents: Epidemiology, clinical manifestations, and diagnosis
Effect of antidepressants on suicide risk in children and adolescents
Epidemiology and risk factors for suicidal behavior in children and adolescents
Evaluation and management of suicidal behavior in children and adolescents
Overview of treatment for adolescent depression
Psychopharmacological treatment for adolescent depression
Psychosocial treatment for adolescent depression
Medical consultation for electroconvulsive therapy
Patient information: A guide to depression

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The American Academy of Child and Adolescent Psychiatry (AACAP)

      (www.aacap.org)

• Federal Drug Administration

      (www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273)

• The American Psychiatric Association

      (www.psych.org)

• American Psychological Association

      (www.apa.org)

• National Alliance for the Mentally Ill

      (www.nami.org)

• National Institute of Mental Health

      (www.nimh.nih.gov/health/topics/depression/index.shtml)

• National Mental Health Association

      (www.nmha.org)

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