Depressive Disorders

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Fast facts

  • Antidepressant medication is effective in treating severe depression in adolescents, but caution is needed as a possible side effect is an increase in suicidal thoughts.
  • Effective psychological therapies include CBT, Interpersonal Therapy for Adolescents (IPT-A), family therapy and psychodynamic psychotherapy.
  • A combination of a specific psychological therapy with antidepressant medication appears to be the most effective treatment for severe depression.
  • There are several innovative or new interventions that show promise, including computerised CBT.

Interventions that work – at a glance

This table represents a compilation of information from several different sources (Fonagy et al. (2015), The Matrix (2015), NICE (2015) and Dunnachie (2007) and is designed to provide an overview only. Directly consulting these sources will provide considerable additional information.

 

Gold

Silver

Bronze

Not recommended

Mild to moderate depression

Cognitive Behavioural Therapy

 

Interpersonal Therapy for Adolescents (IPT-A)

 

Family therapy

 

Computerised CBT 

Physical exercise 

Omega-3 fatty acid supplements 

Antidepressant medication 

Severe depression

Antidepressant medication alone or in combination with a specific psychological therapy 

 

Electroconvulsive Therapy (ECT) 

 

 

The fine print

1. CBT alone is recommended when young people are motivated to engage in treatment, and where there is mild to moderate depression (Fonagy et al., 2015, Malhi et al., 2015; The Matrix, 2015). Two programmes that have particularly strong research support are ACTION (a very structured group intervention for 9-13 year old girls; see Stark et al., 2008) and the Adolescent Coping with Depression course for older adolescents (CWDA; see Clarke et al., 1990) (Fonagy et al., 2015). CBT is less effective where there are high levels of family conflict, or in complex presentations - for example, young people with a history of sexual abuse, or emerging symptoms of personality disorder (Fonagy et al., 2015).

Interestingly, recent guidelines have suggested that several psychological therapies (CBT, IPT-A, family therapy and psychodynamic psychotherapy) have roughly equivalent outcomes (NICE, 2015), while the reviews mentioned above have suggested that CBT is more effective.

2. Some reviews have recommended medication alone where there is severe depression (Fonagy et al., 2015). Selective Serotonin Reuptake Inhibitors (SSRIs), particularly Fluoxetine, are indicated as first line antidepressant treatment for severe depression (Malhi et al., 2015). Yet other guidelines have suggested that Fluoxetine should only be offered to 12-18 year olds after 4-6 sessions of a specific psychological therapy (such as individual CBT, IPT, family therapy, or psychodynamic psychotherapy) have not been effective (NICE, 2015). As outlined above, researchers are divided as to whether CBT is superior or roughly equivalent in effectiveness to other specific psychological therapies (IPT-A, family therapy, psychodynamic psychotherapy). It should be noted that a recent Cochrane review has identified an increased risk of suicide-related outcomes (i.e. deliberate self-harm and suicidal thinking) in those adolescents receiving antidepressants relative to placebo treatment (Hetrick et al., 2012). It is also important to acknowledge that untreated depression also carries a risk of suicide-related outcomes.

3. Regular physical exercise may improve symptoms of depression, but more research is needed (Fonagy et al., 2015).

4. ECT may be useful in presentations of severe depression that have not responded to other treatments, but more research is required to confirm this (Fonagy et al., 2015).

5. Dietary changes, such as taking omega-3 fatty acid supplements may improve depression, but more studies are required.

6. Antidepressant medication should not be used as a first line treatment for mild depression (NICE, 2015).

7. Computerised CBT packages are very promising and can produce equivalence results to face-to-face therapy, certainly in the short term (Ebert et al., 2015; Fonagy et al., 2015; The Matrix, 2015). More research is required to confirm these findings.

Description and demographics

There are several diagnoses within the category of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association). For a diagnosis of Major Depressive Disorder, it is required that children and adolescents display a minimum of a 2 week period of sadness or irritability (which represent a change from previous functioning), and a loss of interest or pleasure in activities (American Psychiatric Association, 2013). Diagnosis also requires changes in physiological or biological functioning, for example in appetite, sleep, and energy levels (American Psychiatric Association, 2013). These changes collectively need to have a significant detrimental impact on daily functioning.

Symptoms of depression in children and adolescents often present similarly to those in adults. However, rather than verbally expressing low mood, children may demonstrate mood lability, temper tantrums, social withdrawal or somatic difficulties (Malhi et al., 2015).

Disruptive Mood Dysregulation Disorder (DMDD) is a new diagnosis in DSM-5, and refers to children with chronic and persistent irritability and frequent temper outbursts (American Psychiatric Association, 2013), who may go on to develop depression (Malhi et al., 2015). Previously children with these symptoms may have been thought to have childhood bipolar disorder (Malhi et al., 2015). However DMDD is a somewhat controversial diagnosis, as it is highly comorbid with other disorders, and potentially pathologises healthy children (Malhi et al., 2015).

Depression is one of the most common mental health concerns, and rates increase throughout childhood and adolescence. A paper which amalgamated data from both the Christchurch and Dunedin longitudinal studies found that the prevalence of depression in New Zealand children and adolescents is less than 2% at 11 years of age, and between 4-7% at 15 years of age (Fergusson et al., 1997). The majority of children with depression have also been diagnosed with other difficulties, such as anxiety disorders, or disruptive behaviour disorders (Fonagy et al., 2015).

Adaptations to effective treatments for depression with Māori are emerging, and show significant promise. The New Zealand computerised CBT package for young people - SPARX - was developed in partnership with Māori clinicians and researchers. Research showed that SPARX was both acceptable to Māori, and effective in treating depression in Māori young people (Shepherd, 2011). And useful Māori-specific adaptations to CBT interventions for adults (such as Bennett et al., 2014) are likely to promote research into child and adolescent depression interventions.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association.

Bennett, S.T., Flett, R.A. and Babbage, D.R. (2014). Culturally adapted cognitive behaviour therapy for Māori with major depression. The Cognitive Behaviour Therapist, 7.

Clarke, G. N., Lewinsohn, P. M., & Hops, H. (1990). Leader’s manual for adolescent groups: Adolescent Coping With Depression course. Retrieved from https://research.kpchr.org/Research/Research-Areas/Mental-Health/Youth-Depression-Programs#Downloads

Dunnachie, B. (2007). Evidence-based Age-appropriate Interventions – A guide for child and adolescent mental health services (CAMHS). Auckland: The Werry Centre for Child and Adolescent Workforce Development.

Ebert, D. D., Zarski, A-C, Christensen, H., Stikkelbroek, Y., Cuijpers, P., Berking, M., & Riper, H. (2015).

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Youth: A Meta-Analysis of Randomized Controlled Outcome Trials. PLOS ONE 10(3).

Fergusson, D. M., Horwood, J., Lynskey, M. (1997). Children and Adolescents. In Ellis, P. M., & Collings, S. C. D. (Eds). Mental Health in New Zealand from a Public Health Perspective. Wellington: Ministry of Health.

Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What Works for Whom? A critical review of treatments for children and adolescents (2nd Ed). New York: Guilford.

Hetrick, S. E., McKenzie, J. E., Cox, G. R., Simmons, M. B., & Merry, S. N. (2012). Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 11: CD004851.

Malhi, G. S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P. B, Fritz, K., Hopwood, M., Lyndon, B., Mulder, R., Murray, G., Porter, R., & Singh, A. B. (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry 49(12), 1-185.

National Institute for Health and Clinical Excellence (NICE; 2015). Depression in children and young people: Identification and management. Clinical Guideline 28 and guideline addendum. London: Author.

Shepherd, M. (2011). An investigation into the design, applicability and evaluation of a computerised cognitive behavioural therapy programme-SPARX for Māori young people experiencing mild to moderate depression. Unpublished thesis, University of Auckland.

Stark, K. D., Hargrave, J., Hersh, B., Greenberg, M., Herren, J., & Fisher, M. (2008). Treatment of childhood depression: The ACTION programme. In J. R. Z. Abela & B. L. Hankin (Eds.), Handbook of depression in children and adolescents. New York: Guildford Press.

The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.