Treating depression in children and adolescents: what options now?

There have been significant developments in the understanding of depression in children and adolescents in the past few years, including an increased recognition that significant depressive illness occurs in this patient group. Pharmacological and psychotherapeutic treatments are used to manage depression in children and adolescents, and there is evidence from randomised, double-blind, placebo-controlled trials of benefit for both approaches. However, not all medication trials have been positive. In addition, there have been increasing concerns about specific safety issues related to the use of medications to treat depression, with an overall finding of mood-related adverse effects, including suicide attempts, in 4% of active drug versus 2% of placebo recipients in controlled trials involving children and adolescents. This has resulted in regulatory actions in a number of countries that have ranged from the declaration of contraindication for most antidepressants (in Great Britain), to relegation of antidepressants to a second-line intervention (in New Zealand) to a Black Box warning (in the US). It can be concluded that best practice combines treatment with both medication and psychotherapy, and that important safety issues must be monitored carefully when children and adolescents are treated for depression. On balance, there appears to be evidence of the benefit for antidepressant medications in children and adolescents, which outweigh safety concerns.