Interventions for childhood depression.

Professor Du has provided a succinct summary of child and adolescent depression and its treatment with antidepressants.[1] There remains some controversy over the prevalence of depression in children and adolescents: Professor Du reports that 20% of individuals experience depression prior to the age of 18 while other epidemiological reports indicate that the rate is closer to 17%.[2]–[4] But this difference in rates is relatively small and may be due to methodological differences in the studies. As noted by Professor Du, suicidal ideation may increase in depressed children and adolescents who receive antidepressant treatment, but the rates of suicidal acts do not appear to increase. Overall, the beneficial effects of antidepressants, at least among depressed teenagers, appear to outweigh the risks.[5]

Fortunately, the incidence of depression is lower in children than in adolescents. Antidepressant use is of greatest concern in younger children: physicians are more willing to prescribe fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) ‘off label’ for older adolescents with depression than they are for younger adolescents and children. For children, non-pharmacological psychosocial treatments such as Behavioral Activation[6],[7] (that may more easily be rendered age-appropriate than cognitive-behavioral therapy [CBT] or interpersonal psychotherapy [IPT]) are increasingly available and appear to be efficacious.

A new and important direction of research on childhood depression is the focus on preventing depression. Investigators throughout the world have implemented and evaluated specific interventions to prevent the occurrence of a first full-criteria episode of depression in children. Universal prevention programs are applied to entire populations of children (e.g., all the students in a school). Indicated prevention programs are targeted on selected ‘high-risk’ (or ‘at-risk’) children–those with identifiable risk factors (e.g., cognitive distortions) or subsyndromal depressive symptoms.[8],[9]

Universal programs have produced small effect sizes and their long-term results have, at best, been described as ‘mixed’.[10] Findings for Indicated prevention programs have been more encouraging: a CBT-based prevention program[11] effectively prevented depressive episodes among children of parents who suffered from depressive disorders; and a large U.S. prevention study based on CBT principles[12] prevented depression among at-risk children (unless there was a depressed mother in the child's household). Similarly, a school-based CBT program[13] administered by current school staff to at-risk 14- and 15-year olds (the peak age for the onset of adolescent depression) in Iceland prevented an initial episode of depression and the preventive effects were maintained over a 1-year follow-up period. This program is currently being evaluated in a prevention program in schools in Portugal.

These findings about the prevention of childhood depression are important for a number of reasons. First, the prevention of an initial episode of depression among children at risk prevents the personal, social and societal effects of a Major Depressive Episode. Second, data show clearly that once a first episode of depression has occurred, the risk of a second episode is greatly increased, so the prevention (or at least delay) of an initial episode may forestall the development of a chronic relapsing condition.[3] The delay in onset of the initial episode also allows more time for the development of academic and social skills and more time for the maturation of neural pathways of resilience among at-risk youth. And since antidepressant use is more acceptable in older than younger adolescents, delay of the initial episode of depression will have the result that a wider range of alternative treatments are available if and when a Major Depressive Episode occurs.