Key advisor: Dr Sally Merry, Senior lecturer in child and adolescent psychiatry, Werry Centre for Child
and Adolescent Mental Health, Dept of Psychological Medicine, University of Auckland
Summary of advice:
- Antidepressants may increase suicidal thoughts, but there is no compelling evidence of an increased risk of actual
- Behavioural therapy and other psychosocial interventions are considered first line treatment for depression in young
- If drug therapy is indicated, fluoxetine is the best choice of antidepressant for adolescents or children.
- It is important to maintain regular contact with young patients with depression and to monitor the risk of suicide,
especially in the few weeks following a first antidepressant prescription.
Depressive disorder is a major health issue for adolescents in New Zealand, affecting between 4 to 8% of 15 year olds,
rising rapidly to rates of 17 to 18% by the age of 18.1-6 In young people, depressive disorder is pervasive
and affects not only function but overall development.7 It is associated with poor academic functioning, social
dysfunction, substance abuse, attempted and completed suicide.7-12 Co-morbidity is high, with up to half of
those with major depressive disorder having another psychiatric disorder at some stage in their life.7-13
Despite this high prevalence, it is estimated that over three quarters of depressive disorder in adolescents is undetected.
Health professionals are being encouraged to screen for depression and to provide treatment. However FDA black box warnings
about the potential for newer antidepressants to increase the risk of suicide have led to concern about the place of antidepressants
in the management of depressive disorders in children and adolescents.
How should depression in young people be treated?
|Monitoring suicide risk
Monitoring suicide risk is complex. The New Zealand Guidelines Group offers practical advice on how to investigate
Questions a clinician may consider include:
- How has your mood been lately?
- Has anything been troubling or worrying you?
- Have you had times when you have been feeling sad or down?
- Have you ever felt like life is just getting on top of you?
- Do you sometimes wish you could just make it all stop, or that you could just end it?
- Have you thought about how you might do this?
- Have you ever wished you were dead?
- Have you ever thought about taking your own life?
If the patient endorses any of these statements, the clinician then needs to determine level of intent, existence
of a plan, access to means, underlying mental health problems and availability of support and protective factors.
guideline "Assesment and Management of People at Risk of Suicide". Complete document available from:
There are two major approaches to managing depression in children and adolescents - psychological and pharmacological.
Choosing a treatment involves a team approach including GP, family and patient. With more severe depression, specialist
mental health professionals should also be involved. There is no simple tool for determining who will and who will not
respond to treatment.
More detailed information on how to assess risk and manage
depression can be found in the UK based National Institute of Clinical Excellence (NICE) guidelines and the Guidelines
for Adolescent Depression in Primary Care (GLAD-PC) toolkit. This document contains useful flow charts for clinical management
and assessment. The New Zealand Guidelines Group (NZGG) is due to release their guidelines on treating depression in children
and adolescents shortly.
Websites and a list of resources can be found at the end
of this article.
Psychological treatments recommended as first line
There is evidence that cognitive behavioural therapy and interpersonal therapy are both effective in the treatment
of depression in children and adolescents.14, 15 Psychological therapies are recommended as first line treatment,
especially in mild to moderate depression.10, 16 Even for more severe depression up to 13% of young people
respond to support and monitoring.17
A "stepped care" method should be used, so that simpler and less risky approaches are tried first, dependent on severity
of depression. For mild depression, start with "active monitoring" followed by one of the psychological therapies if there
is no response.10, 16 For more severe depression, specialist referral is recommended.
|Training for health professionals:
(email gordon via our "contact us" page and we'll pass on your message
to any of the above)
- The Werry Centre in Auckland runs occasional workshops to teach cognitive strategies that can be used as a first
- The University of Auckland offers two papers teaching cognitive behavioural therapy for children and adolescents
(block teaching, suitable for people from anywhere in New Zealand). For information contact Janine Joubert
- The University of Otago (Christchurch School of Medicine) offers occasional workshops on Interpersonal Therapy
training, as well as post graduate courses. For information contact Associate Professor Sue Luty
For active monitoring:
- Provide psychoeducation (educate about depression, how to treat it and how to recognise signs of relapse)
- Provide supportive counselling
- Facilitate parental and patient self-management
- Refer for peer support
- Regularly monitor for depressive symptoms and suicidality
See GLAD-PC toolkit for a clinical management flow chart.
Referral to a child and adolescent mental health service or to a clinical psychologist is currently the best method
for accessing psychological treatment, but may not be available in all areas. Other resources could be trialled where
psychological therapies are unavailable (see below).
Fluoxetine in combination with cognitive behavioural therapy
If young people fail to respond to simpler approaches, if their depression is more severe or if psychological treatments
are unavailable, fluoxetine may be considered. Combining fluoxetine with cognitive behavioural therapy is an effective
- A meta-analysis of the effectiveness of tricyclic antidepressants did not provide convincing evidence of effectiveness
of these medications for children and adolescents.19
- Authors of a number of meta-analyses of SSRIs and other newer generation antidepressants concluded that the risk benefit
ratio is only favourable for fluoxetine.18-21
- There is limited evidence that the other medications have anything more than a placebo response. Even for fluoxetine
the overall response rate is low.22
GPs may wish to consider consulting with a child psychiatrist before prescribing an antidepressant to a person under
18 years. Although there is little evidence to support the use of antidepressants other than fluoxetine, they may be effective
The Child and Adolescent Psychiatry Trials Network, based in the USA, has recently commenced work on a "safety registry"
for newer antidepressants. It is hoped to identify factors that predict benefit and harm and who should and should not
receive a particular medication.23
Other resources for treating depression in young people
Because of the limited availability of psychological therapies there has been some interest in the use of technology
to deliver these interventions by way of the internet or computer games. Trials show computerised cognitive behavioural
therapy compares well with that delivered by a therapist and is a recommended intervention for adults in the NICE guidelines.
Trials for adolescents lag behind but resources are being developed. The Australian based Inspire Foundation has created
"Reach Out Central", a user-friendly web-site with an interactive problem solving game for teenagers. This has not been
evaluated but could be suggested as a self-help resource alongside active monitoring of mood and suicidal ideation.
In New Zealand, the Ministry of Health have produced a user friendly website aimed at young adults as part of their
National Depression Initiative. "The Lowdown" provides interactive resources, chat and support.
Facilitating lifestyle changes, including regular exercise is also an effective management technique.