Major Depressive Episodes: Reaching Out to Adolescents

Left untreated, depression can become chronic and refractory.

The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks the incidence of depression among Americans. SAMHSA watches adolescents—youths aged 12 to 17 years—quite closely because more than 9% of adolescents experience at least 1 major depressive episode (MDE) annually, and 6.3% are severely impaired by their depression, but only one-third of clinically depressed adolescents receive appropriate treatment. MDE rates increase steadily between 12 and 17 years of age, with adolescent girls more than twice as likely as boys to experience an MDE.¹ Depression can cause significant problems in mood and thinking, as well as in behavior at home, in school, and with peers. Left untreated, it can progress to chronic, refractory adult depression.

Diagnostic criteria for depression are the same for adolescents and adults: a period of 2 weeks or longer during which the individual has either a depressed mood or loss of interest and at least 4 other symptoms that reflect a change in functioning. Adolescents with depression—compared with adults with depression—are more likely to experience anhedonia, boredom, hopelessness, hypersomnia, weight change (including failure to reach appropriate weight milestones), and suicide attempts. Those who have an MDE are more than 3 times as likely as other adolescents to use alcohol or drugs.¹ Younger children with depression are more likely to have somatic symptoms, restlessness, separation anxiety, phobias, and hallucinations.² Clinicians should note that parents are more likely to notice externalized symptoms such as irritability, but adolescents are more likely to report internalized symptoms such as depressed mood.³

Treatment

Depression in adolescents is treatable. Adolescent depression is classified as mild, moderate, or severe. Mild or moderate depression is often treated with counseling alone, often cognitive—behavioral therapy (CBT) or interpersonal psychotherapy. If the depressive symptoms are moderate to severe or fail to improve or worsen within 6 to 12 weeks, clinicians usually consider antidepressants. Treatment with medication and an evidence- based psychological therapy (ie, CBT or interpersonal psychotherapy) increases the likelihood that symptoms will resolve.

Treatment of depression in children and adolescents should continue for 6 months after remission because studies show that patients who are treated adequately are less likely to relapse.^4-7 Prescribers should consider medication early in patients who have had a previous MDE, in those with a family history of depression, and especially in patients who present with medication-responsive depression.⁸ If pharmacologic treatment is successful, patients report improved interpersonal relationships, greater selfconfidence, and better coping.

Data supporting the use of antidepressant treatments in youth, although growing substantially, are limited compared with data on adults. Practice guidelines for adolescent depression rely on studies of depressed adolescents, adult depression research, and practical experience. Pharmacists should use caution in extrapolating adult data on antidepressants to adolescents, remembering that adolescents’ neural pathways may not be fully developed and serotonin and norepinephrine systems have different maturation rates.⁹ Selective serotonin reuptake inhibitors (SSRIs; Table) are preferred to atypical antidepressants, tricyclics, or monoamine oxidase inhibitors.

Pharmacists play a crucial role in monitoring for side effects because of their frequent contact with patients. Suicidality is a serious concern (Online Sidebar: Suicidality Among Adolescents Taking Antidepressants). If side effects occur and are intolerable, lowering the dose or considering an alternative drug may help. Because SSRIs have shorter half-lives in children, and withdrawal may occur as early as 12 hours after the last dose of medication, dose tapering is advised to avoid serotonin syndrome.¹⁰

SUICIDALITY AMONG ADOLESCENTS TAKING ANTIDEPRESSANTS

A 2004 study suggested that antidepressant medication use may induce suicidal behavior in youths.7 A more recent comprehensive pediatric trial review conducted between 1988 and 2006 suggested that the benefits of antidepressants likely outweigh the risks in children and adolescents. In addition, results of the National Institutes of Mental Health—funded Treatment for Adolescents with Depression Study found that medication combined with psychotherapy is the most effective treatment for adolescents with depression. The FDA recommends face-to-face contact with patients or their family members or caregivers during the first 4 weeks of drug treatment, then visits every other week for the next 4 weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks.10

Recurrence

Based on a few community epidemiologic and clinical studies, recurrence following adolescent MDE is common. One study examined 5-year outcomes in 196 adolescents with MDEs who received 1 of the following: fluoxetine, CBT, fluoxetine plus CBT, or placebo. The researchers found that although 96.4% of treated patients recovered within 2 years, 46.6% relapsed within 5 years despite a comprehensive maintenance treatment protocol.¹¹ Recurrence rates are similar in adults. The authors note that treatments with established short-term efficacy do not protect against recurrence, and girls are at greater risk for recurrence than boys.^12,13 Clinicians are advised to inform teenagers and their families that they need to stay vigilant for signs of recurrence.

Patients with 3 or more MDEs have a 90% likelihood of recurrence, and they should be considered for maintenance treatment with a full therapeutic dose of an antidepressant. Adolescents with severe, nonresponsive depression should be assessed for electroconvulsive therapy.¹⁰

Pharmacist’s Role

Pharmacists can help teens in 3 ways. First, pharmacists must heighten awareness of the signs of adolescent depression. Second, pharmacists should encourage screening for adolescent depression in multiple health care settings. Finally, pharmacists can be instrumental in making information concerning treatment options readily available. Ultimately, all clinicians need to use sound clinical judgment when working with depressed adolescents, and always err on the side of safety.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy

References

1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. http://archive.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/2K12MHF/NSDUHmhfr2012.htm. Accessed February 7, 2015.

2. Williams SB, O’Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123:e716-e735.

3. Richardson LP, Katzenellenbogen R. Childhood and adolescent depression: the role of primary care providers in diagnosis and treatment. Curr Probl Pediatr Adolesc Health Care. 2005;35:6-24.

4. Best evidence statement: treatment of children and adolescents with major depressive disorder (MDD) during the acute phase. Cincinnati Children's Hospital Medical Center website. www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9198/de750725-339e-4e67-b927-b60c6173bd4a.pdf. Accessed February 7, 2015.

5. Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120(5):e1313-e1326.

6. Emslie GJ, Mayes TL. Mood disorders in children and adolescents: psychopharmacological treatment. Biol Psychiatry. 2001;49(12):1082-1090.

7. Emslie GJ, Heiligenstein JH, Hoog SL, et al. Fluoxetine treatment for prevention of relapse of depression in children and adolescents: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 2004;43(11):1397-1405.

8. Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012;86:442-448.

9. Bylund DB, Reed AL. Childhood and adolescent depression: why do children and adults respond differently to antidepressant drugs? Neurochem Int. 2007;51:246-253.

10. Hughes CW, Emslie GJ, Crismon ML, et al. Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:667-686.

11. Curry J, Silva S, Rohde P, et al. Recovery and recurrence following treatment for adolescent major depression. Arch Gen Psychiatry. 2011;68:263-269.

12. Johansson O, Lundh LG, Bjärehed J. Twelve-month outcome and predictors of recurrence in psychiatric treatment of depression: a retrospective study [published online ahead of print January 18, 2015]. Psychiatr Q.

13. Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev. 2007(3):CD004851.