Depression

Description

Other Names

Major Depressive Disorder

Diagnosis Coding

ICD-9

296.2, Major depressive disorder, single episode

296.3, Major depressive disorder, recurrent episode

296.90, Unspecified episodic mood disorder

300.4, Dysthymic disorder

311, Depressive disorder, not elsewhere classified

See Depressive Disorders DSM-IV Criteria for more detail on diagnosis coding and criteria, but know that ICD-9 will be officially retired sometime in 2014.

DSM-5 and ICD-10

F32.x, Major depressive disorder, single episode

F33.xx, Major depressive disorder, recurrent episode

F32.8, Other specified depressive disorder

F32.9, Unspecified depressive disorder

F34.1, Persistent depressive disorder (formerly Dysthymia)

F34.8, Disruptive mood dysregulation disorder

F43.21, Adjustment disorder with depressed mood

F43.23, Adjustment disorder with mixed anxious and depressed mood

N94.3, Premenstrual dysphoric disorder

For major depressive disorder, a 4th digit, indicated by x, is required (and for recurrent episodes, a 5th digit may be required) to indicate severity/status - consult ICD10Data.com, DSM-5 [American: 2013].

Description

Depression is common, affecting up to 20% of youth by age 18. [Lewinsohn: 1998] A depressive disorder is diagnosed when a child or adolescent has a distinct change in mood to one that is persistently depressed, sad, or irritable and/or has loss of interest or pleasure lasting at least two weeks. The mood must differ from the patient’s baseline and the change in mood must affect social or school/occupational functioning.

Criteria for the diagnosis of Major Depression outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) [American: 2000] require additional symptoms including 5 or more of the following: sleep disturbance, appetite or weight disturbance, low energy, psychomotor slowing, poor concentration, guilt or shame, and suicidal thoughts or behavior. Proposed revisions and draft diagnostic criteria for a 5th Edition of DSM were released for public comment in February 2010, with planned publication in May 2013.

Depressive disorders in children and adolescents include:
  • Major depressive disorder consists of one or more Major Depressive Episodes (two weeks or more of the symptoms described above). If mania or hypomania is present or has been present in the past, Major Depressive Disorder (MDD) cannot be diagnosed (thus, Bipolar Disorder excludes Major Depression).
  • Persistent Depressive Disorder consists of depressed mood on most days for a period of at least one year (in children, 2 years in adults). Persistent Depressive Disorder may be less severe in terms of overall number of symptoms than Major Depression but, due to its chronicity, can result in greater dysfunction in social and school/occupational areas.
  • Other Specified Depressive Disorder, or Unspecified Depressive Disorder may be diagnosed in situations when a patient has depressed mood but does not meet full symptom or duration criteria for MDD or Persistent Depressive Disorder. “Sub-syndromal” symptoms of depression (i.e., symptoms that do not meet the threshold for diagnosis of major depressive disorder) are associated with 4-5 fold increased risk for subsequent onset of a depressive disorder. [Fergusson: 2005] Certain symptoms (e.g., sad mood, irritability, low motivation) are of greater concern than others (e.g., appetite or weight disturbance, poor concentration) with regard to this increase in risk.

Bipolar depression is characterized by the presence of all of the symptom criteria for major depressive disorder and a history of mania or hypomania. Bipolar disorder often presents with symptoms of depression and is important to consider when evaluating a patient for a suspected depressive disorder. Many aspects of diagnosis and treatment of bipolar disorder are distinct from those of other depressive disorders. Suspected bipolar disorder is a strong criterion for referral to a child and adolescent psychiatrist.

Prevalence

The prevalence of depressive disorders is 2% in prepubertal children and 4-8% after puberty. In prepubertal children, males and females are equally affected; after puberty, rates of depression are twice as high in females. [Birmaher: 2007] The Epidemiologic Catchment Area study suggested an increase in prevalence of childhood depression in successive birth cohorts. [Burke: 1991] However, subsequent studies have called this conclusion into question. [Murphy: 2000] A possible explanation for the apparent increase in prevalence is the use of retrospective study methods, which rely on the recall of individuals as to when their first episode of depression occurred. More recent cohorts have been asked to recall events from the more recent past, which may allow better recall of more and earlier depressive symptoms. Prospective studies of childhood depression show stable prevalence over time.

Genetics

Multiple studies support a genetic component to depression. However, candidate genes are not well defined and a multifactorial etiology that may include environmental factors, is hypothesized.

Prognosis

Major depression is most often a recurrent illness, with up to 70% of affected youths experiencing recurrence within 5 years of an episode. [Birmaher: 2007] The likelihood of subsequent recurrence increases with each episode.

Roles Of The Medical Home

Primary care pediatric clinicians are often the first line in evaluation AND treatment of depressive disorders. The majority of children and adolescents with depressive disorders can be treated successfully in a primary care setting. Failure to improve with adequate treatment trials is a criterion for consultation with, or referral to, a qualified child and adolescent psychiatrist.

Practice Guidelines

Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H, Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-26. PubMed abstract

Helpful Articles

PubMed search for Depression in Children and Adolescents for the last two years

Angold A, Costello EJ.
Puberty and depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):919-37, ix. PubMed abstract

Kennard BD, Emslie GJ, Mayes TL, Hughes JL.
Relapse and recurrence in pediatric depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1057-79, xi. PubMed abstract

Stalets MM, Luby JL.
Preschool depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):899-917, viii-ix. PubMed abstract

Zalsman G, Brent DA, Weersing VR.
Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):827-41, vii. PubMed abstract

Zalsman G, Oquendo MA, Greenhill L, Goldberg PH, Kamali M, Martin A, Mann JJ.
Neurobiology of depression in children and adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):843-68, vii-viii. PubMed abstract

Brent DA, Birmaher B.
Treatment-resistant depression in adolescents: recognition and management.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1015-34, x. PubMed abstract

Apter A, King RA.
Management of the depressed, suicidal child or adolescent.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):999-1013, x. PubMed abstract

David-Ferdon C, Kaslow NJ.
Evidence-based psychosocial treatments for child and adolescent depression.
J Clin Child Adolesc Psychol. 2008;37(1):62-104. PubMed abstract
A concise review of evidence based psychosocial treatments (mainly psychotherapies) for depressive disorders in children and adolescents.

Hughes CW, Emslie GJ, Crismon ML, Posner K, Birmaher B, Ryan N, Jensen P, Curry J, Vitiello B, Lopez M, Shon SP, Pliszka SR, Trivedi MH.
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(6):667-86. PubMed abstract

Klomek AB, Mufson L.
Interpersonal psychotherapy for depressed adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):959-75, ix. PubMed abstract

March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.
JAMA. 2004;292(7):807-20. PubMed abstract

Moreno C, Roche AM, Greenhill LL.
Pharmacotherapy of child and adolescent depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):977-98, x. PubMed abstract

Stein D, Weizman A, Bloch Y.
Electroconvulsive therapy and transcranial magnetic stimulation: can they be considered valid modalities in the treatment of pediatric mood disorders?.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1035-56, xi. PubMed abstract

Weersing VR, Brent DA.
Cognitive behavioral therapy for depression in youth.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):939-57, ix. PubMed abstract

Clinical Assessment

Overview

Lacking a reliable laboratory test or universally applicable approach to evaluation, the diagnosis of depressive disorders is defined by somewhat complex criteria. These are helpful for describing the various types of depression and for guiding treatment and understanding expected clinical courses and outcomes.

Screening

For The Condition

Screening tools for depression are validated in research settings but poorly studied in “real world” clinical use. Routine screening for asymptomatic patients is not currently recommended. Capability of responding to a positive screen should be considered before screening.

Consider using the validated assessment instruments below when you suspect depression. They may also be used to follow and quantify changes in depression severity over time or in response to treatment. Specific instructions for use can be found on the websites where they are sold. [Sharp: 2002]

Children's Depression Inventory (CDI) age 7 to 17; 1st grade reading level, Spanish version available; self-, parent-, or teacher-report; 27 items, 10 to 30 minutes to complete. Available at MHS Psychological Assessments and Services.

Center for Epidemiological Studies-Depression Scale for Children (CES-DC): ages 12 to 18; 6th grade reading level, Spanish version available; 20 items, 5 to 10 minutes to complete. Depression Scale for Children (Bright Futures) (PDF Document 37 KB).

Center for Epidemiological Studies-Depression Scale (CES-D): ages 14 and older; 6th grade reading level, no Spanish version; 5 to 10 minutes to complete. Center for Epidemiologic Studies - Depression Scale (CES-D) (PDF Document 171 KB).

Reynolds Child Depression Scale: ages 8 to 12; 2nd grade reading level, Spanish version available; self-report; 30 items, 10 to 15 minutes to complete. Available at Reynolds Child Depression Scale (PAR, Inc.) or search from the retailer's home page at PAR, Inc..

Reynolds Adolescent Depression Scale: ages 13 to 18; 3rd grade reading level, no Spanish version; self-report; 30 items, 5 to 10 minutes to complete. Available at Reynolds Adolescent Depression Scale (PAR, Inc.) or search from the retailer's home page at PAR, Inc..

Beck Depression Inventory (BDI): ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete. Available at Pearson Assessments.

Patient Health Questionnaire 9, modified for Adolescents (PHQ-9A): ages 13-17; 6th grade reading level, Spanish version available, 5 minutes to complete. Available at Patient Health Questionnaire 9

Of Family Members

AAP recommends screening for maternal depression at well child visits up to 4 months of age. The USPSTF recommends screening for depression in the general adult population if mental health support and treatment is available.

Detecting parental depression is important as it is well demonstrated that parental depression leads to increased risk of mood and behavior problems in children.

Edinburgh Postnatal Depression Scale (EPDS): age; reading level, Spanish version available; 10 item, self report, 5-10 minute to complete. EPDS has been studied in men and also valid in that population. Edinburgh Postnatal Depression Scale (English) (PDF Document 120 KB) [Cox: 1987] Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.

Center for Epidemiological Studies-Depression Scale (CES-D): ages 14 and older; 6th grade reading level, no Spanish version; 5 to 10 minutes to complete. Center for Epidemiologic Studies - Depression Scale (CES-D) (PDF Document 171 KB)

Presentations

See the Depression through Childhood Development Issue page for detail about common presentations of depression at various developmental stages.

Diagnostic Criteria

We have requested permission to replicate here the DSM-5 criteria for Major Depressive Disorder.

Differential Diagnosis

A broad array of psychiatric disorders share symptoms with depressive disorders and must be distinguished from depressive disorders during evaluation.

Bipolar disorder may present with depressive symptoms. ALL of the symptoms of depression can be present in patients with bipolar disorder, in which patients alternate between depression and elevated mood states known as mania or hypomania. Diagnostic criteria for bipolar disorder in adults are well established but there is controversy over their application in children and adolescents, referral to a child and adolescent psychiatrist for diagnostic confirmation is appropriate.

Anxiety disorders may present with low self esteem, worthlessness, apparent lack of motivation (often anxiety-based avoidance rather than true low motivation), sleep disturbance (insomnia is common as the patient lies awake worrying), eating problems (decreased appetite or eating rituals), poor concentration. Eliciting specific mood symptoms (sadness, irritability) is important in differentiating these diagnoses.

Disruptive behavior disorders/ADHD may present with low self esteem and worthlessness due to social and academic difficulties, as well as poor concentration.

Substance use disorders often present with depressed or irritable mood. Timing of symptom onset is important because of possible comorbidity with depressive disorders and substance abuse disorders. If history indicates that mood was normal prior to onset of substance use (and especially if mood returns to normal after use is discontinued), then the mood problem may be secondary to substance use.

Anorexia nervosa often presents with depressed or irritable mood, low motivation, and low energy, in addition to decreased food intake and weight loss.

Medical illness, such as cancer, hematologic disorders, endocrine disorders, immunologic disorders, and infectious diseases (especially HIV), may present with depressive symptoms. "Vegetative symptoms," such as low energy, psychomotor retardation, sleep disturbance, and appetite disturbance, are more common in medical illnesses that mimic depression. Presence of prominent guilt, worthlessness, or suicidal thoughts or behavior suggests co-morbid depression. Consider depression when depressive symptoms pre-date diagnosis of the medical illness or arise in a chronically ill patient when other aspects of the illness are stable or improving.

Adjustment disorder with depressed mood consists of depressed mood and impaired function within 3 months of a clearly defined stressful life event. To be diagnosed with an adjustment disorder, the patient cannot meet full criteria for a major depressive episode.

History & Examination

Family History

Family history is helpful in evaluation – depressive disorders have a well-demonstrated genetic component. A full psychiatric family history should include family history of depression, suicide or suicide attempts, psychiatric hospitalizations, bipolar disorder, anxiety disorders, substance use disorders, ADHD, learning disorders, and schizophrenia.

Pregnancy Or Perinatal History

There is growing interest in the relationship of perinatal factors, such as low birth weight, with depression in later life but conclusive data is lacking.

Current & Past Medical History

The history should address symptoms of depression that overlap with those of medical illness (e.g., insomnia, hypersomnia, low energy, appetite changes, and weight changes) and symptoms that might indicate an underlying medical cause for depression.

An up-to-date history of medication use and current medications (including herbal medications [particularly St. John's Wort], dietary supplements, and OTC medications) is important, especially if medication therapy for depression is a consideration.

Interim History: Asking about depressive symptoms is the first step in ongoing assessment. A stepwise approach may help save time:
  1. Has the patient felt depressed, hopeless, or sad often over the past month, or has she/he felt less interest in or enjoyment of usual activities often over the past month. Depression and diminished interest (aka anhedonia) are cardinal symptoms of depression – one or the other must be present for diagnosis.
  2. Positive replies should prompt further questioning. The combination of either depressed mood or diminished interest in usual activities, along with 4 of the following symptoms fulfills criteria for major depression:
    • changes in sleep
    • feelings of guilt or worthlessness
    • low energy
    • poor concentration
    • appetite or weight change
    • psychomotor slowing or agitation
    • suicidal thoughts or gestures
  3. See the above Pearl, SIGECAPS mnemonic for depressive symptoms. Gather information from both the child/adolescent and a guardian. Most child/adolescent mental health professionals agree that adding together symptoms from these separate reports is sufficient for diagnosis of depression. Symptoms must cause significant distress or dysfunction to meet criteria – ask about the impact on school, home, and social areas/activities. Because children may not report symptoms clearly, assessment of changes in behavior or function may provide the best clues.
Use of a validated screening tool (see “Screening” above) is up to the clinician. A screening tool may be administered prior to a visit, eliminating or reducing the need for the questions outlined in 1 and 2. If depression concerns are uncovered in the course of a routine visit, scheduling another visit within a week to address depression may be reasonable and a screening tool could be administered in the interim. If a patient is expressing suicidal thoughts, measures must be taken immediately to ensure safety. See the Related Issue Suicidality.

Developmental & Educational Progress

Always consider the child's developmental level when looking for behaviors and changes in mood that might signal a depressive disorder.

Children and adolescents with developmental delays can also develop depression. The term "dual diagnosis" refers to the combination of intellectual disability/mental retardation and a psychiatric disorder in the same patient.

See the Related Issue page Depression through Childhood Development for more detail.

Social & Family Functioning

Clinically significant distress or impairment in social, occupational, or other important areas of functioning is one of the criteria for diagnosis of a major depressive episode. It is common for children and adolescents with depression to be more withdrawn from family or friends, more irritable, or less interested in normal activities.

Physical Exam

General

A normal physical exam can help to rule out medical illness as a cause for depressive symptoms. Examination is also helpful to address the multiple physical complaints (e.g., abdominal pain) which often accompany depression. If a patient presents with concerns of depression, has had a recent physical exam (within the past 6-12 months), and has no new physical complaints or illnesses on review of systems, the physical exam may be deferred at the clinician's discretion to allow more time for interviewing.

Testing

Laboratory Testing

Tests to consider in evaluation for a depressive disorder include TSH to screen for hypothyroidism and urine drug screen to screen for substance use, either of which may complicate or cause depression. A urine pregnancy test should be considered in females to allow for consideration of pregnancy in treatment decisions.

Imaging

Routine use of imaging or EEG in the clinical evaluation of depressive disorders is not recommended.

Genetic Testing

No genetic tests are available to aid in the evaluation of depression. Microarray analysis of cytochrome P450 enzyme gene subtypes, which can identify differences in metabolism of antidepressants, is becoming available but studies to guide clinical use are lacking.

Subspecialist Collaborations & Other Resources

Patients currently expressing active suicidal ideation or who have recently made a suicide attempt should be referred for inpatient psychiatric hospitalization.

Psychiatrist, Child-18 (see Services below for relevant providers)

May aid in diagnosing depression and related conditions. Due to chronic shortages in the US, they often see only those patients with the most severe mental illnesses or those with complicating biological, psychological, or social factors. Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features.

See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.

Psychologist, Child-18 (see Services below for relevant providers)

A clinical child psychologist will have a PhD or PsyD. Clinical or counseling psychologists are most apt to evaluate depression, performing diagnostic interviewing or specific testing, such as intelligence or personality testing.

Social Work (see Services below for relevant providers)

Mental Health and Substance Abuse Social Workers are the most apt to be involved in evaluating depression. Social workers may interview for assessment but usually are not qualified to make a formal mental health diagnosis.

Mental Health Counselors (LPC, CMHC) (see Services below for relevant providers)

Other than psychologists and social workers, a number of disciplines may offer interviewing for assessment purposes but usually are not qualified to make a formal mental health diagnosis. Most often, these counselors hold a masters degree in Clinical Mental Health Counseling, Marriage and Family Therapy, or Substance Abuse and Behavior Counseling.

Treatment & Management

Overview

The major available treatments for children and adolescents with depressive disorders include medication and psychotherapy. Depression is generally episodic with episodes lasting from months to years. Most episodes are 6 to 12 months in duration, so it is recommended that treatment be continued for at least one year from symptom improvement. The goal of this section is to give a rational and evidence-based overview of widely used treatments.

How should common problems be managed differently in children with Depression?

Over The Counter Medications

St. John's Wort (hypericum), an herbal remedy sometimes recommended for depression, induces cytochrome P450 3A4 which can result in lowered blood levels of other drugs that are metabolized by that enzyme (e.g., macrolide antibiotics, azole antifungals, benzodiazepines, calcium channel blockers, and calcineurin inhibitors, like cyclosporin and tacrolimus). St. John's Wort also interacts with SSRIs (e.g., fluoxetine, sertraline) and SNRIs (e.g., venlafaxine) antidepressants. If taken along with these antidepressants, it may increase the risk of serotonin syndrome, a serious and potentially fatal drug reaction.

Pearls & Alerts

Suicide Risk

An independent review of available data by the AMA (American Medical Association Report 2005: Safety and Efficacy of Selective Serotonin Reuptake Inhibitors (SSRIs) in Children and Adolescents) indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established. ...Concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” A more recent analysis of all available antidepressant RCTS in youth suggests that antidepressants have benefits that may outweigh these risks. [Bridge: 2007] There is also data demonstrating a correlation between higher rates of SSRI prescriptions and reduction in child and adolescent suicide rates. [Gibbons: 2006] See the Issue page Medications for Depressive Disorders for more information.

Systems

Mental Health/Behavior

Treatment should be individualized to the patient and take into consideration the patient's and family's wishes and priorities. Medications may not be the first treatment of choice for all patients. Psychotherapy alone may be considered for patients with mild to moderate depression. Some of the best evidence has, however, pointed to an advantage for medication over therapy alone. [March: 2004] Patients currently expressing active suicidal ideation or who have recently made a suicide attempt should be referred for inpatient psychiatric hospitalization.

Antidepressant medications include selective serotonin re-uptake inhibitors (SSRI), such as fluoxetine, sertraline, paroxetine, citalopram, and escitalopram and non-SSRI antidepressants, such as tricyclic antidepressants (TCA), bupropion, venlafaxine, desvenlafaxine, mirtazapine, and duloxetine.

Fluoxetine has FDA approval for treatment of Major Depressive Disorder in children and adolescents aged 7 to 17 years. Escitalopram has FDA approval for treatment of Major Depressive Disorder in adolescents aged 12 to 17 years. Use of all other antidepressants is considered “off label” in children and adolescents.

For more details on specific medications, as well as a discussion of antidepressants and suicidal adverse events, see Medications for Depressive Disorders.

General considerations for medication treatment with any antidepressant include: [Boylan: 2007]
  • Start at low doses and titrate up over several days as tolerated.
  • Patients should have frequent follow up, preferably weekly until dose is stable and medication is tolerated.
  • Trial at an adequate dose should go on 2 to 4 weeks before any further dose increase as it may take that long to see any benefit. If there is no beneficial effect after 2 to 4 weeks, dose may be increased.
  • Antidepressants work best when taken daily at the same time.
  • Most antidepressants with once a day dosing can be taken in the morning or evening based upon patient preference and observed side effects.
  • Total trial time should be at least 6 to 8 weeks. A medication trial should not be considered a failure until maximal tolerated dose has been used for this long without improvement.
  • Family history of response to particular medication may be used as an approximate guide for medication selection.
  • The FDA approval of fluoxetine and escitalopram may make those medications appealing choices for clinicians, however, clinical judgment may lead to the use of other medications.

An algorithm for medication treatment of children and adolescents with Major Depressive Disorder published by the Texas Department of State Health Services may be of interest: Guidelines for Management of Depressive Disorders, Texas Department of State Health Services.

The other major treatment modality is psychotherapy, which refers to any psychology-based treatment directed by a trained mental health professional and delivered by means of communication or behavioral techniques. Psychotherapy is often referred to as ”counseling“ or “talk therapy.” Several types of psychotherapy exist but the only two with significant research evidence for efficacy in the treatment of depressive disorders in children and adolescents are cognitive behavior therapy (CBT) and interpersonal therapy (IPT). See Treatment of Depressive Disorders in Youth: Psychotherapy for further discussion of the different psychotherapy modalities used in children and adolescents.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

May aid in providing and managing treatment and ongoing care. Due to chronic shortages in the US, they often see onlly those patients with severe mental illness or those with complicating biological, psychological, or social factors. Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features. Consider referral for depression for patients who:

  • Have no improvement after 6 to 8 weeks of medications or therapy
  • Require more than two psychotropic medications to control symptoms
  • Require psychiatric hospitalization
  • Have parents with significant emotional impairment or substance use issues
  • Have complex psychosocial issues (e.g. history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
  • Have family history suggesting adverse reactions to therapy (e.g. planned antidepressant therapy in a patient with family history of bipolar disorder)
  • Are young (6 years or under)
  • Have chronic medical illness
See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.

Psychologist, Child-18 (see Services below for relevant providers)

A clinical child psychologist will have a PhD or PsyD and may provide psychotherapy but are generally not trained nor permitted to prescribe medications (although two states, Louisiana and New Mexico, allow clinical psychologists with special training to prescribe some medications). Many psychologists will, however, consult with prescribers to help coordinate diagnosis and treatment.

Social Work (see Services below for relevant providers)

There are varying levels of academic degrees and fields of expertise in Social Work. Mental Health and Substance Abuse Social Workers, generally with masters degrees, are the most apt to be involved in treating depression; they may provide psychotherapy and may consult with other specialists to coordinate treatment.

Mental Health Counselors (LPC, CMHC) (see Services below for relevant providers)

Other than psychologists and social workers, a number of disciplines that may provide psychotherapy. Most often, these counselors hold a masters degree in Clinical Mental Health Counseling, Marriage and Family Therapy, or Substance Abuse and Behavior Counseling.

Pharmacy & Medications

The following is not an exhaustive review and should not be substituted for clinician training and judgment. For full prescribing information for all of the following medications please refer to the manufacturer’s package insert.

Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the best studied antidepressant medications for children and adolescents. They also have significant benefit for anxiety disorders including Generalized Anxiety Disorder, Panic Disorder, and OCD. The effects of SSRIs upon anxiety are important given that anxiety is commonly comorbid with depression.

SSRI side effects are usually mild and often transient. Common side effects include: headaches, GI upset, somnolence, agitation, and sexual side effects (e.g. decreased libido, anorgasmia).

In both adults and children SSRIs confer a small risk of serotonin syndrome, which is an adverse reaction and a medical emergency. Symptoms of serotonin syndrome include fever, confusion, and tremor/rigidity. Risk is increased by certain medication interactions. The most significant and dangerous medication interaction for SSRIs is with MAOIs (monoamine oxidase inhibitors – another type of antidepressant which is infrequently used in children). All patients should be questioned about other medications they are taking, including herbal and OTC medications. If serotonin syndrome is suspected in a patient, SSRI should be immediately discontinued and the patient should be referred to an emergency room for hospital admission. Treatment is supportive.

  • Fluoxetine (Prozac ®): Fluoxetine has the most positive data from controlled trial in children and adolescents with 3 trials demonstrating significant difference from placebo. [March: 2004], [Emslie: 2002], [Emslie: 1997] It also has FDA approval for use in children ages 7 to 18 with Major Depressive Disorder. Fluoxetine has a longer half-life than most other SSRIs (1 to 4 days) and an active metabolite, norfluoxetine, which has an even longer half-life (7 to 15 days). This can be a useful pharmacokinetic feature as it is somewhat more forgiving than other SSRIs when doses are missed. However, if a patient has an adverse reaction to fluoxetine, the long half-life can extend the duration of such a reaction. Starting dose for adolescents: 10 to 20mg once daily, initial target dose 20mg once daily, dose range 10mg to 60mg once daily.
  • Sertraline (Zoloft ®): Sertraline has one positive trial (two studies, which were combined by study design), however the significance of the trial results was lessened by very high placebo response rate (53%). [Wagner: 2003] High placebo response rates are characteristic of all existing trials of antidepressants in children and adolescents. Starting dose for adolescents: 12.5mg to 25mg once daily, initial target dose 50mg once daily, dose range 25mg to 200mg once daily.
  • Paroxetine (Paxil ®, Paxil CR ®): Paroxetine has one trial with mixed results [Keller: 2001] and one negative trial (unpublished, see [Cheung: 2005]), so the evidence for efficacy is equivocal. Paroxetine also appears to be less well tolerated in children and adolescents in this author’s opinion, and has significant discontinuation symptoms (possibly due to short half life of 20 hours). Other SSRIs may be better choices for children and adolescents.
  • Citalopram (Celexa ®): Citalopram has had two controlled trials. One had positive results [Wagner: 2004] and the other did not show significant difference from placebo (unpublished). The non-significant study included inpatients and also had a high dropout rate, which may have made the results difficult to interpret. Citalopram has also been studied in pediatric patients with functional abdominal pain. In August 2011, the FDA issued a Drug Safety Communication warning of the potential for QT prolongation and Torsades de Pointes in patients taking citalopram at doses higher than 40mg daily, and stated that citalopram shoud no longer be used at doses higher than 40mg daily. The FDA also discouraged use of citalopram at any dose in patients with certain cardiac conditions predisposing to arrhythmia, including congenital long QT syndrome. Starting dose for adolescents: 10mg once daily, initial target dose 10mg to 20mg once daily, dose range 10mg to 40mg once daily.
  • Escitalopram (Lexapro ®): Escitalopram is the S-isomer of citalopram. Escitalopram has had 3 controlled trials. One controlled trial in adolescents aged 12 to 17 years had positive results (unpublished data, Forest Laboratories). Two other controlled trials ([Wagner: 2006] and unpublished data, Forest), did not show significant difference from placebo. Of note, a post-hoc analysis of the data from the published negative study showed a significant difference from placebo for the adolescent age group. On the strength of the positive study and data from a positive study of citalopram, escitalopram was recently granted FDA approval for treatment of depression in adolescents aged 12 to 17 years. Starting dose for adolescents: 5mg to 10mg once daily, initial target dose 10mg once daily, dose range 10mg to 30mg once daily.

Tricyclic Antidepressants Tricyclic antidepressants (TCAs)
TCAs have been available for many years but have been eclipsed by the SSRIs, largely due to the SSRIs having fewer side effects and less toxicity. It is important for pediatric providers to know that multiple trials of TCAs have failed to show significant benefit compared to placebo for treatment of depression in children and adolescents.

Other Non-SSRI Antidepressants
  • Bupropion (Wellbutrin ®, Wellbutrin SR®, Wellbutrin XL®, Zyban ®). There are no controlled studies of bupropion for depression in children and adolescents. There is one open study of bupropion in children with depression and comorbid ADHD that has positive results. [Daviss: 2001] Bupropion is used in adults for depression and smoking cessation. Unlike SSRIs, bupropion has little effect on anxiety. It may be useful in patients with Bipolar Disorder and depression as it is less likely than other antidepressants to induce mania. There is a small risk of generalized seizures with bupropion, which is higher at doses greater than 300mg daily. Due to increased risk of seizures, bupropion is contraindicated in patients with an active eating disorder. Starting doses in adolescents: bupropion SR 75mg twice daily, initial target dose 100mg twice daily, dose range 75mg to 150mg twice daily; bupropion XL (Wellbutrin XL ®) starting dose 150mg once daily, initial target dose 150mg to 300mg once daily, dose range 150mg to 450mg once daily.
  • Venlafaxine (Effexor ®, Effexor XR ®): Venlafaxine is an SNRI (serotonin-norepinephrine reuptake inhibitor) and thus possesses an additional mechanism of action compared with SSRIs. The spectrum of effects of venlafaxine is nonetheless similar to that of the SSRIs. In fact, at lower doses (less than 225 mg daily) the norepinephrine reuptake action is not present, effectively making venlafaxine an SSRI at these doses. There have been few studies of its use in children and adolescents. Venlafaxine was studied in a large RCT involving patients who continued to have depression despite adequate treatment with one SSRI, and was not significantly better in that context than a second SSRI; there was no placebo arm. [Brent: 2008] One unpublished study and one small, randomized controlled trial did not show significant benefits [Boylan: 2007] Pooled results of these two studies showed a small benefit for adolescents only. Studies may have been hampered by a high rate of placebo response. Venlafaxine also has significant discontinuation symptoms that may begin within a few hours of a missed dose. For these reasons, venlafaxine is at best a second line medication for children and adolescents with depression.
  • Mirtazapine (Remeron ®): Mirtazapine is also considered an SNRI, although it has other actions at the CNS receptor level that may also contribute to antidepressant effect. There have been two unpublished trials of mirtazapine for depression in children and adolescents.Neither trial demonstrated significant difference from placebo. Like with venlafaxine, this lack of apparent effect may be due to high placebo response rates. Still, mirtazapine would not be a first line medication choice for children and adolescents with depression.
  • Duloxetine (Cymbalta ®): There has been one open label trial of duloxetine with children and adolescents, looking primarily at safety and tolerability. [Prakash: 2012] Until more positive findings are produced, duloxetine would not be a first line medication for children and adolescents with depression.
  • Levomilnacipran (Fetzima ®): The newest SNRI on the market, just approved by FDA for treatment of depression in adults in July 2013. No studies in children or adolescents.
Antidepressants and Suicidal Adverse Events (SAEs)
Use of antidepressant medication in children has become a controversial topic ever since the British Medications and Healthcare Regulatory Agency banned the use of all antidepressants with the exception of fluoxetine in patients less than 18 years of age in the United Kingdom. This ban was instituted due to concerns about the potential for suicidal thoughts or behavior in patients taking antidepressant medication. Subsequent evaluation of this question by the U.S. FDA led to institution of a black box warning for all antidepressants stating that they may increase the risk of suicidal thinking and behavior in children and adolescents with Major Depressive Disorder and other psychiatric disorders. No antidepressant is exempt from this warning. The FDA is now examining data and considering a similar warning for antidepressant use in adults.

It should be noted that the FDA did not institute a ban on use of antidepressants in children and adolescents, nor did the agency revoke the approval of fluoxetine for treatment of depression in patients aged 7 to 18.

An independent review of available data by the AMA (American Medical Association Report 2005: Safety and Efficacy of Selective Serotonin Reuptake Inhibitors (SSRIs) in Children and Adolescents) indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established.” It went on to state that the “concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” A more recent analysis of all available antidepressant RCTS in youth suggests that antidepressants have benefits that may outweigh these risks. [Bridge: 2007] There is also data demonstrating a correlation between higher rates of SSRI prescriptions and reduction in child and adolescent suicide rates [Gibbons: 2006].

Given concerns for SAEs, rational prescribing practices include making patients and parents aware of the safety concerns around antidepressant use. Patients who are started on antidepressant medication should be observed closely for clinical worsening, suicidal thoughts, or unusual changes in behavior. Families and caregivers should be advised to closely observe the patient and to communicate with the prescribing physician. Follow up should occur within one week after a patient is newly started on an antidepressant.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Can be very helpful in guiding and/or managing pharmacologic therapy, particularly for patients who do not respond promptly or well to standard medications.

Frequently Asked Questions

Are others in the family at risk for depression?

Depression does appear to have a genetic component. Risk of depression in first degree relatives of a person with depression is about 2 times as high as someone in the general population.

Is there depression-related research that the family might be interested in?

Please see the section on “Studies and Registries” under Treatment & Management, and also under Resources for good links to information in research.

My child was diagnosed with depression. How long will he/she need treatment?

Depression is most commonly episodic. Episodes can last from months to years. The majority of episodes will last from 6 months to one year, so the general recommendation for medications is that they be continued for at least one year from symptom improvement. By analogy, therapy should probably continue at least that long.

Once a depressive episode is resolved, what is the chance it will come back?

Depression is most often recurrent. Up to 70% of adolescents with Major Depression will experience some degree of recurrence within 5 years.

Are antidepressants safe in children and adolescents? I heard that they could cause suicidal thinking.

In about 3 to 4% of children and adolescents participating in studies of antidepressants, some degree of worsening of suicidality occurred. It is important to note that suicidal thoughts are also a symptom of depression, and these studies were not designed primarily to assess for this side effect. Even more important to note is that in over 4000 subjects, 0 committed suicide in these studies. For more detail on this topic, see “Suicide” under Related Issues.

Is it okay to just do psychotherapy for depression?

In some cases of mild to moderate depression, psychotherapy alone may be a reasonable treatment option. This decision should be made in collaboration with your clinician. Be aware that the positive effects of psychotherapy may take longer to realize than those of medication.

Issues Related to Depression

Resources

Information for Clinicians

Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research, and getting help for depression; American Academy of Child & Adolescent Psychiatry.

Guidelines for Management of Depressive Disorders, Texas Department of State Health Services
These guidelines reflect the state of knowledge, current at the time of publication, on effective and appropriate care, as well as clinical consensus judgements when knowledge is lacking. These guidelines (algorithms) do not apply to all patients, and each must be adapted and tailored to each individual patient. Proper use, adaptation modifications or decisions to disregard these or other guidelines, in whole or in part, are entirely the responsibility of the clinician who uses the guidelines.

Youth Depression in the Primary Care Setting
Webinar by child psychiatrist Lisa L. Giles, M.D. reviews evidence-based guidelines for effective assessment, diagnosis and treatment of youth depressive disorders in the primary care setting.

Resources for Primary Care (AACAP)
From the American Academy of Child Adolescent Psychiatry; a compilation of Practice Parameters, guides on collaboration between child psychiatry and the medical home, and information for patients and families.

Helpful Articles

PubMed search for Depression in Children and Adolescents for the last two years

Angold A, Costello EJ.
Puberty and depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):919-37, ix. PubMed abstract

Apter A, King RA.
Management of the depressed, suicidal child or adolescent.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):999-1013, x. PubMed abstract

Brent DA, Birmaher B.
Treatment-resistant depression in adolescents: recognition and management.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1015-34, x. PubMed abstract

David-Ferdon C, Kaslow NJ.
Evidence-based psychosocial treatments for child and adolescent depression.
J Clin Child Adolesc Psychol. 2008;37(1):62-104. PubMed abstract
A concise review of evidence based psychosocial treatments (mainly psychotherapies) for depressive disorders in children and adolescents.

Hughes CW, Emslie GJ, Crismon ML, Posner K, Birmaher B, Ryan N, Jensen P, Curry J, Vitiello B, Lopez M, Shon SP, Pliszka SR, Trivedi MH.
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(6):667-86. PubMed abstract

Kennard BD, Emslie GJ, Mayes TL, Hughes JL.
Relapse and recurrence in pediatric depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1057-79, xi. PubMed abstract

Klomek AB, Mufson L.
Interpersonal psychotherapy for depressed adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):959-75, ix. PubMed abstract

March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.
JAMA. 2004;292(7):807-20. PubMed abstract

Moreno C, Roche AM, Greenhill LL.
Pharmacotherapy of child and adolescent depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):977-98, x. PubMed abstract

Stalets MM, Luby JL.
Preschool depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):899-917, viii-ix. PubMed abstract

Stein D, Weizman A, Bloch Y.
Electroconvulsive therapy and transcranial magnetic stimulation: can they be considered valid modalities in the treatment of pediatric mood disorders?.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1035-56, xi. PubMed abstract

Weersing VR, Brent DA.
Cognitive behavioral therapy for depression in youth.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):939-57, ix. PubMed abstract

Zalsman G, Brent DA, Weersing VR.
Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):827-41, vii. PubMed abstract

Zalsman G, Oquendo MA, Greenhill L, Goldberg PH, Kamali M, Martin A, Mann JJ.
Neurobiology of depression in children and adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):843-68, vii-viii. PubMed abstract

Clinical Tools

Assessment Tools/Scales

Depression Scale for Children (Bright Futures) (PDF Document 37 KB)
Depression screening tool, with 20 questions, which takes about 10 minutes to complete; Center for Epidemiological Studies. No fee required.

Beck Depression Inventory-II (Pearson Assessments)
ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete.

Center for Epidemiologic Studies - Depression Scale (CES-D) (PDF Document 171 KB)
free short depression scoring tool for ages 14 years and older, 6th grade reading level.

MHS Psychological Assessments and Services
Children's Depression Inventory (CDI) may be purchased and downloaded from this website.

PAR, Inc.
Reynolds Child Depression Scale may be purchased and downloaded from this website.

Patient Health Questionnaire Screeners
Free screening tools to be used by primary care providers to help detect mental health disorders: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4. All PHQ, GAD-7 screeners and translations are downloadable from this website and no permission is required to reproduce, translate, display, or distribute them.

Reynolds Adolescent Depression Scale (PAR, Inc.)
Screening instrument for depressive symptomatology in adolescents; purchasable from this site.

Reynolds Child Depression Scale (PAR, Inc.)
Screen for depressive symptoms in grades 3-6, available for purchase.

Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care)
Designed for primary care practices to help in the diagnosis and management of maternal depression. Contains screening tools, patient handouts, medication information, resources, and references and includes the 9-question Public Health Questionnaire (PHQ-9). Available for download upon agreement to terms.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Child Mental Health (Medline Plus)
Mental health problems can disrupt daily life at home, at school or in the community. Talk to your health care provider if you have concerns about your child's behavior.

Children's Mental Health (Mental Health America)
A primary goal of Mental Health America is to educate the general public about the realities of mental health and mental illness.

Depression (NAMI)
Clinical depression is a brain disorder (mental illness) that affects the whole person-it affects the way one feels, thinks, and acts. Early-onset depression can lead to school failure, alcohol or other drug use, and even suicide. However, it is highly treatable.

Teens & Young Adults (NAMI)
What families need to know about adolescent depression, by NAMI, National Alliance on Mental Illness

Mental Health America
National non-profit organization, with numerous local affiliates, dedicated to helping all people live mentally healthier lives. Includes information on a variety of mental health topics in English and Spanish.

National Alliance on Mental Illness
Provides information about mental illnesses, links to state chapters, information about conferences, and links to additional resources.

National Institute of Mental Health
The Child and Adolescent Mental Health menu for National Institute of Mental Health.

Teen Mental Health (Medline Plus)
Being a teenager is hard. You're under stress to be liked, do well in school, get along with your family, and make big decisions. Feeling very sad, hopeless or worthless could be warning signs of a mental health problem. You might need help if you have the signs mentioned above.

The Depressed Child (AACAP)
Children and teenagers as well as adults may have depression, as well. Depression is defined as an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function and is treatable.

Understanding Depression (Kidshealth)
Depression is the most common mental health problem in the United States. Each year it affects 17 million people of all age groups, races, and economic backgrounds. As many as 1 in every 33 children may have depression; in teens, that number may be as high as 1 in 8.

Support National & Local

National Alliance on Mental Illness
Provides information about mental illnesses, links to state chapters, information about conferences, and links to additional resources.

NAMI Utah
Utah Chapter of the National Alliance on Mental Illness; provides advocacy and information about mental illnesses.

Services for Patients & Families

Clinical Social Worker (LCSW, MSW)

See all Clinical Social Worker (LCSW, MSW) services providers (223) in our database.

Mental Health Counselors (LPC, CMHC)

See all Mental Health Counselors (LPC, CMHC) services providers (307) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (28) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

Social Work

See all Social Work services providers (3) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Author: Thomas G. Conover, MD - 8/2013
Content Last Updated: 9/2013

Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013.

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision).
4th edition (June 2000) ed. Washington, DC: American Psychiatric Association; 2000. 0890420254

Angold A, Costello EJ.
Puberty and depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):919-37, ix. PubMed abstract

Apter A, King RA.
Management of the depressed, suicidal child or adolescent.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):999-1013, x. PubMed abstract

Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H, Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-26. PubMed abstract
The most recent practice parameter on the diagnosis and treatment of depressive disorders in children and adolescents. Our prevalence calculation roughly adjusts the cited age-specific prevalences for the age distribution in typical primary care pediatric practice.

Boylan K, Romero S, Birmaher B.
Psychopharmacologic treatment of pediatric major depressive disorder.
Psychopharmacology (Berl). 2007;191(1):27-38. PubMed abstract

Brent D, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller M, Vitiello B, Ritz L, Iyengar S, Abebe K, Birmaher B, Ryan N, Kennard B, Hughes C, DeBar L, McCracken J, Strober M, Suddath R, Spirito A, Leonard H, Melhem N, Porta G, Onorato M, Zelazny J.
Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial.
JAMA. 2008;299(8):901-13. PubMed abstract / Full Text

Brent DA, Birmaher B.
Treatment-resistant depression in adolescents: recognition and management.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1015-34, x. PubMed abstract

Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA.
Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials.
JAMA. 2007;297(15):1683-96. PubMed abstract

Burke KC, Burke JD Jr, Rae DS, Regier DA.
Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations.
Arch Gen Psychiatry. 1991;48(9):789-95. PubMed abstract

Cheung AH, Emslie GJ, Mayes TL.
Review of the efficacy and safety of antidepressants in youth depression.
J Child Psychol Psychiatry. 2005;46(7):735-54. PubMed abstract

Cox JL, Holden JM, Sagovsky R.
Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale.
Br J Psychiatry. 1987;150:782-6. PubMed abstract
A 10-item self-report scale (EPDS) to screen for Postnatal Depression in the community was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring.

David-Ferdon C, Kaslow NJ.
Evidence-based psychosocial treatments for child and adolescent depression.
J Clin Child Adolesc Psychol. 2008;37(1):62-104. PubMed abstract
A concise review of evidence based psychosocial treatments (mainly psychotherapies) for depressive disorders in children and adolescents.

Daviss WB, Bentivoglio P, Racusin R, Brown KM, Bostic JQ, Wiley L.
Bupropion sustained release in adolescents with comorbid attention-deficit/hyperactivity disorder and depression.
J Am Acad Child Adolesc Psychiatry. 2001;40(3):307-14. PubMed abstract

Emslie GJ, Heiligenstein JH, Wagner KD, Hoog SL, Ernest DE, Brown E, Nilsson M, Jacobson JG.
Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial.
J Am Acad Child Adolesc Psychiatry. 2002;41(10):1205-15. PubMed abstract

Emslie GJ, Rush AJ, Weinberg WA, Kowatch RA, Hughes CW, Carmody T, Rintelmann J.
A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression.
Arch Gen Psychiatry. 1997;54(11):1031-7. PubMed abstract

Fergusson DM, Horwood LJ, Ridder EM, Beautrais AL.
Subthreshold depression in adolescence and mental health outcomes in adulthood.
Arch Gen Psychiatry. 2005;62(1):66-72. PubMed abstract

Gibbons RD, Hur K, Bhaumik DK, Mann JJ.
The relationship between antidepressant prescription rates and rate of early adolescent suicide.
Am J Psychiatry. 2006;163(11):1898-904. PubMed abstract

Hughes CW, Emslie GJ, Crismon ML, Posner K, Birmaher B, Ryan N, Jensen P, Curry J, Vitiello B, Lopez M, Shon SP, Pliszka SR, Trivedi MH.
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(6):667-86. PubMed abstract

Keller MB, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B, Hagino OR, Koplewicz H, Carlson GA, Clarke GN, Emslie GJ, Feinberg D, Geller B, Kusumakar V, Papatheodorou G, Sack WH, Sweeney M, Wagner KD, Weller EB, Winters NC, Oakes R, McCafferty JP.
Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial.
J Am Acad Child Adolesc Psychiatry. 2001;40(7):762-72. PubMed abstract

Kennard BD, Emslie GJ, Mayes TL, Hughes JL.
Relapse and recurrence in pediatric depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1057-79, xi. PubMed abstract

Klomek AB, Mufson L.
Interpersonal psychotherapy for depressed adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):959-75, ix. PubMed abstract

Lewinsohn PM, Rohde P, Seeley JR.
Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications.
Clin Psychol Rev. 1998;18(7):765-94. PubMed abstract

March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.
JAMA. 2004;292(7):807-20. PubMed abstract

Moreno C, Roche AM, Greenhill LL.
Pharmacotherapy of child and adolescent depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):977-98, x. PubMed abstract

Murphy JM, Laird NM, Monson RR, Sobol AM, Leighton AH.
A 40-year perspective on the prevalence of depression: the Stirling County Study.
Arch Gen Psychiatry. 2000;57(3):209-15. PubMed abstract

Prakash A, Lobo E, Kratochvil CJ, Tamura RN, Pangallo BA, Bullok KE, Quinlan T, Emslie GJ, March JS.
An open-label safety and pharmacokinetics study of duloxetine in pediatric patients with major depression.
J Child Adolesc Psychopharmacol. 2012;22(1):48-55. PubMed abstract

Sharp LK, Lipsky MS.
Screening for depression across the lifespan: a review of measures for use in primary care settings.
Am Fam Physician. 2002;66(6):1001-8. PubMed abstract / Full Text

Stalets MM, Luby JL.
Preschool depression.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):899-917, viii-ix. PubMed abstract

Stein D, Weizman A, Bloch Y.
Electroconvulsive therapy and transcranial magnetic stimulation: can they be considered valid modalities in the treatment of pediatric mood disorders?.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):1035-56, xi. PubMed abstract

Wagner KD, Ambrosini P, Rynn M, Wohlberg C, Yang R, Greenbaum MS, Childress A, Donnelly C, Deas D.
Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials.
JAMA. 2003;290(8):1033-41. PubMed abstract

Wagner KD, Jonas J, Findling RL, Ventura D, Saikali K.
A double-blind, randomized, placebo-controlled trial of escitalopram in the treatment of pediatric depression.
J Am Acad Child Adolesc Psychiatry. 2006;45(3):280-8. PubMed abstract

Wagner KD, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE.
A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents.
Am J Psychiatry. 2004;161(6):1079-83. PubMed abstract

Weersing VR, Brent DA.
Cognitive behavioral therapy for depression in youth.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):939-57, ix. PubMed abstract

Zalsman G, Brent DA, Weersing VR.
Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):827-41, vii. PubMed abstract

Zalsman G, Oquendo MA, Greenhill L, Goldberg PH, Kamali M, Martin A, Mann JJ.
Neurobiology of depression in children and adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(4):843-68, vii-viii. PubMed abstract