Treating Children and Adolescents for Depression and Anxiety
What should be the initial treatment for young depressed or anxious persons?
Posted May 15, 2018
Children and adolescents can develop clinically significant depressive and anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are often prescribed to help children and adolescents with these disorders. But do these medications work? Are they safe? Are there better alternatives?
In a paper published in JAMA Psychiatry, Cosima Locher and colleagues utilized a statistical technique called meta-analysis to combine data from previously published medication trials (36 trials involving 6778 participants) to address these questions. An accompanying editorial by Sally Merry, Sarah Hetrick, and Karolina Stasiak discussed treatment recommendations based on the Locher et al. meta-analysis.
The meta-analysis showed that medications can help young people suffering from depressive and/or anxiety disorders, but the benefit of such treatments was not much greater than treatment with placebo. The positive effect of medication treatment was found to be small when treating depression and moderate when treating anxiety disorders.
Treatment with medications is not without risks. Locher and colleagues reported that common side effects were present in both placebo and medication treatment groups; however, potentially severe side effects such as thoughts of suicide were more common in the medication groups. Also, more individuals discontinued medications when taking active drug than taking placebo. Thus, this analysis suggests that medications are a bit more effective than placebo but have the potential for significant side effects. The benefit versus risk profile of taking medications was more favorable in the treatment of anxiety disorders than in the treatment of depressive disorders.
The data also clearly showed that there is a substantial placebo response in treating these disorders, with the placebo response for depressive disorders being greater than for anxiety disorders. The term “placebo response” may be a bit misleading. Many patients with a wide range of illnesses tend to improve from the non-specific effects of having a caring treatment team. The placebo effect is a complex but very real and clinically important phenomenon.
Youth-directed and family-directed psychotherapies can be effective in helping young people with depression and anxiety disorders. Little is known about risks from specific psychotherapies, but it is believed that the benefit versus risk profile is better for evidenced-based talk therapies than for medications. Also, there is some literature suggesting that internet-based therapy, such as cognitive behavioral therapy, is not inferior to costlier face-to-face therapy in adults. These latter observations, if shown to be applicable to a younger population, are potentially important because of the shortage of therapists with training in evidence-based forms of psychotherapy.
Merry and colleagues make several reasonable suggestions in their editorial. First, it is important to recognize when a child or adolescent develops a depressive or anxiety disorder. Once recognized, non-specific treatments that take advantage of “placebo effects” might be an effective first strategy. This approach could involve members of the treatment team staying in close communication with the patient and his or her family. For those who do not improve with such interventions, evidenced-based psychotherapy would be a reasonable next step. For those who are uninterested in psychotherapeutic approaches or who have not responded well to such treatments, pharmacotherapy could be considered. Whenever medications are introduced, careful follow-up is important.
Depressive and anxiety disorders in children and young adolescents are associated with significant dysfunction as well as psychopathology and disabilities later in life. Early recognition and treatment is important. The papers we review here offer thoughtful guidance in how to approach such treatment while taking into account the complex nature of childhood depression and anxiety.
This post was written by Eugene Rubin MD, PhD and Charles Zorumski MD.
Locher, C., Koechlin, H., Zion, S.R., Werner, C., Pine, D.S., Kirsch, I., Kessler, R.C., & Kossowsky, J. (2017). Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic review and meta-analysis. JAMA Psychiatry. 74 (10): 1011-1020.
Merry, S.N., Hetrick, S.E., & Stasiak, K. (2017). Effectiveness and safety of antidepressants for children and adolescents: implications for clinical practice. JAMA Psychiatry. 74 (10): 985-986.