Assessment strategies
Semi-structured interviews such as the Child and Adolescent Psychiatric Assessment, the Diagnostic Interview for Children and Adolescents, and the Kiddie Schedule for Affective Disorder and Schizophrenia are useful for assessing depression in pediatric patients (Table 2).13-16 These tools can be used to assess depression criteria based on information gathered from several sources. Many instruments can be used to assess and monitor pediatric depression, including the Children’s Depression Inventory, the Reynolds Child Depression Scales and Adolescent Depression Scales, and the Child Depression Rating Scale.
To assess suicide risk in depressed younger patients:
- ask about emotional difficulties
- identify lack of developmental progress
- estimate their level of distress
- detect impairment in functioning
- estimate the level of danger to themselves and others.17
The best way to assess for suicidal ideation is to ask about it directly while interviewing the patient and his or her parents. Simple questions such as “Have you ever thought about killing yourself or wish you were dead?” and “Have you ever done anything on purpose to hurt or kill yourself?” can be effective.10 These questions are best placed in the middle or toward the end of a list of questions about depressive symptoms.
Adolescents may be more likely than adults to disclose information about suicidality on self-reports.6 However, self-assessment suicide scales are not a substitute for clinical assessment because they tend to be oversensitive and non-specific and lack predictive value. A positive response to either of these questions should prompt a more detailed clinical investigation. There is no evidence that asking about suicide risk increases suicidal behavior, even in high-risk youths.
Table 2
Assessing children and adolescents: 3 semi-structured interviews
| Interview | Features |
|---|---|
| Child and Adolescent Psychiatric Assessment13 | For patients age 9 to 17. Assesses symptoms from the past 3 months. Administration time: 1 to 2 hours. Requires minimal interviewer experience. Assesses impairment in multiple areas (family, peers, school, leisure activities) |
| Diagnostic Interview for Children and Adolescents14 | Separate versions for children (age 6 to 12) and adolescents (age 13 to 17). Assesses lifetime psychopathology. Administration time: 1 to 2 hours. Interrater reliability varies (poor to good) |
| Kiddie Schedule for Affective Disorders and Schizophrenia15 | Assesses lifetime and current psychopathology. Administration time: 35 minutes to 2.5 hours. Interrater reliability: fair to excellent16 |
Treatment options
Psychotherapy. Several controlled studies and meta-analyses support the efficacy of cognitive-behavioral therapy (CBT) for mild depression in pediatric patients.18-20 Two recent meta-analyses of CBT studies in depressed adolescents found the mean effect size of CBT was 0.34 to 0.35.19,21 However, a separate analysis found CBT did not have long-term benefits for depressed adolescents, particularly patients with a history of abuse.22
Interpersonal therapy also can be effective in adolescent outpatients with mild to moderate depression. One study found the effect size of psychotherapy was modest (0.36).19
Pharmacotherapy. Two meta-analyses support selective serotonin reuptake inhibitors (SSRIs) for treating mild to moderate depression in children and adolescents. One found 61% of depressed patients age <19 who received an SSRI were “much improved” or “very much improved.”23 Another meta-analysis that compared SSRIs and placebo found fluoxetine was more effective than sertraline or citalopram for depressed adolescents.24 Other studies have shown that for severe depression, the effect size of antidepressants (0.69) is higher than that of placebo (0.39).25 Antidepressants are more effective in adolescents than in children.25
Fluoxetine is the only FDA-approved medication for treating depression in children age ≥8. In 2007 the FDA extended to all antidepressants its “black-box” warning about increased risk of suicidality in patients up to age 24. The results of studies that analyzed data about the safety of antidepressants in children and adolescents have been mixed—some found evidence of increased suicidality with antidepressant use,26,27 whereas others showed no increased risk.28,29Table 3 summarizes steps to minimize the risk of antidepressant-induced suicidality.17
Psychotherapy plus pharmacotherapy. Researchers who compared fluoxetine to CBT and to a combination of the 2 in adolescents with moderate to severe depression found that fluoxetine was most effective in the first 12 weeks of treatment.30 Surprisingly, CBT’s effectiveness was not different from placebo.30 However, studies have shown that combining psychotherapy and medication results in greater symptom improvement,30 faster clinical response,31 improvement of global functioning and quality of life,32 and reduced suicidality.33 At 6 months, the difference in response between medication and psychotherapy was small.25 The Treatment of Resistant Depression in Adolescents study found that for chronic adolescent depression, pharmacotherapy (fluoxetine and venlafaxine) combined with CBT produced a higher response rate than pharmacotherapy alone (54% vs 41%).34