Treatment data in adolescents have been reviewed ().10,129
Three important issues are highlighted. First, treatment choices are not the same in adolescents as in adults. Second, best treatment practice is controversial because accepted practice and clinical guidelines vary in different countries, and because of concerns about the use of antidepressant drugs in patients younger than 18 years, with some recommendations based on consensus rather than on evidence. Third, the evidence relates to the short-term effectiveness of psychological treatments and medication. Evidence for the long-term benefits of treatment to rates of recurrence and for the effectiveness of non-specialist interventions is scarce.
Treatment strategies for adolescents with depression*
The two best studied psychological treatments are cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT). There have been two published meta-analyses of CBT (based on 35 trials in children and adolescents,130
and 11 in adolescents only131
). Both recorded that CBT was an effective treatment, but neither showed an effect size greater than 0·3, which is the lower limit for a moderately effective treatment.130,131
The largest randomised controlled trial (RCT) of adolescents with moderate to severe depression showed similar response rates in the CBT and placebo groups (43% vs
although another large study noted that the addition of CBT to antidepressant medication was beneficial in treatment-resistant depression.132
Overall, the data suggest that CBT is probably effective in adolescents with milder forms of depression, but it fails to consistently produce more beneficial effects than do control treatments in those with moderate to severe depression, which has raised some questions on applicability and who is most likely to benefit.
Three RCTs suggest that IPT is a useful treatment.133–135
However, most countries do not have an adequate pool of trained therapists to deliver this treatment. Although in many countries, including the UK, simple non-specific psychosocial strategies () are recommended as initial treatment for mild depression, there is little good quality evidence of their effectiveness.
Unlike in adults, tricyclic antidepressants are not an effective treatment for adolescents with depression.136
Fluoxetine, a selective serotonin reuptake inhibitor, seems effective in meta-analyses137
but evidence is sparse for other antidepressants. RCTs suggest that escitalopram might be effective,140
which led the US Food and Drug Administration to approve its use in adolescents. Irrespectively, even in the best circumstances, antidepressants seem no more than moderately effective in adolescents with depression.
Suicidal risk in relation to antidepressant use is controversial.137,141
Several studies, including a meta-analysis, suggest a significant association with such risk,137
especially in young people. Individuals younger than 25 years of age treated with antidepressants are more likely than older adults to develop thoughts about suicide. However, a large meta-analysis141
showed that the benefits of such treatments still outweigh the risks (numbers needed to treat 10 vs
numbers needed to harm 143). With the mixed evidence and because untreated depression in adolescents is itself so strongly associated with risk of suicide, suicidal risk should be monitored in this clinical group, irrespective of treatment choice. Selective serotonin reuptake inhibitors, notably fluoxetine, can also cause agitation and precipitate hypomanic symptoms in some individuals.
The two largest treatment trials for depression in adolescents have examined the combined benefits of medication and CBT, and although they reached different conclusions, we note that there were differences in sample selection, treatment protocols, and outcome measures.
In the UK Adolescent Depression, Antidepressants, and Psychotherapy Trial (ADAPT) all participants received routine specialist mental health service care.138
The addition of CBT to fluoxetine did not improve outcomes. However, the US Treatment for Adolescents with Depression Study (TADS)42
showed that 12 weeks of combined treatment with CBT and fluoxetine produced greater improvements than did fluoxetine alone.
Other investigations assessed treatment resistance. One American RCT132
reported that switching from fluoxetine to another antidepressant (paroxetine or citalopram) and the addition of CBT resulted in greater improvement in symptoms than a medication switch alone (54·8% vs
40·5%). A switch to venlafaxine resulted in adverse side-effects (mainly cardiovascular), and was thus not recommended.
The scarcity of access to and availability of some treatments (notably CBT and IPT) for adolescents with depression in non-specialist contexts in many countries is a major concern. One RCT in the USA showed that the use of primary care-based case-managers who supported clinicians’ management of depression and delivered CBT when required led to a significant improvement in symptoms of depression in adolescents.142
Counselling programmes in schools and primary care are being introduced in some countries that could offer a more pragmatic way of initially dealing with mild or sub-threshold depression in adolescents and improve access to treatment for this group.143
Other less expensive approaches that could also be used in primary care, delivered through the internet or by non-specialists are now being investigated for use in adults with depression, but have not yet been widely assessed for adolescents.
A report by a special WHO panel has drawn attention to the importance of treatment of mental health disorders in low-income and middle-income countries where resources are scarce, with depression in adolescents identified as a key priority area.144,145
One promising approach is the treatment of mental health problems in children exposed to traumatic events with IPT delivered by trained local community workers. A well designed, RCT examined the efficacy of IPT in adolescent survivors of war and displacement in northern Uganda. The study recorded that IPT delivered by local community workers significantly improved symptoms of depression in adolescent girls.146