Childhood mental disorders form a significant burden of disease that affects children and adolescents. According to the data provided by the Global Burden of Disease Study 2010 (GBD 2010), childhood mental and behavioral disorders were attributed to causing 185 million disability-adjusted life years (DALYs) in 2010 accounting for 7.4 % of DALYs globally (Polanczyk, 2013). Notably, several childhood mental disorders contributed to this burden in different proportions with major contributors including pervasive developmental disorders, conduct disorders, and attention deficit hyperactivity disorders. In addition, early onset of major psychiatric illnesses such as major depressive disorder and other depressive disorders, bipolar disorder, schizophrenia and other psychotic spectrum disorders, and anxiety disorders similarly contributed to the aforementioned burden of mental disorders in children and adolescents. It suffices to reiterate that the childhood mental illnesses affect their social and emotional development thereby affecting other spheres of development. Moreover, premature death rates are higher among children and adolescents with mental disorders owing to the association of several mental illnesses with suicidal ideations, suicidal attempts and suicide (Halfon et al., 2013). Evidently, mental disorders in children contribute to a significant burden of disease in the child and adolescent population.
Child and adolescent depressive disorders are managed principally through a comprehensive multimodal approach involving both pharmacologic and psychosocial interventions. According to Reeves and Anthony (2009), practice guidelines indicate that in the management of depression in children and adolescents, psychosocial interventions such as psychotherapy and parental skills needs to be used alongside medications. Further, it has been shown through large pediatric, multicenter randomized trials that multimodal approach has better outcomes by addressing both the symptoms of mental illness as well as aspects of family functioning namely adjustment to life stressors, parent-child conflict, and maladaptive coping behaviors (Reeves & Anthony, 2009). For parents and guardians who make decisions on the treatment that their child is given, it is important to be informed on the merits and demerits of the available treatment modalities available in order to make informed decisions. Although the use of the comprehensive multimodal approach is the most efficacious approach to treatment, findings based on relevant literature suggest that psychotherapy is superior to pharmacotherapy alone in the treatment of depression in children and adolescents.
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Summary of Treatment of Childhood Depressive Disorders
Depressive disorders in children and adolescents affect a fundamental proportion of children resulting to significant social and economic burden. According to the Diagnostic and Statistical Manual of Mental Disorders 5 of 2013, children and adolescents are affected by a myriad of depressive disorders. From the manual, just like adults, children can be affected by major depressive disorder, persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder and premenstrual dyphoric disorder (American Psychiatric Association [APA], 2013). Moreover, it is equally important to address the depressive component of Bipolar disorders such as Bipolar I and Bipolar II, which also affect children and adolescents significantly. As such, it is observable from a parent’s perspective that depression greatly affects the social and occupational functioning of children and adolescents resulting to slow progression in school, social withdrawal and overall poor growth.
Understanding the epidemiology and clinical presentation of depressive disorders in childhood is important in the management approach taken in treating the condition. According to Moffitt et al. (2010), the prevalence of major depressive disorders in early adulthood is in the region of between 10%-17%. However, the disease is relatively uncommon in pre-pubertal children with the prevalence being 1%-2% with little difference in occurrence between boys and girl. As teenage approaches, the prevalence of depressive disorders rises exponentially with a more modest rise in boys than girls. The result is a prevalence of 4%-5% of depressive disorders among teens and adolescents with a sharp female preponderance that is reflected in adult depression as well. In addition to the epidemiology of depression as aforementioned, child and adolescent depression characteristically present with other comorbid psychiatric illnesses. According to Wichstrom et al. (2012), depression in children and adolescents occurs with one comorbid disorder in a third of patients and with two other psychiatric disorders in 10% of depressed adolescents. Moreover, overlap with other childhood psychiatric disorders such as attention-deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder is common among depressed children and adolescents (Wichstrom et al., 2012). It is important to understand the burden and pattern of distribution of childhood depression as aforementioned in order to guide management of the condition. Given that psychotherapy and pharmacotherapy both have a role in the management of depression in children; it is crucial to understand the dynamics of each treatment modality as provided below in order to help care givers make informed decisions over their children’s treatment
Psychotherapy in Childhood Depressive Disorders
Interpersonal Psychotherapy for Adolescents (IPT-A) is a psychotherapy technique that has been shown to be beneficial in treating childhood depressive disorders. According to the American Psychological Association [APA] (2008), IPT-A tackles depression in adolescents through the modification of issues that occur commonly during the adolescent period. Such issues include separation from parents, role transitions, authority conflicts, peer pressure and development of healthy peer relationships, death of a relative or friend, and the challenges associated with single- or step-parent families (APA, 2008). IPT-A has been shown to be beneficial in reducing symptoms of depression to a significant level in addition to having improvement in social functioning (Mufson et al., 2014). Furthermore, IPT has been shown to be efficacious in the treatment for adolescent depression for which it has been shown to be superior to twice-monthly supportive clinical management, with differences most prominent in those who were moderately or severely depressed and in older teens (Birmaher & Brent, 2007). As such, IPT represents an important psychotherapeutic intervention for child and adolescent depression.
Cognitive behavior therapy (CBT) as a psychotherapeutic technique has been shown to be beneficial in the treatment of depressive disorders in childhood. It suffices to reiterate that in CBT the aim of the therapy is to reduce negatively distorted techniques in the child or adolescent in order to improve problem-solving and coping skills that increase the patient’s involvement in healthy, pleasurable activities. CBT has been shown to be efficacious in the management of childhood depression. According to the findings posted by Weisz et al. (2006) from analysis of 35 randomized clinical trials, overall CBT has a positive effect in reducing depressive symptoms. Moreover, no clear correlation was established between the length of treatment and effect, which makes this form of psychotherapy to be cost effective as brief sessions can be used to treat depressed youths. However, variability in response was noted based on whether the depression was acute or chronic with acute cases registering more modest results (Birmaher & Brent, 2007). In addition, CBT has not shown any significant improvement for externalizing symptoms that commonly occur in depression. As such, CBT as a psychotherapy technique, although with some caveats on the impact of duration of treatment offers a beneficial effect on the treatment of childhood depressive disorders.
Pharmacotherapy in Childhood Depressive Disorders
Pharmacotherapy has been made use of to a significant level in the treatment of depressive disorders in children and adolescents. Notably, selective serotonin reuptake inhibitors (SSRIs) are the mainstream class of antidepressants that have been used clinically to a substantial amount in the treatment of childhood depressive disorders (Bridge et al., 2007). According to Birmaher & Brent (2007), data from published randomized clinical trials on the SSRIs effect on depression have shown that overall SSRIs have a relatively good response rate of 40%-70%. However, the response rate in the group treated with placebo similarly showed a high response rate of 30%-60% (Birmaher & Brent, 2007). From this data, it is clear that the need to treat (NNT), which is a way of conceptualizing the efficacy of a medication was NNT=10 with a 95% confidence interval. It is clear from this analysis the efficacy of SSRIs in the treatment of depression bear little significance in comparison with failing to treat. An exception to this is the SSRI Fluoxetine, which has been approved by the Food and Drug Administration for the treatment of depression among children and adolescents. The justification of this is that, fluoxetine has been shown in clinical trials to have a larger difference between its effects and placebo as compared to the other classes of antidepressants and other SSRIs (Birmaher & Brent, 2007). Clinical trials on other classes of antidepressants have yielded no better results than with the SSRIs. For instance, according to Emslie et al. (2007) no differences was observed between the trials of venlafaxine (Serotonin Norepinephrine Reuptake Inhibitor [SNRI]) or mirtazapine (atypical antidepressant) and placebo in the treatment of child and adolescent depression. Moreover, other disadvantages the use of antidepressants in child and adolescent is associated with systemic adverse drug reaction as well as a higher proclivity to suicidality. As such, despite the difference in efficacy, pharmacological agents such as SSRIs show some beneficial impact in the treatment of depressive disorders in children and adolescents.
Discussion
The successful treatment of a child or an adolescent who has a depressive disorder requires a comprehensive approach involving various modalities. In essence, in addition to the aforementioned techniques of psychotherapy and pharmacotherapy, various situations necessitate the use of other treatment options such as psychoeducation, family therapy, and school involvement. Supportive psychotherapeutic techniques such as active listening and reflection, restoration of hope, problem solving, coping skills, and strategies for maintaining participation in treatment also need to be integrated as appropriate in the management of a depressed child or adolescent (Birmaher & Brent, 2007). Given that pharmacotherapy and psychotherapy are two widely used techniques in the management of depression in children, as a parent or guardian it is important to understand the fundamental pros and cons for each modality in order to make an informed decision in the best interest of the patient.
The use of pharmacotherapy in the treatment of depression in children is associated with adverse drug reaction, a phenomenon that is not observed when psychotherapy is used as the only intervention. According to Birmaher & Brent (2007), although the SSRIs used in the treatment of depression have been generally well tolerated, several adverse effects have been associated with their usage. The adverse effects include gastrointestinal symptoms, sleep changes (e.g., insomnia or somnolence, vivid dreams, nightmares, impaired sleep), restlessness, diaphoresis, headaches, akathisia, changes in appetite (increase or decrease), and sexual dysfunction. Moreover, impulsivity, agitation, irritability, silliness, and “behavioral activation” are observable in 3% to 8% of children who have been exposed to pharmacological treatment of depression (Birmaher & Brent, 2007). Although occurring more rarely, serotonin syndrome which is characterized by high proclivity to bleeding is an adverse effect that has been associated with the usage of SSRIs in the management of depression in children (Weinrieb et al., 2005). On the other hand, psychotherapy in the treatment of childhood depression has not been associated with the aforementioned adverse effects seen in pharmacotherapy. As such, psychotherapy as an intervention for treating childhood depression exhibits a better safety profile compared to pharmacotherapy.
Both psychotherapy and pharmacotherapy have been shown to improve symptoms of depression in childhood, with the efficacy of psychotherapy extended to cover special situations. According to Reeves & Anthony (2009), fluoxetine as an FDA approved SSRI used in childhood depression has shown significant improvement in symptomatology compared to placebo. However, the other antidepressants have not exhibited appreciable difference with effect of placebo with a review of 35 RCTs showing a NNT=10. On the other hand, psychotherapy techniques of IPT-A and CBT have demonstrated marked improvement of the symptoms of depression (Weisz et al., 2006). In addition to that, Birmaher & Brent (2007) report that psychotherapy has been associated with significant improvement of symptoms of anxiety in patients treated for depression. A change in the externalizing symptoms has, however, have disapointgly only been modestly altered by psychotherapy. Given that depression has been shown to coexist along with other psychiatric illnesses in up to a third of depressed children and adolescents, psychotherapy provides an easier option for treating the other comorbidities as well than pharmacotherapy alone.
In the treatment of depression in children and adolescents, psychotherapy has a lower suicide risk as compared to pharmacotherapy. According to Birmaher & Brent, (2007) six studies that have examined suicidality as an outcome in their study of psychotherapy in childhood depression have all reported a reduction, albeit small, in the risk of suicide in such patients. On the contrary, a suicidality evaluation of nine antidepressants used in 24 acute RCTs by the FDA and Columbia University reported an average increase in suicidal adverse events (Hammad et al., 2006). In essence the evaluation reveals an overall risk ratio (RR) of 1.95, 1.74 and 1.90 for suicidality, suicidal ideation and suicidal attempts respectively. In a separate meta-analysis of published and unpublished RCTs of antidepressants by Bridge et al. (2007), a comparable overall small but significant increased relative risk for spontaneous reported suicidality was reported. Evidently, with regard to the risk of suicide among children and adolescent treated for depression, psychotherapy offers a better safety profile compared to pharmacotherapy.
Conclusion
Mental disorders continue to pose a significant public health concern owing to the significant Disability-Adjusted Life Years (DALYs) that they contribute to. Depression in children and adolescents is a major contributor to this phenomenon as it affects 1%-2% of pre-pubertal children and 4%-5% of teenagers and adolescents. The recommended modality of treatment for the condition is a comprehensive multimodal approach that in addition to psychotherapy and pharmacotherapy utilizes family, school and other supportive interventions in managing the depressed child or adolescent. However, psychotherapy and pharmacotherapy are two interventions that are commonly utilized in the condition. Albeit both are useful in the management of a depressed child or adolescent, an analysis based on adverse effects profile, addressing comorbid mental illnesses; and the risk of suicide during treatment shows that psychotherapy exhibits superiority than pharmacotherapy alone in the management of child and adolescent depressive disorders.
References
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