106 Chapter 10
Treatment
Family therapy, school liaison, and supportive individual therapy are com-
monly used to tackle depression by reducing stress levels. For example, if a
bullied child becomes depressed, then tackling the bullying may be enough
to cure the depression as well. In other cases, however, it is necessary to
treat the depression itself, either because it is not possible to identify and
abolish key stresses, or because the original stressor has triggered off a
vicious cycle that needs to be interrupted. The best researched psycho-
logical treatments for depression are cognitive-behavioural therapy (CBT)
and interpersonal therapy (IPT). These have a moderate effect size and are
discussed in Chapter 40. Thecognitive restructuringcomponent of CBT is
designed to alter negative cognitions, improve self-esteem and enhance
coping skills. The equally importantbehavioural activationcomponent is
designed to increase involvement in normal and rewarding activities.
Social skills training, problem solving treatment and remedial help with
specific learning problems may also be offered.
The role of medication is controversial. It is clear that practically any
medication, including placebo, can have a large effect – but less clear which
medication performs better than placebo. Meta-analyses of controlled trials
of tricyclic antidepressants suggest that they are little or no better than
placebos for children and adolescents. By contrast, there is evidence that
serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, are better
than placebos at treating child and adolescent depression (especially severe
depression). Fluoxetine is the only antidepressant approved by the US
Food and Drug Administration (FDA) for the treatment of depression in
children. However, there are also concerns that SSRIs increase the risk
of self-harm or suicide. Analyses of reported adverse effects do suggest
an increase in suicidal ideation and threats, with few attempts and no
completed suicides. In the light of reported levels of adverse effects with
different SSRIs, the British Government guidelines do not support the use
of SSRIs other than fluoxetine for depressed children or adolescents.
Given current uncertainties about the psychological and pharmacolog-
ical treatments for depression, how should clinicians manage depressed
children and adolescents? The best plan probably depends on the severity
of the depression:
Inmilddepression, support and stress reduction are often sufficient.
Inmoderatedepression, a three-step plan can be helpful:
1 Try support and stress reduction.
2 If this fails, try CBT or IPT.
3 If this fails, consider a trial of fluoxetine.
Inseveredepression, some clinicians prefer to combine stress reduction,
CBT (or IPT) and perhaps fluoxetine from the outset. Others advise
jumping straight to fluoxetine by itself, with some trial evidence suggesting
that this can be as effective as combined pharmacological and psychological
treatment (and more cost-effective). Admission to an in-patient unit is