Child and Adolescent Psychiatry

Depression 107

indicated when there is severe suicidality, psychotic symptoms, or refusal
to eat and drink.
Except for very mild depression, it may be advisable to continue suc-
cessful therapy (whether psychological or pharmacological) for about six
months after symptomatic remission in order to prevent early relapse.
Pharmacological treatment of depression occurring in the context of a
known bipolar disorder poses additional challenges. Treatment resistance
is common, and SSRIs can trigger mania. Neuroleptics may be useful, for
example, quetiapine alone, or olanzepine combined with fluoxetine. There
may be a role for mood stabilisers such as lithium or carbamazepine.
While resistant depression is sometimes treated with combinations of
different medications or ECT, these are techniques that should probably
only be used in specialist centres.

Prognosis

1 Likelihood of recurrence.An adjustment disorder with depressed mood
usually lasts a few months and does not typically recur. Major depressive
episodes often last six to nine months and commonly recur. Dysthymia
typically persists for several years; dysthymic individuals are at a high
risk of major depressive episodes. Someone with ‘double depression’
(that is, major depressive episodes superimposed on dysthymia) is par-
ticularly likely to experience recurrent major episodes.
2 Adult outcome.Depression occurring in adolescence is often followed by
depression in adult life, and also predicts a roughly six-fold increase in
adult suicide rates. Depression occurring before puberty is less likely to
lead to adult depression. Whereas ‘pure’ depression does not increase
the risk of adult antisocial outcomes, the mixture of depression and con-
duct disorder is associated with higher rates of subsequent criminality.

Subject review

Brent D, Weersing VR. (2008) Depressive disorders in childhood and ado-
lescence.In: Rutter Met al.(eds)Rutter’s Child and Adolescent Psychiatry,
5th edn. Wiley-Blackwell, Chichester, pp. 587–612.

Further reading

Goodyer I.et al. (2007) Selective serotonin reuptake inhibitors (SSRIs)
and routine specialist care with and without cognitive behaviour therapy
in adolescents with major depression: Randomised controlled trial.BMJ
335 , 142–146.