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Effective Health Care Program

Open for comment:

Treatment of Childhood Depression

Open for comment until 11:59 p.m. eastern time on February 21, 2018.

Treatment of Childhood Depression
Please fill out the form below to provide comments on the key questions associated with this topic.

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Comment on Key Questions

Key Question 1. In adolescents and children, what are the benefits and harms of non-pharmacological interventions for

  1. Major depressive disorder?
  2. Persistent depressive disorder (PDD) or dysthymia?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

Key Question 2. In adolescents and children, what are the benefits and harms of pharmacological interventions for

  1. Major depressive disorder?
  2. Pervasive depressive disorder?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

Key Question 3: In adolescents and children, what are the comparative benefits and harms of treatments for depressive disorders (pharmacological and non-pharmacological interventions) for

  1. Major depressive disorder?
  2. Persistent depressive disorder (PDD) or dysthymia?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

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Draft Key Questions

Key Question 1. In adolescents and children, what are the benefits and harms of non-pharmacological interventions for

  1. Major depressive disorder?
  2. Persistent depressive disorder (PDD) or dysthymia?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

Key Question 2. In adolescents and children, what are the benefits and harms of pharmacological interventions for

  1. Major depressive disorder?
  2. Persistent depressive disorder (PDD) or dysthymia?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

Key Question 3: In adolescents and children, what are the comparative benefits and harms of treatments for depressive disorders (pharmacological and non-pharmacological interventions) for

  1. Major depressive disorder?
  2. Persistent depressive disorder (PDD) or dysthymia?
  3. By subpopulation (eg, patient characteristics, disorder characteristics, history of previous treatment, comorbid condition, etc.)?

Draft Analytic Framework

Figure 1. Draft analytic framework for Treatment of Childhood Depression

 This figure depicts the key questions within the context of the PICOTS for childhood depressive disorders. In general, the figure illustrates how pharmacologic and/or pharmacologic treatments versus other treatments or control for major depressive disorder, pervasive depressive disorder and patient subgroups may result in final health outcomes such as remission, depressive symptoms, suicidality, and mortality. Also, adverse events may occur at any point after the treatment is received.

Acronyms: KQ= key question; MDD= major depressive disorder; PDD= Persistent depressive disorder

Figure 1: This figure depicts the key questions within the context of the PICOTS for childhood depressive disorders. In general, the figure illustrates how pharmacologic and/or pharmacologic treatments versus other treatments or control for major depressive disorder, pervasive depressive disorder and patient subgroups may result in final health outcomes such as remission, depressive symptoms, suicidality, and mortality. Also, adverse events may occur at any point after the treatment is received.

Background

Approximately 1 in 10 adolescents aged 13-18 has either a major depressive disorder or persistent depressive disorder (PDD)/ dysthymia).1 Depressive disorders negatively impact social2 and academic outcomes,3 and are associated with poor long-term outcomes and increased risk of suicide.4 Some believe that persistent depressive disorder (PDD), or dysthymia, is important to diagnose and manage for children and adolescents since the consequences of PDD are increasingly recognized as grave; and can include severe functional impairment, increased morbidity from physical disease, and increased risk of suicide. Current clinical guidelines recommend the use of psychotherapy with or without antidepressants for children and adolescents with depressive disorders seen in primary5,6 and mental health care,7 and outline steps for treating children and adolescents with acute mental health and behavioral problems presenting in emergency department.8 However, there continue to be concerns that antidepressants may be associated with higher rates of suicidality.9 It is also unclear how non-pharmacological and pharmacological treatments compare to each other, whether certain treatments are more effective for certain population subgroups, and whether early interventions can effectively prevent the development of depressive disorders.

Population(s)

  • KQ 1a, 2a, and 3a: Children and adolescents <18 years old with major depressive disorder
  • KQ 1b, 2b, and 3b: Children and adolescents <18 years old with persistent depressive disorder (PDD) or dysthymia?
  • KQ 1c, 2c and 3c: Subpopulations: patient characteristics, disorder characteristics, history of previous treatment, and comorbid condition

Interventions

  • KQ 1: Any non-pharmacological treatment (eg, psychotherapy, cognitive behavioral therapy (CBT), online CBT, self-help, etc)
  • KQ 2: Any pharmacological treatment (eg, second generation antidepressants, tricyclic antidepressants)
  • KQ 3: Any non-pharmacological or pharmacological treatment
  • Co-interventions may include other non-pharmacologic or pharmacologic treatment

Comparators

  • KQ 1: Any comparator (such as placebo, treatment as usual, wait list controll)
  • KQ 2: Any comparator (such as placebo, treatment as usual, wait list control)
  • KQ3: Any non-pharmacologic or pharmacologic treatment

Outcomes

Final health outcomes

  1. Remission
  2. Depressive symptoms
  3. Suicidality
  4. Mortality

Any adverse effects of intervention

Timing

  • All

Setting

  • Outpatient

References

  1. Health NIMH. Dysthymic Disorder Among Children. http://www.nimh.nih.gov/health/statistics/prevalence/dysthymic-disorder-among-children.shtml. Accessed August 25, 2016.
  2. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clin Psychol Rev. 1998;18(7):765-794.
  3. Fletcher JM. Adolescent depression: diagnosis, treatment, and educational attainment. Health Econ. 2008;17(11):1215-1235.
  4. Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up. JAMA. 1999;281(18):1707-1713.
  5. American Academy of Pediatrics. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, Assessment, and Initial Management. Pediatrics. 2007;120(5).
  6. American Academy of Pediatrics. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management. Pediatrics. 2007;120(5).
  7. Birmaher B, Brent D, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.
  8. American Academy of Pediatrics. Executive Summary: Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. Pediatrics. 2016.
  9. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews. 2012(11).