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Effective Health Care Program

Treatment of Depression in Children: A Systematic Review

Systematic Review Draft

Open for comment through Jul 5, 2019

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Purpose of Review

The purpose of the review is to examine the efficacy and comparative effectiveness of both benefits and harms of commonly used types of nonpharmacological and pharmacological treatments of child and adolescent depressive disorders.

Key Messages

  • For adolescents (mean ages 13 through 18) with major depressive disorder (MDD), cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine plus CBT may reduce depressive symptoms in the short term.
  • For adolescents with mixed depression diagnoses, CBT and family therapy may improve symptoms, response, or functional status.
  • For adolescents and children with MDD, CBT plus medications may help prevent relapse.
  • Evidence on children with MDD or mixed depression diagnoses is sparse.
  • We found insufficient evidence to judge harms associated with nonpharmacological interventions. For pharmacological interventions, selective serotonin reuptake inhibitors (SSRIs) as a class may improve response and functional status among adolescents and children. However, they may be associated with a higher risk of serious adverse events (AEs) among adolescents or children with MDD, and with a higher risk of withdrawal due to AEs among adolescents with MDD. Paroxetine may be associated with a higher risk of suicidal ideation or behaviors; we did not, however, find the same results for SSRIs as a drug class, owing to insufficient evidence.
  • Further research is needed on the effects of interventions in children, in groups with DDs other than MDD, and after the end of active treatment (often 8–12 weeks). Further research is also needed on head-to-head comparisons of interventions.

Structured Abstract

Background. Depressive disorders can affect long-term mental and physical health functioning among children and adolescents, including increasing risk of suicide. Despite access to several nonpharmacologic, pharmacologic, and combined treatment options to treat childhood depression, clinicians contend with sparse evidence and are concerned about harms associated with treatment.

Methods. We conducted a systematic review to evaluate the efficacy, comparative effectiveness, and moderators of benefits and harms of available nonpharmacological and pharmacological treatments for child and adolescent depressive disorders. We searched five databases and other sources for evidence available from inception to July 25, 2018, dually screened the results, and analyzed eligible studies.

Results. We included data from 55 studies (83 articles) that met our review eligibility criteria in our analyses. For adolescents with major depressive disorder (MDD), cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine and CBT may improve depressive symptoms in the short term (end of treatment, often ranging from 8–12 weeks)). For adolescents with mixed depression diagnoses, CBT and family therapy may offer benefit. Evidence from studies that include both adolescents and children suggest that CBT plus medications may help prevent relapse. Evidence on children with MDD or mixed depression diagnoses was sparse; family-based interpersonal therapy may improve symptoms for children with mixed depression diagnoses. We found insufficient evidence to judge the risk of harms associated with nonpharmacological interventions. Regarding pharmacological interventions, selective serotonin reuptake inhibitors (SSRIs) as a class may improve response and functional status among adolescents and children. However, they may be associated with a higher risk of serious adverse events among adolescents or children with MDD, and with a higher risk of withdrawal due to adverse events among adolescents with MDD. Paroxetine may be associated with a higher risk of suicidal ideation or behaviors; we did not, however, find the same results SSRIs as a drug class, owing to insufficient evidence. Baseline depression severity and comorbid conditions may moderate the effects of some of the studied interventions.

Conclusions. The findings confirmed that efficacious treatments exist for adolescents with MDD. Little evidence exists for children, depressive disorders other than MDD, long-term outcomes, comparative effectiveness, and potential moderators.