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American Academy of Pediatrics guidelines for treating depression in adolescents
Clinical Question
What are the guidelines from the American Academy of Pediatrics for the management of depression in adolescents?
Bottom line
The American Academy of Pediatrics eschews drug therapy as first-line treatment for adolescents with depression, though it still jumps to medication management faster than guideline writers in other countries. For mild depression, adolescents should be monitored (watchful waiting) without further treatment for 6 weeks to 8 weeks; only then should patients be considered for psychotherapy and/or antidepressant medication. Adolescents with moderate to severe depression should be referred for psychotherapy and started on a low-dose antidepressant. Monitor their symptoms, as well as their functioning at school, at home, and with peers. Refer adolescents with depression and accompanying substance abuse or psychosis to a specialist 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Various (guideline)
Synopsis
These guidelines were developed by an organization and endorsed by the American Academy of Pediatrics. The guidelines are based on a systematic review of the evidence, followed by consensus development by an expert working group, and the process was overseen by a steering committee. No patients or research analysts were included in the group. All recommendations were based on graded evidence, which for the most part was of low-quality despite the predominantly strong recommendations. There were no conflicts of interest reported by the guideline developers. The major recommendations are: • Mild depression, at least initially, should not be treated but patients should have active support and monitoring, consisting of weekly or biweekly visits for 6 to 8 weeks (very strong recommendation based on moderate evidence). • For adolescents with moderate or severe depression, or mild depression not responding to support and monitoring, consider psychotherapy (cognitive behavioral therapy or interpersonal psychotherapy) for adolescents and/or antidepressant treatment (very strong recommendation based on high-quality evidence). Use low doses of antidepressants and monitor for adverse effects. • Systematically track symptoms, as well as functioning at school, home, and among peers (very strong recommendation based on low quality evidence). Tools for tracking are available at www.gladpc.org. • An adolescent with moderate or severe depression and substance abuse or psychosis should be referred for mental health specialist consultation with ongoing co-management by the primary physician (strong recommendation based on weak evidence). These guidelines are similar to those issued by the National Institute for Health and Care Excellence (NICE) of the United Kingdom, which avoids medical treatment of mild depression without trying psychotherapy first, and recommends fluoxetine as the first-line antidepressant for moderate to severe depression, again, only if psychotherapy is ineffective. For their guidance, see: https://www.nice.org.uk/guidance/cg28.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
This is a difficult issue to address with increase in marijuana use also in this group of patients . We need to mindful of all the distress this creates in the family and for the future of the adolescent.
A team approach would be required in most cases.
This leaves primary care physicians and parents and adolescents alert and worried, correctly, with for most, no helpful interventions. School and social function declines, often with life long consequences. Where is the recommendation for increased physical activity, for engagement in community building projects, in music, in art etc where accomplishments can bolster self esteem, and obligations can enhance healthy function even in the setting of low mood.
With social and economic problems plaguing more and more families, good quality early child care spaces’ numbers stagnant due to political laziness, schools not being funded to assess, identify and then service their needy students, the outright unhinged toxicity of social media on teens and young adults and mental health being talked about way more than acted on with proper services, it’s no wonder those of us in the trenches are seeing and trying to manage increasing numbers of patient with anxiety and depression. The putting in practice of an upstream model is urgently needed, but in the meanwhile, it is helpful to have the AAP guidelines in our corner, lending justification to our clinical approaches, including the judicious use of medications in some cases.
Any severity of depression is an opportunity for the healthcare provider to teach patients how to better self manage these unpleasant emotional states. We are missing a therapeutic moment and not providing skill building counselling. We also miss the target by treating unpleasant emotional states chemically without a major emphasis on skill building. Without building the skills to be gentler, more understanding, more knowledgeable and more confident of oneself, future life problems will come along to cause emotional chaos. Unless the pharmaceutical options were dramatically more effective, people eventually grow more and more hopeless of this painful cycle. Psychotherapy is the key towards healing. It is not so much the brand of psychotherapy but it is the ability of the skilled therapists to connect and convey hope, maturity and wisdom to the patient. It disturbs me to see that the future of our human species is not being offered a better chance earlier on in life than what is recommended in this publication.
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