Purpose of review
Adolescent depression is a prevalent condition that has been on the rise in recent years. The primary care setting is often the front line to mental health needs, specifically identifying and treating early depression. This review presents the current evidence base about adolescent depression, its identification, and treatment approaches.
The US Preventive Services Task Force and American Academy of Pediatrics recommend universal screening for depression in adolescents in primary care settings. There are several depression screening measures that could be useful in primary care. Recommended treatment approaches which include therapy, medication, or a combination of the two are based on an adolescent’s presentation and degree of impairment. There is sufficient empirical evidence supporting use of three therapies and two Selective Serotonin Reuptake Inhibitors for adolescent depression.
Currently, there are resources, screening measures, and research evidence available to adequately support pediatricians in the identification and treatment of adolescent depression.
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References and Recommended Reading
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Cummings JR, Druss BG. Racial/ethnic differences in mental health service use among adolescents with major depression. J Am Acad Child Adolesc Psychiatry. 2011;50(2):160–70. https://doi.org/10.1016/j.jaac.2010.11.004.
Merikangas KR. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50:32–45. https://doi.org/10.1016/j.jaac.2010.10.006.
Strawn JR, Dobson ET, Giles LL. Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety. Curr Probl Pediatr Adolesc Health Care. 2017;47:3–14. https://doi.org/10.1016/j.cppeds.2016.11.008.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.
Dunn V, Goodyer IM. Longitudinal investigation into childhood-and adolescence-onset depression: psychiatric outcome in early adulthood. Br J Psychiatry. 2006;188:216–22. https://doi.org/10.1192/bjp.188.3.216.
Thapar A, Collishaw S, Pine DS, Thapar AK. Depression in adolescence. Lancet. 2012;379:1056–67. https://doi.org/10.1016/S0140-6736(11)60871-4.
Carballo JJ, Muñoz-Lorenzo L, Blasco-Fontecilla H, Lopez-Castroman J, García-Nieto R, Dervic K, et al. Continuity of depressive disorders from childhood and adolescence to adulthood: a naturalistic study in community mental health centers. Prim Care Companion CNS Disord. 2011;13:PCC.11m01150. https://doi.org/10.4088/PCC.11m01150.
Fergusson DM, Woodward LJ. Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry. 2002;59:225–31. https://doi.org/10.1001/archpsyc.59.3.225.
Avenevoli S, Swendsen J, He JP, Burstein M, Merikangas KR. Major depression in the National Comorbidity Survey–Adolescent Supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry. 2015;54:37–44. https://doi.org/10.1016/j.jaac.2014.10.010.
• Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics. 2016;138:e20161878. https://doi.org/10.1542/peds.2016-1878. This study is an epidemiological study demonstrating that depression rates have increased in adolescents over time, however, treatment rates have remained the same
Boyd RC, Butler L, Benton TD. Understanding adolescents’ experiences with depression and behavioral health treatment. J Behav Health Serv Res. 2017;45:105–11. https://doi.org/10.1007/s11414-017-9558-7.
Wright DR, Katon WJ, Ludman E, McCauley E, Oliver M, Lindenbaum J, et al. Association of adolescent depressive symptoms with health care utilization and payer-incurred expenditures. Acad Pediatr. 2016;16:82–9. https://doi.org/10.1016/j.acap.2015.08.013.
Benton TD, Boyd R, Ifeagwu J, Feldtmose E, Smith-Whitley K. Psychiatric diagnosis in adolescents with sickle cell disease: a preliminary report. Curr Psychiatry Rep. 2011;13:111–5. https://doi.org/10.1007/s11920-011-0177-3.
Katon W, Lozano P, Russo J, McCauley E, Richardson L, Bush T. The prevalence of DSM-IV anxiety and depressive disorders in youth with asthma compared with controls. J Adolesc Health. 2007;41:455–63. https://doi.org/10.1016/j.jadohealth.2007.05.023.
Knight A, Weiss P, Morales K, Gerdes M, Rearson M, Vickery M, et al. Identifying differences in risk factors for depression and anxiety in pediatric chronic disease: a matched cross-sectional study of youth with lupus/mixed connective tissue disease and their peers with diabetes. J Pediatr. 2015;167:1397–403. https://doi.org/10.1016/j.jpeds.2015.07.048.
Muehlenkamp JJ, Claes L, Havertape L, Plener PL. International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child Adolesc Mental Health. 2012;6:10. https://doi.org/10.1186/1753-2000-6-10.
National Center for Injury Prevention and Control, Center for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS), 10 Leading Causes of Death, United States, 2015, All Races, Both Sex. https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2015-a.pdf
Goodman SH. Depression in mothers. Annu Rev Clin Psychol. 2007;3:107–35. https://doi.org/10.1146/annurev.clinpsy.3.022806.091401.
McLeod BD, Weisz JR, Wood JJ. Examining the association between parenting and childhood depression: a meta-analysis. Clin Psychol Rev. 2007;27:986–1003. https://doi.org/10.1016/j.cpr.2007.03.
Sander JB, McCarty CA. Youth depression in the family context: familial risk factors and models of treatment. Clin Child Fam Psychol Rev. 2005;8:203–19. https://doi.org/10.1007/s10567-005-6666-3.
Ttofi MM, Farrington DP, Lösel F, Loeber R. Do the victims of school bullies tend to become depressed later in life? A systematic review and meta-analysis of longitudinal studies. J Aggress Confl Peace Res. 2011;3:63–73. https://doi.org/10.1108/17596591111132873.
Colman I, Jones PB, Kuh D, Weeks M, Naicker K, Richards M, et al. Early development, stress and depression across the life course: pathways to depression in a national British birth cohort. Psychol Med. 2014;44:2845–54. https://doi.org/10.1017/S0033291714000385.
Hankin BL. Depression from childhood through adolescence: risk mechanisms across multiple systems and levels of analysis. Curr Opin Psychol. 2015;4:13–20. https://doi.org/10.1016/j.copsyc.2015.01.003.
•• Sui AL. Screening for depression in children and adolescents: US preventive services task force recommendation statement. Pediatrics. 2016;137:1–8. https://doi.org/10.1542/peds.2015-4467. This article presents the USPSTF recommendations and its corresponding empirical support of screening and treatment of youth depression in primary care
•• Zuckerbrot RA, Cheung AH, Jensen PS, REK S, Laraque D, GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081. https://doi.org/10.1542/peds.2017-4081. This article updates the clinical practice guidelines to assist primary care providers in the management of adolescent depression with a focus on practice preparation, identification, assessment, and initial management
Johnson JG, Harris ES, Spitzer RL, Williams JB. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30:196–204. https://doi.org/10.1016/S1054-139X(01)00333-0.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the patient health Questionnaire-9 item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117–23. https://doi.org/10.1542/peds.2010-0852.
Richardson LP, Rockhill C, Russo JE, Grossman DC, Richards J, McCarty C, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics. 2010;125(5):e1097–103. https://doi.org/10.1542/peds.2009-2712.
Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1997;1:385–401. https://doi.org/10.1177/014662167700100306.
Radloff LS. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc. 1991;20:149–66. https://doi.org/10.1007/BF01537606.
Stockings E, Degenhardt L, Lee YY, Mihalopoulos C, Liu A, Hobbs M, et al. Symptom screening scales for detecting major depressive disorder in children and adolescents: a systematic review and meta-analysis of reliability, validity and diagnostic utility. J Affect Disord. 2015;174:447–63. https://doi.org/10.1016/j.jad.2014.11.061.
Haroz EE, Ybarra ML, Eaton WW. Psychometric evaluation of a self-report scale to measure adolescent depression: the CESDR-10 in two national adolescent samples in the United States. J Affect Disord. 2014;158:154–60. https://doi.org/10.1016/j.jad.2014.02.009.
Pilkonis PA, Yu L, Dodds NE, Johnston KL, Maihoefer CC, Lawrence SM. Validation of the depression item bank from the patient-reported outcomes measurement information system (PROMIS®) in a three-month observational study. J Psychiatr Res. 2014;56:112–9. https://doi.org/10.1016/j.jpsychires.2014.05.010.
Olino TM, Yu L, McMakin DL, Forbes EE, Seeley JR, Lewinsohn PM, et al. Comparisons across depression assessment instruments in adolescence and young adulthood: an item response theory study using two linking methods. J Abnorm Child Psychol. 2013;41:1267–77. https://doi.org/10.1007/s10802-013-9756-6.
Irwin DE, Stucky B, Langer MM, Thissen D, DeWitt EM, Lai JS, et al. An item response analysis of the pediatric PROMIS anxiety and depressive symptoms scales. Qual Life Res. 2010;19:595–607. https://doi.org/10.1007/s11136-010-9619-3.
Psychological Corporation. Manual for the Beck depression inventory–II. San Antonio, TX: Beck AT, Steer RA, Brown GK; 1996.
•• Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein RE, GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics. 2018;141(3):e20174082. https://doi.org/10.1542/peds.2017-4082. This article updates the clinical practice guidelines to assist primary care providers in the management of adolescent depression with a focus on ongoing treatment
Picardi A, Gaetano P. Psychotherapy of mood disorders. Clin Pract Epidemiol Ment Health. 2014;10:140–58. https://doi.org/10.2174/1745017901410010140.
Curry JF, Hersh J. Development and evolution of cognitive behavior therapy for depressed adolescents. J Ration Emot Cogn Behav Ther. 2014;32:15–30. https://doi.org/10.1007/s10942-014-0180-9.
• Weersing VR, Jeffreys M, Do MT, Schwartz KTG, Bolano C. Evidence base update of psychosocial treatments for child and adolescent depression. J Clin Child Adolesc Psychol. 2017;46:11–43. https://doi.org/10.1080/15374416.2016.1220310. This review present the current empirical evidence for therapy with youth with depressive disorders and identify those that are well-established to effectively treat depression
Richardson T, Stallard P, Velleman S. Computerised cognitive behavioural therapy for the prevention and treatment of depression and anxiety in children and adolescents: a systematic review. Clin Child Fam Psychol Rev. 2010;13:275–90. https://doi.org/10.1007/s10567-010-0069-9.
Weersing VR, Brent DA. Cognitive behavioral therapy for depression in youth. Child Adolesc Psychiatr Clin N Am. 2006;15:939–57. https://doi.org/10.1016/j.chc.2006.05.008.
Pu J, Zhou X, Liu L, Zhang Y, Yang L, Yuan S, et al. Efficacy and acceptability of interpersonal psychotherapy for depression in adolescents: a meta-analysis of randomized controlled trials. Psychiatry Res. 2017;253:226–32. https://doi.org/10.1016/j.psychres.2017.03.023.
Mufson L, Dorta KP, Moreau D, Weissman MM. Interpersonal psychotherapy for depressed adolescents. 2nd ed. New York: The Guildford Press; 2004.
Diamond GS, Wintersteen MB, Brown GK, Diamond GM, Gallop R, Shelef K, et al. Attachment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2010:49122–31. https://doi.org/10.1097/00004583-201002000-00006.
Diamond GS, Reis BF, Diamond GM, Siqueland L, Isaacs L. Attachment-based family therapy for depressed adolescents: a treatment development study. J Am Acad Child Adolesc Psychiatry. 2002;41:1190–6. https://doi.org/10.1097/01.CHI.0000024836.94814.08.
Ewing ESK, Diamond G, Levy S. Attachment-based family therapy for depressed and suicidal adolescents: theory, clinical model and empirical support. Attach Hum Dev. 2015;17:136–56. https://doi.org/10.1080/14616734.2015.1006384.
March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA. 2004;292:807–20. https://doi.org/10.1001/jama.292.7.807.
Kratochvil C, Emslie G, Silva S, McNulty S, Walkup J, Curry J, et al. Acute time to response in the treatment for adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1412–8. https://doi.org/10.1097/01.chi.0000237710.73755.14.
Kennard B, Silva S, Vitiello B, Curry J, Kratochvil C, Simons A, et al. Remission and residual symptoms after short-term treatment in the treatment of adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1404–11. https://doi.org/10.1097/01.chi.0000242228.75516.21.
Vitiello B, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller MB, et al. Long-term outcome of adolescent depression initially resistant to selective serotonin reuptake inhibitor treatment: a follow-up study of the TORDIA sample. J Clin Psychiatry. 2011;72:388–96. https://doi.org/10.4088/JCP.09m05885blu.
Kennard BD, Emslie GJ, Mayes TL, Nakonezny PA, Jones JM, Foxwell AA, et al. Sequential treatment with fluoxetine and relapse-prevention CBT to improve outcomes in pediatric depression. Am J Psychiatry. 2014;171:1083–90. https://doi.org/10.1176/appi.ajp.2014.13111460.
Nemets H, Nemets B, Apter A, Bracha Z, Belmaker RH. Omega-3 treatment of childhood depression: a controlled, double-blind pilot study. Am J Psychiatry. 2006;163:1098–100. https://doi.org/10.1176/appi.ajp.163.6.1098.
Trebatická J, Hradečná Z, Böhmer F, Vaváková M, Waczulíková I, Garaiova I. Emulsified omega-3 fatty-acids modulate the symptoms of depressive disorder in children and adolescents: a pilot study. Child Adolesc Mental Health. 2017;11:30. https://doi.org/10.1186/s13034-017-0167-2.
Brent D, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller M, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901–13. https://doi.org/10.1001/jama.299.8.901.
Emslie GJ, Kennard BD, Mayes TL. Predictors of treatment response in adolescent depression. Pediatr Ann. 2011;40:300–6. https://doi.org/10.3928/00904481-20110512-05.
Goodyer IM, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, et al. A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial. Health Technol Assess. 2008;12:iii–v, ix-60. https://doi.org/10.3310/hta12140.
Curry J, Rohde P, Simons A, Silva S, Vitiello B, Kratochvil C, et al. Predictors and moderators of acute outcome in the treatment for adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1427–39. https://doi.org/10.1097/01.chi.0000240838.78984.e2.
March JS, Vitiello B. Clinical messages from the treatment for adolescents with depression study (TADS). Am J Psychiatry. 2009;166:1118–23. https://doi.org/10.1176/appi.ajp.2009.08101606.
Curry J, Silva S, Rohde P, Ginsburg G, Kennard B, Kratochvil C, et al. Onset of alcohol or substance use disorders following treatment for adolescent depression. J Consult Clin Psychol. 2012;80:299–312. https://doi.org/10.1037/a0026929.
Emslie GJ, Kennard BD, Mayes TL, Nightingale-Teresi J, Carmody T, Hughes CW, et al. Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. Am J Psychiatry. 2008;165:459–67. https://doi.org/10.1176/appi.ajp.2007.07091453.
Kratochvil CJ, May DE, Silva SG, Madaan V, Puumala SE, Curry JF, et al. Treatment response in depressed adolescents with and without co-morbid attention-deficit/hyperactivity disorder in the treatment for adolescents with depression study. J Child Adolesc Psychopharmacol. 2009;19:519–27. https://doi.org/10.1089/cap.2008.0143.
Crawley SA, Caporino NE, Birmaher B, Ginsburg G, Piacentini J, Albano AM, et al. Somatic complaints in anxious youth. Child Psychiatry Hum Dev. 2014;45:398–407. https://doi.org/10.1007/s10578-013-0410-x.
• Strawn JR, Welge JA, Wehry AM, Keeshin B, Rynn MA. Efficacy and tolerability of antidepressants in pediatric anxiety disorders: a systematic review and meta-analysis. Depress Anxiety. 2015;32:149–57. https://doi.org/10.1002/da.22329. This review and meta-analysis reviews outcomes of anti-depressants use with anxiety disorders in youth and demonstrates their benefits, side effects and lack of increase in suicidality
Safer DJ, Zito JM. Treatment-emergent adverse events from selective serotonin reuptake inhibitors by age group: children versus adolescents. J Child Adolesc Psychopharmacol. 2006;16:159–69. https://doi.org/10.1089/cap.2006.16.159.
Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297:1683–96. https://doi.org/10.1001/jama.297.15.1683.
Rahn KA, Cao YJ, Hendrix CW, Kaplin AI. The role of 5-HT1A receptors in mediating acute negative effects of antidepressants: implications in pediatric depression. Transl Psychiatry. 2015;5:e563. https://doi.org/10.1038/tp.2015.57.
FDA Public Health Advisory: Suicidality in children and adolescents being treated with antidepressant medications. Oct. 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/default.htm.
Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503–26. https://doi.org/10.1097/chi.0b013e318145ae1c.
Asarnow JR, Jaycox LH, Duan N, LaBorde AP, Rea MM, Murray P, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293:311–9. https://doi.org/10.1001/jama.293.3.311.
Mindell JA, Owens JA, Carskadon MA. Developmental features of sleep. Child Adolesc Psychiatr Clin N Am. 1999;8:695–725.
Carskadon MA. Patterns of sleep and sleepiness in adolescents. Pediatrician. 1990;17:5–12.
Axelson DA, Bertocci MA, Lewin DS, Trubnick LS, Birmaher B, Williamson DE, et al. Measuring mood and complex behavior in natural environments: use of ecological momentary assessment in pediatric affective disorders. J Child Adolesc Psychopharmacol. 2003;13:253–66. https://doi.org/10.1089/104454603322572589.
Goetz RR, Puig-Antich J, Ryan N, Rabinovich H, Ambrosini PJ, Nelson B, et al. Electroencephalographic sleep of adolescents with major depression and normal controls. Arch Gen Psychiatry. 1987;44:61–8. https://doi.org/10.1001/archpsyc.1987.01800130069009.
Liu X, Buysse D, Gentzler AL, Kiss E, Mayer L, Kapornai K, et al. Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression. Sleep. 2007;30:83–90. https://doi.org/10.1093/sleep/30.1.83.
Roberts RE, Roberts CR, Chen IG. Impact of insomnia on future functioning of adolescents. J Psychosom Res. 2002;53:561–9. https://doi.org/10.1016/S0022-3999(02)00446-4.
Walsh JK, Benca RM, Insomnia BM. Assessment and Management in Primary Care. Am Fam Physician. 1999;59:3029–38.
Perlis M, Jungquist C, Smith MT, Posner D. Cognitive behavioral treatment of insomnia, a session-by-session guide. New York, NY: Springer; 2005.
Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia. An American Academy of sleep medicine review. Sleep. 1999;22:1134–56. https://doi.org/10.1093/sleep/22.8.1134.
Brent DA. Screens and doors: the management of adolescent depression in primary care. Arch Pediatr Adolesc Med. 2006;160:755–6. https://doi.org/10.1001/archpedi.160.7.755.
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Boyd, R.C., Lewis, J., Borreggine, K. et al. Adolescent Depression: Identification and Treatment. Curr Treat Options Peds 4, 350–362 (2018). https://doi.org/10.1007/s40746-018-0135-y