The first and foremost consideration in treating depression is assessing the safety of the youth, as well as any threatening thoughts or actions toward family, peers and the community.
1) If safety cannot be ensured, psychiatric hospitalization should be seriously considered.
2) Depressed youth should not have access to firearms or sharp objects; two-thirds of youth suicides in Oregon occur with guns. Health practitioners should recommend that all firearms be removed from the home
. Health practitioners should make it clear to parents that if they choose to keep a gun in the home, their child and others are at greatly increased risk of injuries or death. If kept in the home, guns should have a safety lock, and ammunition should be stored separately.
3) All medications in the home of a suicidal youth should be placed in a locked cabinet.
4) Appropriate supervision of clinically depressed youth is essential. Consultation with the health practitioner treating the youth for depression can help to establish guidelines for supervision. Further treatment should be tailored to the needs of the youth and family, and should involve an understanding of the biopsychosocial causes of depression for the youth.
Individual psychotherapy with the youth should focus on improving coping skills and helping the youth look at his or her difficulties in getting along with others. Individual therapy should also deal with issues around any trauma, separation or loss. Any thinking errors that contribute to the depression will need to be addressed in individual therapy as well. Individual therapy must be sensitive to the culture of the youth. Note that a small portion of youth will not make good use of therapy until after their depression has been addressed with anti-depressant medication.
Family therapy should work toward improving the understanding and communication between the youth and family members. It is critical that parents connect with their children; parents may need help to understand that depression creates a bigger parent/child barrier, and consequently, greater effort and time commitments are required for a healthy reconnection to occur. This should also be a time to determine whether there should be limitations on time spent on TV, video games and computers and with negative peers. Given the strong hereditary nature of depression, family therapy can also be an opportunity to assess other family members who may suffer from unrecognized depression, so that their depression may also be identified and treated. Family therapy is also a time for all in the family to be further educated on the medical basis and signs of depression and on its tendency to recur.
Group therapy can be a particularly helpful form of treatment, given that adolescents are working through separation and individuation issues. Youth are often more amenable to feedback from their peers, so that beneficial change is more likely to occur in this setting. In work at Oregon Health Sciences University, Clarke, et al., developed an adolescent group cognitive/behavioral therapy curriculum specifically tailored to treat adolescent depression.
Other interventions can complement these therapeutic interventions. Efforts should be made to determine a youth?s strengths so that he or she can become involved in activities that improve self-esteem (depressed youth can be quite creative artists and writers; sports should also be considered). Youth should be involved in physical exercise on a regular basis, as determined by the primary care physician. All youth should have good role models; innovative programs such as Friends of the Children in Portland provide mentors for young children who have experienced significant problems. For those families that choose to be involved in religious activities, the spiritual benefits of these can be significant for youth. Programs like the Dougy Center in Portland can help grieving children better deal with the death of a family member.
Support groups such as the Oregon Family Support Network, the National Depressive and Manic-Depressive Association and the National Alliance for the Mentally Ill can offer emotional support to youth experiencing depression and other emotional disorders, as well as to their families.
As noted previously, consultation with school personnel is essential. Teachers need to make sure that academic expectations are appropriate for youth who are having concentration difficulties related to their depression. Expectations can be increased as the student?s depression improves. Establishing a peer mentor relationship with the depressed student can also be helpful. Parent-teacher communication should occur every 1-2 weeks to make sure the youth is making sufficient progress academically and behaviorally. Some students with depression may require an individualized educational program.
A number of youth will continue to be clinically depressed despite receiving these treatment interventions, particularly those youth with a strong family history of depression. Some youth respond dramatically to anti-depressant medication. Some of these medications may also treat co-occurring conditions, which, as noted, are the rule, not the exception. SSRI?s (e.g., Prozac, Paxil and Zoloft) can be effective in treating depression in youth and may also treat associated anxiety disorders such as obsessive-compulsive disorder. These medications will generally not address ADHD symptoms, however. Wellbutrin-SR can address both depression and ADHD in some youth; the slow-release form is preferred, given the increased potential for seizures associated with the regular form of Wellbutrin at higher doses. Tricyclic anti-depressants, such as Imipramine and Nortriptyline, are less likely to be beneficial in treating depression in youth and are generally not recommended in treating suicidal youth, as this type of medication may be lethal in an overdose. Medications like hydroxyzine, clonidine and Trazodone should be considered for those youth with significant sleep problems; the relative risk of developing priapism when considering Trazodone in boys needs to be discussed with the family. Medications like lithium, Depakote and Risperdal should be considered for those youth experiencing bipolar depression.
Key points need to be kept in mind when medication is being considered:
1) Medication alone is rarely "the answer" in treating depression in youth; instead, youth are most likely to achieve maximum improvement in the quickest timeframe when multiple treatment options are utilized.
2) Youth and parents need to be aware of the target goals when a medication is used?an irritable adolescent who skips class, for example, may become less irritable with medication but may continue to skip class unless parents regularly communicate with school personnel, have meaningful consequences for skipping class, etc.
3) Parents must make sure their child is taking the medication as prescribed; some parents discover that youth who resist parental direction also resist taking medication.
4) Anti-depressant medication generally must be taken as prescribed for the recommended number of weeks or months and at a sufficient dose to be effective.
5) It is essential that there be timely communication with the prescribing practitioner if a youth experiences side effects, takes other medications or becomes pregnant.
It is essential for families to understand and comply fully with treatment recommendations. Parents should increase their awareness of their child?s friends and activities throughout the day (including use of the computer) so that this information can be communicated regularly to the treatment provider. Further interventions need to be considered if the youth does not begin to show improvement in 4-6 weeks, or sooner, if safety concerns persist.
A second opinion by a health professional trained in recognizing and treating childhood depression can be an important option if problems persist.
It is important to recognize that alcohol and drug use can seriously increase depression in youth. A formal substance use evaluation is recommended if the youth may be using alcohol or drugs. The fact that depressed youth who use alcohol or drugs are much more likely to die by suicide cannot be overstated. Note again that all alcohol and drug treatment providers need to closely evaluate youth for depression in addition to evaluating the substance use problems; if this is not done, substance use problems related to undiagnosed depression often return after the youth finishes a treatment program.
The first and foremost consideration in treating depression is assessing the safety of the youth as well as any threatening thoughts or actions toward family, peers and the community. Parents may need help to understand that depression creates a bigger parent/child barrier, and consequently, greater effort and time commitments are required for a healthy reconnection to occur. It is essential for families to understand and comply fully with treatment recommendations.