Child and Adolescent Mood Disorders ?
Q.In the 1970s there was a debate in the United States about whether children could be depressed, though European pedo-psychiatrists had long since accepted that they could. In 1975, the National Institute of Mental Health (NIMH) devoted formal attention to this issue, holding a meeting at which researchers and clinicians reviewed the existing literature. The result was agreement on the existence of childhood and adolescent depression. Shortly thereafter, Schulterbrandt and Raskin[1] published a book on the subject that followed the publication of a number of studies of biological markers of depression. One of the most popular markers was the Dexamethasone Suppression Test. Subsequently, however, a number of research groups found negative results, leading to a minimization of this test's importance.
A.In the early 1980s, researchers undertook the challenge of studying parental loss as a model for clinical depression. After conducting pilot studies at the University of Kansas, additional studies were undertaken at Ohio State University, repeating pilot studies to demonstrate feasibility. Subsequently, grants were awarded by the National Institute of Mental Health, which included a study of prepubertal children, a study of adolescents, and a 5-year follow-up of the prepubertal children. These studies have shown that depression is a sequelae of parental death in childhood and adolescents and that the characteristics of pediatric depression are similar to those in adult depression. Approximately one third of children become depressed following the death of a parent. In addition, dexamethasone nonsuppression is high in those who become depressed, which is similar to the level of outpatient clinically depressed children and adolescents. Hence, depression in children and adolescents is phenomenologically and biologically similar to that in adults. This observation was followed by treatment trials in the field of child and adolescent depression. Initially, tricyclic antidepressants (TCAs) were used because those agents were available and clinically proven among adults. Case reports were followed by case series and small open-label studies; these demonstrated that 75% of children and adolescents responded to the treatment. These early reports were followed by double-blind, placebo controlled studies, which were few in number and had a relatively small number of subjects. One positive study[2] in prepubertal hospitalized depressed children reported that if the child was dexamethasone nonsuppressant and had a comorbid anxiety disorder, the child responded better to imipramine than to placebo. However, all other related studies were negative. Hence, the TCAs were not shown to be efficacious in children and adolescents. With the large number of selective serotonin reuptake inhibitor (SSRI) studies for adult depression, child psychiatrists began to study these compounds in children. Currently, there is a double-blind, placebo controlled study[3] published on 96 children and adolescents showing that fluoxetine is superior to placebo. There is also a study comparing paroxetine with imipramine and placebo, reporting that paroxetine is superior to both. However, this study is unpublished, and its sample includes adolescents only. Treatment of Adolescent Depression Study (TADS) The latest movement in the treatment of adolescent depression is toward using multicenter, well-designed studies to gain statistical power. The Treatment of Adolescent Depression Study (TADS) is a study initiated by the National Institute of Mental Health. This study is made up of 9 participating centers and has 4 treatment arms: (1) medication alone, (2) medication plus cognitive behavioral therapy (CBT), (3) CBT alone, and (4) placebo. The feasibility phase has been completed, and the centers are recruiting patients aged 12 to 17 years to participate in this study. Thus, it appears experts have agreed that depression exists in children and adolescents and that it can be diagnosed and treated. Investigators are now attempting to obtain scientific evidence for the treatment.
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