Treatment

The details of both psychological and pharmacological treatments of depression can be found in Ch.ap.t§.L4i5:Z. There is reasonable evidence that both psychological and pharmacological treatments are effective in the management of major depressive episodes. (81,8.2) Antidepressants appear to be unhelpful in most cases of prepubertal depression, but there are no systematic trials of any treatment in this age range. Currently there is no agreed 'gold standard' for practitioners. An urgent research issue is to determine which type or combination of treatments is most effective at what age for a given form of depressive disorder. (See also Chapter.9.5.3.)

Most depressed children and adolescents have been ill for a number of weeks or even months before being referred to a child psychiatrist. Early diagnosis is important as this may decrease the risk of the peer group difficulties that are increased in depression compared with anxiety disorders. (18> Parents are often surprised by the diagnosis and may quickly become concerned that they have failed to be sufficiently vigilant on their child's behalf. The first phase of treatment, as with anxiety disorders, is psychoeducational, involving a careful explanation of the nature and characteristics of the disorder together with an outline of how treatment will proceed. Unlike anxiety disorders, parents are seldom compromised in their parenting style; rather the focus of active treatment is with the child or adolescent. Parents need to be informed of the treatment process and a therapeutic plan should be agreed conjointly with them and the patient. Information from school and best friends can be extremely helpful in judging the degree of friendship difficulties, including bullying.

The second phase, application of treatment, should begin with individual psychological treatment involving cognitive-behavioural techniques. This is likely to last between 8 and 16 weeks. Family therapy does not appear to augment the effectiveness of this approach, but maintaining a clear dialogue with parents and ensuring that they are fully cognisant of the aims of treatment is essential. It is also advisable to monitor the views of siblings and their understanding of the illness as well as its treatment. Where there are severe symptoms including suicidal behaviour, antidepressants should be considered in conjunction with psychological treatment. Marked sleep dysregulation is probably one of the commoner manifestations of severe episodes, with episodic hypersomnia during the day as well as insomnia at night. Selective serotonin-reuptake inhibitors are the first line of pharmacological treatment. However, a test dose, generally half of the starting dose, should be given to determine the risk for behavioural or manic activation.

Treatments should not be discontinued with remission of symptoms. Rather there should be a continuation phase for between 6 and 12 months, with monthly psychological sessions and a review of medication if used.

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